Hypothesis / aims of study
While patients who seek surgical management for synthetic mid-urethral sling (MUS) complications have been demonstrated to benefit in terms of multidimensional outcomes1, it is unclear whether this amelioration of presenting symptoms is sustained with time. The preferred approach to revision at our institution is suburethral sling removal (SSR), which has been evaluated by for several symptom domains, including pain and urinary incontinence. We compared improvement in patient reported symptoms following (SSR) at short and long-term follow-up.
Study design, materials and methods
We reviewed a prospectively maintained, IRB approved database of women undergoing SSR at our institution and excluded patients with neurogenic bladder, urethral erosion, multiple or non-synthetic slings, prior mesh repair of pelvic organ prolapse or follow-up less than 6 months. All patients were seen at 6 weeks postoperatively, 6 months and thereafter yearly. Demographic data, type of sling, and symptoms along with Urogenital Distress Inventory Short Form (UDI-6) scores both before and after SSR were analyzed. An ideal outcome was defined as being free of pelvic pain, urinary incontinence (UI), recurrent UTIs, and being sexually active. Alternate outcomes were also evaluated: allowing for one minimally-invasive anti-incontinence procedure post-SSR, or without accounting for sexual activity post-SSR due to variable documentation and lack of standardized questionnaires. Long-term follow-up was defined as time from SSR to most recent office visit ≥24 months.
From 3/2006-2/2017, 443 women underwent SSR of whom 230 met study criteria. 121/230 (53%) patients had long-term follow-up (median length 46 months, mean 51 months). Most patients (180/230, 78%) reported three or more symptoms at presentation, with median number of symptoms 4 (IQR 3-4) and mean 3.4. Median most recent post-SSR total UDI-6 score was 38 vs 50 at baseline (p<0.0001), with UDI-6 questions 2, 5 and 6, corresponding to symptoms of stress urinary incontinence, urge urinary incontinence, voiding difficulty and pelvic pain respectively demonstrating decreases in median subscore. An ideal outcome was attained in 9/121 (7%) of patients. A modified outcome allowing for one minimally invasive anti-incontinence procedure and excluding sexual activity classified 63/121 (52%) of patients as successes. There were no differences in demographics, medical comorbidities, preoperative symptoms, UDI-6 scores, or proportions of patients reaching an ideal outcome between short or long-term follow-up. However, more patients required minimally-invasive anti-incontinence procedures at long-term follow-up (41/121 vs 14/109, p=0.0002). The majority of anti-continence procedures performed overall were minimally-invasive (62/81).
Interpretation of results
One concern about early results is that they may not be maintained over time. In this study we confirm a sustained improvement in presenting symptoms over time after suburethral sling removal. The similarity of UDI-6 scores, which have been correlated with symptomatic improvement following SSR, at early and late follow-up also suggest that this initial effect is durable. In addition, as expected, the rate of secondary anti-incontinence procedures increased with longer follow-up. These procedures were minimally invasive, mostly involving bulking agents and non-operative interventions for urge incontinence. Most patients were able to avoid invasive procedures for incontinence. These results are concordant with previous investigations of SSR which focused on single symptom domains, such as incontinence, and suggest that MUS failure may be more ideally managed with SSR and subsequent anti-incontinence procedure, rather than repeat MUS placement.2
Strengths of our study include the use of the same SSR technique at one institution over time, and standardized outcome reporting. Our study is limited by incomplete data regarding sexual function, which does impact quality of life in women undergoing MUS.3 We are currently evaluating questionnaires to assess better baseline and post-SSR sexual function and incorporate them into our multidimensional outcome reporting.