This article aims to describe the outcomes of a mid-urethral sling(MUS) in women with gynecology malignancies and additional adjuvant radiotherapy

This descriptive study was conducted retrospectively through a chart review at a large urology and urogynecology practice from May 2000 through May 2019 and approved by the institutional review board(IRB). A chart review was performed for women who underwent the treatment of gynecology malignancies and MUS. All cases were identified and collected by using the procedure code (sling placement 57288, sling revision 57287) and diagnosis code ICD-9 and -10 of gynecology malignancies and confirmed by reviewing operative records and pathology reports of each case. Demographic features, description of operative procedures, clinicopathologic results, and postoperative follow-up data, including adjuvant treatment for cancer and complications related to the procedures, were collected from the electronic medical records of the outpatient clinic. Descriptive statistical analyses were performed.

We identified a total of 70 women with a diagnosis of gynecology malignancies who also underwent MUS between May 2000 and May 2019. 
The mean age of patients was 63 years. The most common type of cancer was endometrial (n=50, 71%), and the rest were ovarian (n=18), tubal (n=2), and cervical (n=1) in origin. 
Seventy-four percent (n=52) underwent retropubic MUS, and 26% (n=18) had trans-obturator (TOT) sling. About 26% (n=18) of total patients received POP repair and MUS concurrently with staging operation for a diagnosis of cancer.  There were four cancer cases (2 tubal cancers, one endometrial cancer, and one ovarian cancer) incidentally detected during MUS concurrent with POP repair. These women subsequently underwent a cancer staging procedure within four weeks.
Among patients with a history of gynecology cancer, eighteen percent (n=13, mean and median age of 72 years) were found to have undergone adjuvant radiation treatment before or after the MUS procedure; 10 patients (69%) had MUS before the treatment of cancer with adjuvant radiotherapy, with a time span between MUS and radiotherapy ranging from 53 days to 5 years (median 127 days). Three patients (23%) underwent MUS after radiation treatment, and the time interval ranged from 10 months to 3 years.  The mean follow-up period after MUS and radiation treatment was 12 months. Of these, in the subset of the radiation group of 13 patients, only one patient (7%), developed mesh extrusion, eventually requiring a sling revision and reoperation. This patient had undergone a retropubic sling after external adjuvant radiotherapy for cervical cancer. The rest of the radiation group who received the adjuvant brachytherapy for endometrial cancer did not have any mesh complications, were satisfied with the outcome and did not require any additional procedure.

There is limited data on the effect of radiation on a synthetic MUS, as patients with a history of pelvic irradiation have explicitly been excluded from many of the clinical trials assessing anti-incontinence procedures. Without more data, there is a concern of a potential risk of a foreign body placement if it may be followed by pelvic radiation or if the patient had previous pelvic radiation. 
We described the outcome of MUS in patients who subsequently underwent radiation treatment or had undergone radiation immediately after or years after the MUS. Only one patient underwent mesh revision and eventually re-operated on for recurrent incontinence; the complication is likely attributable to a relatively higher dose of radiation applied to the patient with cervical cancer. Most patients (n=12 out of 13) did well without complications such as mesh extrusion or reoperation; all twelve patients received vaginal adjuvant brachytherapy after surgical treatment of endometrial cancer. This outcome indicates the safety of MUS in the majority of patients who have had a sling prior to or subsequent to radiation, especially among patients with endometrial cancer. 
Our study suggests that patients with gynecologic cancers that need a concomitant urogynecologic procedure should get it with minimal increase in risk regardless of a possible need for subsequent radiation.

Pelvic floor disorders, including urinary dysfunction, are common urogynecologic problems among the elderly population. However, these conditions are likely to be undertreated or ignored, especially in women undergoing treatment of gynecologic malignancies. 
Based on the results from our descriptive study, a MUS can be performed safely in patients undergoing endometrial cancer staging and additional adjuvant radiation treatment.
Given the impact of stress incontinence on the quality of life of these patients, further studies with larger numbers are needed to confirm our findings.

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