The use of mesh in urogynaecology has created much controversy in the last years. 
The real prevalence of mesh complications is still largely debated due to different definitions used, variable length of followup considered amongst studies, great variability of clinical manifestations, as well as underreporting. What is now clear, is that the rate of  mesh-related complications is higher in patients who have had multiple meshes inserted and that the most frequently reported complications include mesh extrusion and pain. 
Similarly, data regarding outcomes following mesh removal can vary greatly in different studies and depending on symptoms considered; furthermore mesh removal itself may have risks which need to be discussed with patients, including: persistent or recurrent incontinence, urethral strictures, persistent pain or de novo pain, urethral injury, urethrovaginal fistula. 
Our study aims to analyze urodynamics findings and patients reported outcomes after removal of a mid-urethral sling for different indications.

Ours was a retrospective analysis, we included in the study all the women who were referred to the Female Pelvic medicine and Reconstructive Surgery  Division of University College London Hospital and underwent vaginal removal of a mid-urethral sling (TVT, TVT-O, TOT) between January 2014 and January 2020. 
Data regarding patients demographics, past surgical history, post operative patients’ reported symptoms and results of video-urodynamics investigations performed 4 months after  surgery were recorded on the patients’ electronic records, collected and analyzed retrospectively. 
R program was used for statistical analyses of the data.

A total of 204 patients were included in the study. Population characteristics are summarized in table 1: 61.8% of the women included had a TVT, 20.1% a TVT-O and 21.6% a TOT mesh inserted. Notably 7 patients had 2 different continence meshes inserted while no patient had more than 2 slings.

Post operative outcomes are summarized in table 2: 8%, 80.5%, 2.9% of the women included reported voiding dysfunction, stress urinary incontinence (SUI) and overactive bladder (OAB) symptoms respectively, after mesh removal. No patients reported worsening pain after surgery and 10.1% suffered from prolapse symptoms. 

Video-urodynamics investigations proved the presence of pure SUI, pure DO and mixed urinary incontinence in 67.3%, 6.8%, 14.3% of patients respectively; only one patient had urodynamically diagnosed voiding dysfunction while 2 women were found to have a urethral stricture and 10 (9.8%) a significant cystocoele.

Our data shows that recurrence of SUI is the single most frequent complication after continence mesh removal, both in terms of patients’ reported symptoms and urodynamic findings. Women seldom reported OAB symptoms (2.9%), while the prevalence of DO seems to be higher when investigated; on the other hand, 8% of the patients reported some form of difficulties passing urine while only 1 patient (0.7%) had voiding dysfunction confirmed at urodynamics. Finally, in our subset, no patients reported a worsening of their pain following continence mesh removal.

The occurrence of some kind of bladder dysfunction after continence mesh removal is extremely frequent, women should be counseled pre-operatively about risks of surgery. Furthermore, after continence mesh removal, patients should be properly investigated through urodynamics studies as the underlying bladder problems may be more complex than suggested by patients’ symptoms only.

Mesh complications: best practice in diagnosis and treatment -  P. B. Garcia Reyes, H. Hashim. Ther Avd Urol. 2020
Mesh, graft, or standard repair for women having primary transvaginal anterior or posterior compartment prolapse surgery: two parallel-group, multicentre, randomised, controlled trials (PROSPECT) - C.MA Glazener et al. The Lancet 2016

Continence 2S2 (2022) 100267
DOI: 10.1016/j.cont.2022.100267