Secondary midurethral sling (MUS) replacement and displacement procedures are an important and difficult challenge for both the gynecologist and the patient, hence remain an unpopular choice in incontinence surgery. MUS replacement surgery has a high rate of success and upon correct qualification for the procedure may prove to be an effective therapeutic method, even after primary procedure failure.

Upon ineffective primary transobturator MUS surgery 6 years prior, a 67 years old woman with ongoing severe stress urinary incontinence was admitted for MUS removal. Her medical history was uneventful, apart from type 2 diabetes, cholecystectomy and two uncomplicated vaginal births. The body mass index (BMI) was 38.0, indicating obesity. The patient reported no improvement after the first/index MUS surgery. Ultrasonography (US) examination revealed urethral length 29.4mm, and confirmed midurethral sling positioning in the middle of the urethral length, but the tape – urethra distance was 5.1mm, and the sling-symphysis pubis gap was 18.8mm. During stress tests, i.e. cough test and Valsalva maneuver the urethra was rotating around the symphysis pubis and descending, without contacting the midurethral sling, the urine leakage was confirmed. On vaginal examination, no vaginal mesh exposure was observed, the Pelvic Organ Prolapse Quantification (POP-Q) was stage 2 (Aa-2cm, Ba-2cm, Ap-0cm, Bp-2cm, TVL 9cm, D-9cm, C-8cm, PB 5cm, GH 5cm). Therefore the patient was qualified for the MUS removal surgery. After the removal of the sling, SUI symptoms remained stable. After 6 months, the patient was re-operated and a new transobturator MUS was placed again, successfully leading to the resolution of incontinence symptoms.

Transobturator tape (TOT) removal procedure was performed form the vaginal approach, and the vaginal part of the sling was removed to the layer of the internal obturator fascia. Upon completion of healing process, after 6 months the patient was readmitted for TOT secondary surgery which was conducted without complications. During follow up visits patient presented without prior symptoms and confirmed enhancement her everyday life both physical and mental.

Secondary transobturator sling replacement surgery is an operative challenge for the gynecologist, yet may bring effective results and increase the quality of life for the patient. Ultrasound examination provides important information for the diagnosis of sling failure. Careful qualification for MUS replacement is key for surgical success.

Hubka P, Masata J, Martan A, Dvorak J, Lincova M, Svabik K. Association between sonographic sling location and success of surgery for stress urinary incontinence. Ultrasound Obstet Gynecol. 2023 Jul;62(1):143-147. doi: 10.1002/uog.26142.
Kociszewski J, Rautenberg O, Kolben S, Eberhard J, Hilgers R, Viereck V. Tape functionality: position, change in shape, and outcome after TVT procedure--mid-term results. Int Urogynecol J. 2010 Jul;21(7):795-800. doi: 10.1007/s00192-010-1119-z. Epub 2010 Mar 4. Erratum in: Int Urogynecol J Pelvic Floor Dysfunct. 2010 Nov;21(11):1439-41.