In 1990, the prototype mid-urethral sling (MUS) was published as part of the Integral Theory of female urinary incontinence [1]. The MUS includes the retro pubic vaginal tape (TVT), trans obturator tape operation (TOT), and assorted mini-slings. Despite this shift, a proportion of women still require re-operation because of persistent or recurrent incontinence. 
In a meta-analysis, the long-term subjective and objective cure rates were 76.5% and 61.6% for TVT, and 81.6% and 57.2% for TOT (outside-in technique), respectively [2]. The most common problem for MUS is related to mesh. Surgical failure rates after mid-urethral sling (MUS) procedures are variable and range from approximately 8–57% at five years of follow-up. 
Surgical options include repeat slings (with or without removal of existing sling), urethral bulking agents, autologous fascia sling. Repeat MUS and fascial slings are generally the more favoured options. Artificial urinary sphincter implantation (AUS) are being considered, especially in women who have had multiple salvage operation failures, or ISD (intrinsic sphincter defect). There is no universally accepted operation for failed mid-urethral slings (MUS) [3].

This is a single-centre prospective case series with follow-up to 12 months. We included women with recurrent stress urinary incontinence after outside-in TOT. We excluded women with erosion but no recurrent incontinence. Written and oral informed consent had been obtained  from all of the patients included into the study. If mesh erosion was present, we removed as much mesh as possible and closed the vaginal defect during ULP surgery. Urethral ligament plication (ULP) was done all of the patients by AE. We assessed outcome with the cough stress test and a four-point severity grade as on a 4-point scale ranging from 1 (no incontinence) to 4 (worst). Any adverse events, complications, and additional clinical findings were also recorded. 
Urethral ligament plication (ULP) technique: We start with a 4 centimeter parallel full-thickness incision in the distal para urethral sulcus from the bladder neck to the external meatus. The technique consists of the plications of four attachments of pubourethral ligament with 2-0 polyester suture; 1. midurethral insertion 2. retropubic 3.external urethral ligament 4. pubococygeus muscle. After plication, tie the suture gently, not tightly. We cut on the knot to prevent granulations. Vaginal mucosa was sutured with 3-0 absorbable sutures. Ensure the suture is well buried.

Seventeen cases were presented with recurrent stress urinary incontinence following prior outside-in trans obturator tape operations underwent ULP operation.  Mean age of patients was 58.59±2.95  years. There were no cesarean sections; mean number of vaginal births was 2.88±1.53. Mean body mass index (BMI) was 32.42±5.48.  Mean time after TOT operation was 53.18±42.35 months. Preoperatively, all patients had a positive stress test and reported moderate to severe incontinence, with a median incontinence symptom grade of 4 (3–4). At last follow-up, 94.1 (16/17) of patients were continent (grade 1). One patient improved from grade 4 to grade 3 but remained symptomatic. The reduction in symptom grade was statistically significant (wilcoxon signed-rank test, p <0.001). The median follow-up was 3 months (1-10). No additional synthetic mesh was implanted in any case. No major intra operative or early postoperative complications were observed.

This is the first study in the literature about salvage surgery after failed TOT for stress urinary incontinence using the ULP operation, which applies the same etiopathology as the MUS, but without mesh tapes. Based on the absence of any operative contact with the urethra, in selected patients with mesh-related failure, a mesh-less reconstructive approach provides a surgically valid restorative pathway without further synthetic intervention.

Petros PE, Ulmsten UI. An integral theory of female urinary incontinence. Experimental and clinical considerations. Acta Obstet Gynecol Scand Suppl. 1990;153:7-31.
Leone Roberti Maggiore U, Finazzi Agro E, Soligo M, Li Marzi V, Digesu A, Serati M. Long-term outcomes of TOT and TVT procedures for the treatment of female stress urinary incontinence: a systematic review and meta-analysis. Int Urogynecol J. 2017;28(8):1119-30.
Kavanagh A, Sanaee M, Carlson KV, Bailly GG. Management of patients with stress urinary incontinence after failed midurethral sling. Can Urol Assoc J. 2017;11(6Suppl2):S143-S6.

Continence 19S (2026) 102520
DOI: 10.1016/j.cont.2026.102520