Management of patients with stress urinary incontinence after failed midurethral sling

Abstract

Surgical failure rates after midurethral sling (MUS) procedures are variable and range from approximately 8-57% at five years of followup. The disparity in long-term failure rates is explained by a lack of long-term followup and lack of a clear definition of what constitutes failure. A recent Cochrane review illustrates that no high-quality data exists to recommend or refute any of the different management strategies for recurrent or persistent stress urinary incontinence (SUI) after failed MUS surgery. Clinical evaluation requires a complete history, physical examination, and establishment of patient goals. Conservative treatment measures include pelvic floor physiotherapy, incontinence pessary dish, commercially available devices (Uresta ® , Impressa ® ), or medical therapy. Minimally invasive therapies include periurethral bulking agents (bladder neck injections) and sling plication. Surgical options include repeat MUS with or without mesh removal, salvage autologous fascial sling or Burch colposuspension, or salvage artificial urinary sphincter insertion. In this paper, we present the available evidence to support each of these approaches and include the management strategy used by our review panel for patients that present with SUI after failed midurethral sling. IntroductionWith shorter recovery times and comparable efficacy, the midurethral sling (MUS) has surpassed the Burch colposuspension as the "gold standard" treatment for stress urinary incontinence (SUI); however, some patients will not be cured after MUS surgery and currently, there is no consensus on how to manage these patients. This constitutes a major problem not only for the patient, but also for the clinician who is faced with choosing a second surgical procedure with the best possible outcome. Options can include placement of a second synthetic MUS or an autologous sling, such as a pubovaginal sling (PVS). Furthermore, there is no consensus about whether the previously inserted MUS should be excised or if a second tape should simply be placed over the existing tape. The decision on whether to use a sling inserted via an alternative route (retropubic vs. transobturator) also has not been addressed. ranging from 62-98% in the TOR group and from 71-97% in the RPR group. Fewer trials reported medium-term (one to five years) and longer-term (over five years) data, but subjective cure was similar between the groups (RR 0.97; 95% CI 0.87-1.09; five trials, 683 women; and RR 0.95; 95% CI 0.80-1.12; four trials, 714 women). In the long-term, subjective cure rates were similar and ranged from 43-92% in the TOR group and from 51-88% in the RPR group. 2The disparity in long-term failure rates is explained by a lack of long-term followup and lack of a clear definition of what constitutes failure. In the above Cochrane review, only four of 55 included studies actually provided information regarding leakage and adverse events at five years. Additionally, "failure" may be defined differently. Failure can include: persistence of bothersome SUI; cure...

Foundation for an evidence‐informed algorithm for treating pelvic floor mesh complications: a review

“…Although this qualifies as complicated SUI, usually considered an indication for urodynamics, urodynamic parameters do not appear to predict recurrent MUS outcome (grade D: limited evidence; moderate–high bias risk) . However, this low cure rate may be improved by defining the anatomical basis of failure using dynamic ultrasound to guide therapy (grade C: conflicting data, moderate–high bias risk) …”

“…There is insufficient evidence to support surgical over nonsurgical management of recurrent SUI (grade I: limited evidence; low bias risk) . While periurethral injections are often recommended for failed slings, there is inadequate evidence to support them for this indication (grade I: weak evidence; moderate bias risk) . Repeat MUS may have better results than sling plication (grade B: limited evidence; low–moderate bias risk) .…”

“…While periurethral injections are often recommended for failed slings, there is inadequate evidence to support them for this indication (grade I: weak evidence; moderate bias risk) . Repeat MUS may have better results than sling plication (grade B: limited evidence; low–moderate bias risk) . There is also insufficient evidence to support pubovaginal fascial sling or colposuspension over MUS (grade I: limited evidence; moderate–high bias risk) .…”

“…Repeat MUS may have better results than sling plication (grade B: limited evidence; low–moderate bias risk) . There is also insufficient evidence to support pubovaginal fascial sling or colposuspension over MUS (grade I: limited evidence; moderate–high bias risk) . For repeat MUS, retropubic MUS may have better results than transobturator MUS (grade B: limited evidence; low bias risk) …”

Female stress urinary incontinence MDT

“…76,77 They are more appropriate for women with severe leakage or ISD as they can be tensioned to increase urethral resistance (as opposed to s-MUS, which must be inserted tension free) and for those who have failed more than one tape. 61 AUS insertion in women is indicated for patients with severe SUI due to ISD. It is typically considered after other surgical procedures for SUI have failed and worldwide clinical experience of this surgery is limited to several specialist centres.…”