Total trans-obturator tape (TOT) removal; a case series including pain and urinary continence outcomes

Abstract

Introduction and hypothesis For many years, mid-urethral mesh tape (MUT) was the gold-standard procedure for management of stress urinary incontinence (SUI). However, significant concerns were raised over its safety. We present a case series of total trans-obturator tape (TOT) removals, performed in a tertiary unit over a 3-year period. We aim to evaluate improvement of pain and change in urinary continence symptoms following mesh explantation. Methods This is a retrospective case series of the outcomes of total TOT removal. Primary outcome is the change in pain scores following total removal, assessed preoperatively, at discharge and follow-up. Secondary outcomes were perioperative complications, including return to theatre, re-admission rates and incidence of worsening SUI and overactive bladder symptoms (OAB) postoperatively. Statistical analyses were performed using SPSS 27.0 package (IBM, Chicago, IL) and the GraphPad Prism 9 statistical packages. Results Nineteen women were identified. Mean age was 52 years and mean BMI was 31. Indications for mesh removal were: chronic pain (95%), vaginal exposure (37%) and pelvic sepsis (5%). No patients had return to theatre. Median intraoperative blood loss was 200 ml (interquartile range [IQR]: 150–288). Mean length of mesh excised was 22 cm. Mean postoperative hospital stay was 2 days. At follow-up, most patients (72%) reported “improvement” of their mesh-related pain at follow-up, while 6% reported “worsening” of pain. Eighty-three per cent of patients reported worsening SUI, and 50% reported worsening OAB symptoms. Conclusions In the absence of sepsis, significant intraoperative complications are rare during total TOT removals. While 72% of patients reported improvement of their mesh-related pain, 6% still reported worsening pain after total mesh excision.

Clinical outcomes after total excision of transobturator tape inserted for treatment of stress urinary incontinence

“…This was a surprising finding as the midurethral tape was an effective treatment option for stress incontinence. The rate of recurrent SUI is comparable to a similar smaller cohort 9 . A high rate of recurrent stress incontinence may also be partly explained by 20% of women who underwent tape revision before TETOT.…”

“…High rates of loss to follow‐up (60%−70%) have been common in studies reporting outcomes after mesh excision 8,12 . A review of the literature revealed commonality between other studies—frequently, studies reporting outcomes of stress incontinence after mesh excision typically carry heterogenous groups of MUT routes, report outcomes over a short period of time, and are limited to vaginal excisions 8,9,20–23 . These rates cannot be generalized to those undergoing TETOT, in the long‐term.…”

“…The rate of recurrent SUI is comparable to a similar smaller cohort. 9 A high rate of recurrent stress incontinence may also be partly explained by 20% of women who underwent tape revision before TETOT. It is also possible that those with mesh complications without recurrent stress incontinence may not opt for mesh excision over conservative management options due to the risk of recurrent stress incontinence.…”

“…8,12 A review of the literature revealed commonality between other studies-frequently, studies reporting outcomes of stress incontinence after mesh excision typically carry heterogenous groups of MUT routes, report outcomes over a short period of time, and are limited to vaginal excisions. 8,9,[20][21][22][23] These rates cannot be generalized to those undergoing TETOT, in the longterm. Rates of worsening and new stress incontinence provide clinicians with essential information to counsel women.…”

“…7 To date, the reported case series of mesh excision have been too heterogenous to provide individual women information about the outcome of mesh excision as a treatment for pain. [8][9][10][11][12] National Institute for Health and Care Excellence (NICE) found that there is insufficient evidence to guide the management of pain secondary to mesh. 13 Pain associated with a MUT may be managed in a number of ways.…”