Management of Sling Failures: Recurrent Stress Incontinence, Urethral Obstruction and

Overactive Bladder

Howard B Goldman MD

Center for Female Pelvic Medicine and Reconstructive SurgeryGlickman Urologic and Kidney Institute

The Cleveland ClinicLerner College of Medicine

Case Western Reserve University

Sling Outcomes

• Depending on study 5-15% of patients who have had a midurethral sythetic sling procedure are considered “failures”

Rechberger et al, EU, 2009Richter et al, NEJM, 2010

Sling Outcomes

Richter et al, NEJM, 2010

Failure

• Greater than 90% of patients generally happy with outcome – “success”– Exact numbers depend on definition

• What to do with the 5-10% that still leak?• Rule out persistent OAB – treat• SUI???

Persistent Bothersome SUI

• Observation– Does not get better with time

• Bulking Agent– Works temporarily but usually recurs

• “Tighten” sling– Some positive data

• Repeat sling– Retropubic approach better outcomes than

obturator

Bulking Agents

• Outcomes similar to first-line bulking– Works in some patients– Typically not long-lasting– Requires repeat injections

• Sometimes used as temporizing measure

Sling Tightening

• Based on idea that sling was placed too loosely for this particular patient

• Sling dissected out• Folded and permanent suture placed in to

“shorten” length of sling under urethra

De Landsheere, et al, IUGJ, 2010

Redo Sling

• Timing?• What type of sling?• What approach?• What about original sling?

What type of sling?

• Midurethral synthetic sling in most cases• Fascial sling

– If “fixed” perhaps needed fascial sling from the get go

• My sense is more are comfortable with MUS

What approach?

• Retropubic• Transobturator• Mini-sling

Severity of SUI

• 208 patients without ISD randomized according to SUI grade –

• I – loss of urine during significant strain• II – loss of urine during minor strain (worse)

Outcomes SUI I SUI II

retropubic 100% 100

transobturator 100 66%

Araco, et al, Int Urogyn J, 2008

MUCP• 200 patients • Monarc vs TVT• Retrospectively found MUCP below 42 to

predict for failure in obturator slings

Objective Failure Rate

MUCP > 42 MUCP <42

TVT 1/23 1/37

Monarc 1/41 7/44

Miller et al, AJOG. 2006

ISD

Fong, et al, BJUI, 2010

Prior Sling Failures

• 29 patients with prior failed MUS

Cure Failure

Retropubic 12 1

Transobturator 10 6

Lee, et al, J Urol, 2007

Prior Sling Failures

• 77 with prior failed MUS

Second procedure

N Mean VLPP Subjective cure

retropubic 48 57 71%

transobturator 29 84 48%

Stav et al, J Urol, 2010

Risk of Repeat Sling Failure

• 3 yr fu – prospective randomized trial– 6 mo data previously published – Ob Gyn 2008

• TVT vs Monarc n=164• Included those with ISD• Mean 37 months

– 1.2% TVT required another sling– 18.3% Monarc required another sling

Schierlitz, et al, ICS, 2010

What about original sling?

• Don’t look for it – leave alone– Assuming no obstructive or de novo OAB sxs

• If see it (assuming new one is RP)– Original RP – continue next to it– Original TO – may need to cut and strip some off

in either direction• Work under it

• If trochar hits it – move tip slightly

Iatrogenic Obstruction

Symptoms of Iatrogenic Obstruction

• Retention• Incomplete emptying• Diminished force of stream• Bending forward to void• Recurrent UTI• “de novo” OAB

– may be result of obstruction

“de-novo” OAB

• Make sure was not pre-existing and simply did not improve

• If “de-novo” evaluate for:– Infection– Iatrogenic urethral obstruction– Sling in bladder/urethra

Incidence of Iatrogenic Obstruction

• True incidence after SUI surgery difficult to pin down– Literature estimates 2.5 - 24%

– Contemporary mid urethral sling series 0-5%• De Novo Urgency

6 – 25% following TVT0 – 16% following TOT

Basic Evaluation

• History– TEMPORAL RELATIONSHIP - most important– Symptoms

• Retention (obvious)• Diminished force of stream• Positional change to void• Irritative symptoms (urgency, UUI, frequency)• Recurrent UTI (perhaps due to high PVR)• Vague: painful void, pelvic pain, dysuria

• Physical exam– Hyper-suspension or over correction?– Hypermobility, prolapse

• PVR• UA

Goldman, Urologic Clinics N Am, 38, 31-37, 2011

Tests and Secondary Evaluations

• Endoscopy– Eroded sutures– Eroded sling– Urethral kink or displacement

• Urodynamics (not crucial)– Multi-channel pressure flow with EMG– Video-urodynamics

History• Chief Complaint: recurrent UTIs• History: 70yo with recurrent UTIs for last 6 yrs♀

– 4 in past 12 months– Febrile UTIs– Multiple hospital admissions, intravenous abxs

• Surgical history:– 7 years ago:

• Uterosacral vault suspension• Anterior, posterior repair• Retropubic midurethral synthetic sling

Urinary Symptoms• Urinary Symptoms:

– Storage:• No incontinence

– Voiding:• Straining• Positional voiding

– Postmicturition:• Incomplete emptying

Physical Exam• Abdomen:

– Soft, no masses• Pelvic Exam:

– Urethral mobility 0 - 40º– Tenderness at vaginal apex– No prolapse– PVR 65 cc

CystoscopyCystoscopy

High pressure

Low flow

Urodynamics

• Not always helpful in making diagnosis of obstruction after incontinence surgery– Webster & Kreder, 1990

• “Urodynamics may fail to diagnose obstruction”– Foster & McGuire, 1993

• Urodynamics did not predict outcome– Nitti & Raz, 1994

• Pdet and Qmax were not predictive of outcome independently or together. All “acontractile” patients successful

Intervention

• Only absolute selection criteria for urethrolysis should be a temporal relationship between surgery and onset of voiding symptoms

• Failure to generate a detrusor contraction during urodynamics should not exclude a patient from definitive treatment, e.g. urethrolysis

Treatment of Obstruction

• Time– With fascial slings may take weeks to void normally– With MUS should be voiding normally in hours-days

• Loosening– Can “loosen” MUS during first few days

• Full urethrolysis• Sling Incision

Sling Incision

• Inverted U or midline incision

• Isolation of sling in the midline

• Incision of the sling

Sling incision

Sling Incision• Freeing of the sling from

the underlying urethra– May require sharp or

blunt dissection• No perforation of the

endopelvic fascia• No freeing of the

urethra from the pubic bone

• Closure of the vaginal wall

Obstruction From MUS

• In cases of early intervention (up to 7-10 days) may be able to loosen by pulling down

• After 10-14 days need to incise as MUS is ingrown with native tissue

• Critical to identify and cut or loosen sling• If MUS not identified treatment WILL FAIL• Chronically can become a tight band

Sling incision (various slings)N Type of Incision Success Recurrent SUI

Kusada 5 Midline 100% 0%

Nitti 19 Midline 84% 17%

Amundsen 32 Various 94% (for retention)67% (for UUI)

9%

Goldman 14 Midline 93% 21%

Kusada, Urology, 57, 358-59, 2001 Nitti VW , et al. Urology 2002;59:47–52.Amundsen CL, et al . J Urol 2000;164:434–7.Goldman HB. 2003;62:714–8

Infection

Infections

• Sling related soft tissue infections with large pore polypropylene meshes are extremely uncommon

• Urinary tract infections can occur within the first month or later after sling surgery

Current Guidelines

• AUA recommends a single preop dose of intravenous cephalosporin…..and

• ≤ 24 hours of postoperative antibiotics

• Per SCIP a single oral dose of an abx is acceptable

• Few studies address perioperative antibiotics and incontinence procedures

Patterns of Postoperative Antibiotic Use Among US Urologists

0

50

100

150

200

250

300

350

400

No 24 hours abx 3-5 days abx > 5 days abx Other

11.7%

27.5%

3.6%

54.5%

2.8%

Swartz and Goldman, Urology, 2010

Sling Study - Antibiotics One dose versus multiple doses

• Group 1 – one perioperative dose of antibiotics

• Group 2 – one perioperative dose of antibiotics + a few days of oral antibiotics post operatively

Swartz and Goldman, Urology, 2010

Infection and Adverse Events Related to Antibiotic Use After Sling Surgery

Outcomes Peri(n=116)

Peri and post(n=104)

p value

Postoperative UTI 11 (9.5%) 10 (9.6%) NS

Postoperative vaginal yeast infection

1 (0.9%) 6 (5.8%) NS

Antibiotic Adverse Event 1 (0.9) 8 (7.7%) 0.03

Swartz and Goldman, Urology, 2010

Sling Failures

• Continued bothersome SUI– Redo sling

• Retropubic highest success rate

• “de-novo” OAB – rule out:– Obstruction– Sling in bladder/urethra

• Iatrogenic Obstruction– Sling incision

• For MUS – 20-50% recurrent SUI