What type of sling did the patient have initially, and how does this impact a repeat procedure?
Regardless of the initial sling type used, repeat midurethral sling procedures have a significantly lower cure rate than primary midurethral sling procedures.13 Retropubic slings are more effective than transobturator slings for patients with recurrent SUI who have failed a prior sling. When a patient presents with recurrent SUI after a prior transobturator sling, the best option for a repeat procedure is usually a retropubic sling, as it achieves higher objective and subjective cure rates.13,14 (See FIGURE 2 for a comparison of retropubic and transobturator slings.)
Should I remove the old sling prior to placing a new one?
While it is recommended to remove the vaginal portion of the sling if the patient has a mesh exposure or is experiencing other symptoms, such as pain or bleeding, removal of the old sling is not necessarily indicated prior to (or during) a repeat incontinence procedure.15,16 Removing the sling, removing a portion of the sling, or leaving the sling in situ are all reasonable options.
CASE 3 Treated SUI has mesh exposure
Ms. R. is a 60-year-old woman with a history of SUI that was previously managed with a retropubic midurethral sling placed at an outside hospital. She is a smoker and has developed a vaginal mesh exposure. Although she would like the mesh removed, she does not want her incontinence to come back. She tells you that she does not think she would be able to quit smoking.
What would be a reasonable next option for Ms. R.?
While complications from a midurethral sling are rare, mesh exposures occur in approximately 2% of patients, and urinary retention requiring release of the sling occurs in about 1% of patients.3,6 It often helps to clarify for patients that the US Food and Drug Administration public health advisories on the use of transvaginal mesh have been directed specifically toward the use of transvaginal mesh for the treatment of pelvic organ prolapse (POP), not the use of mesh for midurethral slings for SUI or transabdominal mesh for POP.10,17
When considering use of a mesh sling, a thorough discussion of the potential risks, as well as the benefits and alternatives, is imperative. Patients must personally balance the probability of benefit with the potential risk of complications, and while physicians can help outline the benefits and risks through shared decision-making, ultimately it is the patient who should make this decision.
Certain patient populations may be at higher risk for mesh complications18 (See "Risk factors for mesh-related complications," below). These complications are managed in various ways (FIGURE 3). Patients who have experienced mesh complications previously are typically not good candidates for a repeat mesh sling, particularly when the risk factor for complications cannot be modified.
Risk factors for mesh-related complications
• Smoking
• Poorly controlled diabetes
• Decreased estrogen status
• Chronic steroid use
• Prior urethral surgery (urethral diverticulum, urethroplasty)
A mesh sling alternative
The most effective way to manage SUI in patients who are not good candidates for a mesh sling is to consider employing a sling that uses the patient’s own tissue.19-21 Common approaches include harvesting a graft of rectus fascia through a Pfannenstiel skin incision or using fascia lata from the patient’s iliotibial band in the lateral thigh. Autologous slings are safe and effective, and even after a mesh sling has failed, autologous slings have an almost 70% cure rate for SUI.20,21
Continue to: Timing of mesh removal and placement of an autologous fascial sling...