Managing Sling Failures

Educational Objectives

The goal of this program is to improve management of vaginal mesh repairs and their complications. After hearing and assimilating this program, the clinician will be better able to:

1. Diagnose and manage a patient in whom mesh repair has failed.

Summary

Failure after synthetic sling: midurethral synthetic sling (MUS) fails in 5% to 15% of patients; in Trial of Midurethral Slings (TOMUS) comparing transobturator with retropubic slings, 5% to 8% in both arms required retreatment

Treating failures: leaking — rule out persistent overactive bladder (OAB); de novo OAB — perform cystoscopy to assess bladder injury and rule out obstruction; SUI — options include no treatment, bulking agents, tightening existing sling, another sling, or another procedure

Bulking agents: one-third of patients dry, another third improved, and another third remain same; retreatment typically required; useful as temporizing measure immediately after surgery

Tightening sling: dissect out sling, fold, and use permanent sutures to shorten sling; can also place stitch on either side of mesh to avoid bulk in midline; dissect out, grasp sides 2 cm from midline with Allis, then place Prolene stitch on each side to shorten sling; ≈50% success rate

Replacing sling: type — in most cases, replace with synthetic MUS; if urethra fixed, use autologous fascial sling; approach — for severe SUI, retropubic sling superior to transobturator sling or minisling; in patients with maximum urethral closure pressure (MUCP) <42 cm H2O, 1 of 37 transvaginal tape procedures failed, but 7 of 44 transobturator (Monarc) procedures failed; patients with intrinsic sphincteric deficiency (ISD) benefit from retropubic approach; patients with failure of initial sling may have advanced ISD or too-loose sling placement; original sling — ignore first sling if retropubic, but cut it if de novo OAB or obstruction present; if old transobturator sling interferes with passage of new retropubic sling, wiggle trocar slightly to avoid old sling or cut sling in midline, partially dissect, and place new sling beneath it

Iatrogenic obstruction: patients with retention after sling probably obstructed; elevated postvoid residual (PVR), slowed force of stream, need to bend forward to empty bladder, recurrent urinary tract infection (UTI), and de novo OAB suggest obstruction; determine whether de novo OAB truly new; evaluate for obstruction, UTI, or sling in bladder or urethra; 0% to 5% of patients have some degree of obstruction after MUS, but problem not always significant; ascertain temporal relationship of symptoms to procedure and perform cystoscopy

Urodynamics: unnecessary unless patient referred from elsewhere or long time elapsed since procedure; patient with good contractility of bladder may not have increased PVR despite obstruction; urodynamics may show trabeculation; high-pressure voiding with low flow and dilation of proximal urethra with voiding suggest obstruction; urodynamics not always helpful for diagnosing obstruction; detrusor pressure and maximal flow do not predict outcome; patients with voiding difficulties often respond to transection of sling, even if urodynamic findings unremarkable; if symptoms temporally related to procedure, consider incision of sling or urethrolysis; patient with MUS should void normally in hours or days unless extensive repair done

Loosen sling: can loosen within first 1 to 2 wk, but after that may need full urethrolysis to transect sling; begin incision 1 cm proximal to meatus in midline and slowly carry back toward bladder neck while attempting to feel sling; can also use sheath of cystoscope; slowly withdraw sheath with downward pressure to detect location of sling; can sometimes can feel sling with finger during this procedure; need to see MUS and cut it

Outcomes: obstruction resolves in most patients but irritative, OAB complaints may remain; about one-third of patients have recurrent SUI; soft tissue infection rare, but UTI common; patients receiving single perioperative dose of cefazolin (Ancef) have same incidence of UTI as patients receiving additional days of oral antibiotics, but fewer antibiotic-related events such as yeast infection and colitis

Readings

Suggested Reading

Altman D et al: Anterior colporrhaphy versus transvaginal mesh for pelvic-organ prolapse. N Engl J Med. 2011;364(19):1826-36; Armitage S et al: Use of Surgisis for treatment of anterior and posterior vaginal prolapse. Obstet Gynecol Int. 2012;2012:376251; Brubaker L et al: Two-year outcomes after sacrocolpopexy with and without Burch to prevent stress urinary incontinence. Obstet Gynecol. 2008;112(1):49-55; Burgio KL et al: Bladder symptoms 1 year after abdominal sacrocolpopexy with and without Burch colposuspension in women without preoperative stress incontinence symptoms. Am J Obstet Gynecol. 2007;197(6):647.e1-6; Committee on Gynecologic Practice: Vaginal placement of synthetic mesh for pelvic organ prolapse. Female Pelvic Med Reconstr Surg. 2012;18(1):5-9; Davila GW et al: Selection of patients in whom vaginal graft use may be appropriate. Consensus of the 2nd IUGA Grafts Roundtable: optimizing safety and appropriateness of graft use in transvaginal pelvic reconstructive surgery. Int Urogynecol J. 2012;23 Suppl 1:S7-14; Elliott DS: Con: mesh in vaginal surgery: do the risks outweigh the benefits? Curr Opin Urol. 2012;22(4):276-81; Fitzgerald MP et al: Prolapse severity, symptoms and impact on quality of life among women planning sacrocolpopexy. Int J Gynaecol Obstet. 2007;98(1):24-8; Gomelsky A and Dmochowski RR: Vaginal mesh update. Curr Opin Urol. 2012;22(4):271-5; Iglesia CB et al: Vaginal mesh for prolapse: a randomized controlled trial. Obstet Gynecol. 2010;116(2 Part 1):293-30; Khandwala S and Jayachandran C: Transvaginal mesh surgery for pelvic organ prolapse — Prolift+M: a prospective clinical trial. Int Urogynecol J. 2011;22(11):1405-11; Khong SY and Lam A: Use of Surgisis mesh in the management of polypropylene mesh erosion into the vagina. Int Urogynecol J. 2011;22(1):41-6; Krlin RM et al: Pro: the contemporary use of transvaginal mesh in surgery for pelvic organ prolapse. Curr Opin Urol. 2012;22(4):282-6; Lau HY et al: Comparing effectiveness of combined transobturator tension-free vaginal mesh (Perigee) and transobturator tension-free vaginal tape (TVT-O) versus anterior colporrhaphy and TVT-O for associated cystocele and urodynamic stress incontinence. Eur J Obstet Gynecol Reprod Biol. 2011;156(2):228-32; Lukban JC et al: Incidence of extrusion following type I polypropylene mesh “kit” repairs in the correction of pelvic organ prolapse. Obstet Gynecol Int. 2012;2012:354897; Maher CM et al: Surgical management of pelvic organ prolapse in women: the updated summary version Cochrane review. Int Urogynecol J. 2011;22(11):1445-57; Moore RD et al: Prospective multicenter trial assessing type I, polypropylene mesh placed via transobturator route for the treatment of anterior vaginal prolapse with 2-year follow-up. Int Urogynecol J. 2010;21(5):545-52; Onol FF and Onol SY: Review of extraperitoneal sacrocolpopexy as a technique for advanced uterine and vault prolapse. Curr Opin Obstet Gynecol. 2012;24(4):253-8.

Disclosures

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the following has been disclosed: Dr. Goldman is a consultant/advisor for Allergan, American Medical Systems (AMS), Johnson & Johnson, Pfizer, and T-DOC Company; he is also on the Speakers’ Bureaus for Allergan, Astellas Pharma US, Johnson & Johnson, and Pfizer. The planning committee reported nothing to disclose.

Acknowledgements

Dr. Goldman spoke at Female Urology and Urogynecology Symposium, sponsored by OBG Management, TTMed Urology, and The Christ Hospital, and held March 22-24, 2012, in Las Vegas, NV. To learn about upcoming courses sponsored by OBG Management, TTMed Urology, and The Christ Hospital, go to thechristhospital.com/cme. Information about future events from sponsoring organizations can be found by visiting our website, audio-digest.org, and clicking the “upcoming meetings” tab at the bottom of the page. The Audio-Digest Foundation thanks the speaker, OBG Management, TTMed Urology, and The Christ Hospital for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

UR360103

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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