Continence outcomes following partial excision of vaginal mesh exposure after mid-urethral tape insertion

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

INTRODUCTION

Midurethral tapes (MUTs) were the most common surgical treatment for stress urinary incontinence (SUI) between 2008 and 2017. Transobturator tapes were introduced as a novel way to insert MUTs. Some women have experienced life-changing complications, and opt to undergo a total excision of transobturator tape (TETOT). There is a paucity in evidence about the outcomes of TETOT, which is a complex operation. This study aims to report clinical outcomes of all women who underwent TETOT in a specialist mesh center.

METHODS

All women between 2017 and 2022 who underwent TETOT in one mesh center were reviewed. Background demographics and preoperative symptoms were recorded retrospectively. Outcome data were collected using patient global impression of improvement (PGI-I) scales via telephone review and analyzed using SPSS 25.

RESULTS

Forty-five women underwent telephone review in May 2022, on average 27.9 months (range: 3-60) after TETOT. Mean age was 55 and body mass index (BMI): 30; 82% were postmenopausal, 20% were smokers, and 73.3% had recurrent SUI before excision. Indications for excision were infection (4%), vaginal exposure (24%), urethral perforation (9%), and chronic pain not associated with other complications (60%). Two women with recurrent SUI opted for a concomitant fascial sling; both reported a PGI of "very much improved" regarding SUI postoperatively. Only 12 women (26.5%) did not have SUI before excision; of these 9 (75%) reported new SUI postoperatively. Pain improved for 57.8%, but worsened for 24.4%. Although not statistically significant (p = 0.055), more women who underwent TETOT for pain alone reported worsening pain than those with pain with an additional complication (37% vs. 5.55%). Overall, 62.2% women felt "better" after their excision, 17.8% felt "worse."

DISCUSSION

After TETOT, 62% of women felt better. Improvement in pain was reported by 58%-those with chronic pain without another complication reported improvement in pain less frequently (48% vs. 72%) and worsening pain more frequently (37% vs. 6%). Existing SUI worsened in 65% of women and 75% developed new SUI. There appears to be discordance between reporting global improvement with worsening of commonly measured clinical outcomes.

CONCLUSION

Outcome data are important for counseling women about the risks and benefits of TETOT. Women and clinicians may have different attitudes to the possible benefits of TETOT, as evidenced by women reporting feeling better despite continuing pain or SUI. Conventional outcome measures do not adequately capture all outcomes that are important to patients.

Surgical Removal of Midurethral Sling in Women Undergoing Surgery for Presumed Mesh-Related Complications: A Systematic Review

OBJECTIVE

To assess whether some, or all, of the mesh needs to be removed when a midurethral sling is removed for complications.

DATA SOURCES

A systematic review and meta-analysis was conducted. MEDLINE, Cochrane, and ClinicalTrials.gov databases from January 1, 1996, through May 1, 2021, were searched for articles that met the eligibility criteria with total, partial, or a combination of anti-incontinence mesh removal.

METHODS OF STUDY SELECTION

All study designs were included (N≥10), and a priori criteria were used for acceptance standards. Studies were extracted for demographics, operative outcomes, and adverse events. Meta-analysis was performed when possible.

TABULATION, INTEGRATION, AND RESULTS

We double-screened 11,887 abstracts; 45 eligible and unique studies were identified. Thirty-five were single-group studies that evaluated partial mesh removal, five were single-group studies that evaluated total mesh removal, and five were studies that compared partial mesh removal with total mesh removal. All of the studies were retrospective in nature; there were no randomized controlled studies. Comparative studies demonstrated that partial mesh removal had lower rates of postoperative stress urinary incontinence (SUI) than total mesh removal (odds ratio 0.46, 95% CI 0.22-0.96). Single-group studies supported lower rates of postoperative SUI with partial mesh removal compared with total mesh removal (19.2% [95% CI 13.5-25.7] vs 48.7% [95% CI 31.2-66.4]). Both methods were similar with respect to associated pain, bladder outlet obstruction, mesh erosion or exposure, and lower urinary tract symptoms. Adverse events were infrequent.

CONCLUSION

Postoperative SUI may be lower with partial mesh removal compared with total mesh removal. Other outcomes were similar regardless of the amount of mesh removed.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD 42018093099.

Assessing the use of the IUGA/ICS classification system for prosthesis/graft complications in publications from 2011 to 2015

INTRODUCTION AND HYPOTHESIS

Complications of pelvic organ prolapse and urinary incontinence surgery have gained increasing attention from both lay media and medical societies. The International Urogynecological Association and International Continence Society proposed the category-time-site system to classify complications in 2011. Our objective is to assess the usage of the category-time-site system in the literature.

METHODS

We conducted a systematic review and identified records using PubMed search terms "mesh" and "prolapse or incontinence" and "complication or excision" (February 2011 to December 2015) to select publications following the introduction of category-time-site system. Relevant publications were included and reviewed for study design, initial procedure, number of patients assigned codes, number of unique codes applied, purpose of assigning codes, and duration of clinical follow-up.

RESULTS

Of 167 eligible records, 23 (14 %) used the system, 137 (82 %) used no system, and 7 (4 %) used another system. They included three study designs: randomized control trials, case reports, and case series. Given the very limited amount of data, no statistical tests were performed, but trends were noted.

CONCLUSIONS

Fourteen percent of the reports in the literature describing complications related to prosthesis/graft use in pelvic surgery utilize the category-time-site system. The system's limited and inconsistent use hinders the ability to draw conclusions useful for clinical practice. Effort should be directed toward improving appropriate usage or revising the system to increase its exposure in related publications. An improved system will better prepare pelvic surgeons for assessing future generations of prostheses/grafts.

Martius graft for TOT extrusion: a case series

INTRODUCTION

The management of mid-urethral tape extrusion is inconsistent. We believe that we present here the first case series detailing the use of the Martius graft for trans-obturator tape (TOT) extrusion.

METHODS

Five women had a Martius graft for TOT extrusion. Data were obtained retrospectively from case notes and a review postoperatively to investigate the results in the short and intermediate term.

RESULTS

All extrusions were greater than 1 cm in diameter and situated between the midline and the lateral vaginal sulcus. In 3 women the tape extrusion was discovered at 6-12 weeks postoperatively and 2 presented with symptoms again after 12 months. Following the Martius graft, there was no ipsilateral recurrence of tape extrusion or exposure. Postoperatively, 2 women received oral antibiotics. Two women developed de novo sexual problems, which had resolved at follow-up.

CONCLUSIONS

It is promising that all the tape extrusions were successfully treated with a Martius Graft, thus preserving tape function. There was a high incidence of minor complications initially, but there was minimal long-term morbidity and no cosmetic dissatisfaction. We believe that testing this proposition in a larger case series will provide better evidence.