title: Incontinence rates after midurethral sling revision for vaginal exposure or pain.
abstract: BACKGROUND
  Midurethral slings have become the preferred surgical treatment for stress urinary incontinence. Midline transection of midurethral sling for dysfunctional voiding is an effective treatment and also has a low rate of recurrent stress incontinence. Recurrent stress incontinence after sling revision for pain and mesh exposure has not been well defined. It is therefore difficult to counsel patients on risk of recurrent stress incontinence when sling revision is performed for pain or mesh exposure.
  
  
  OBJECTIVE
  We examined the rate of postoperative stress incontinence after midurethral sling revision for the indication of mesh exposure or pain, as well as postoperative pain and urinary urgency.
  
  
  METHODS
  This is a retrospective cohort of 245 patients undergoing a vaginal midurethral sling revision in a 10-year period for the indication of mesh exposure or pain. Preoperative indication for revision, baseline characteristics, and preoperative reports of stress incontinence, pain, and urgency were collected. The type of sling revision was then categorized into partial or complete removal. A partial removal of the sling was defined as removing only the portion of sling exposed or causing pain. A complete removal of the sling was defined as vaginal removal of sling laterally out to the pubic rami. Subjective reports of stress incontinence, pain, and urgency at short-term (16 weeks) and long-term (>16 weeks) follow-up visits were gathered. The primary outcome of the study was recurrent stress incontinence.
  
  
  RESULTS
  In our cohort of 245 women who underwent midurethral sling revision, 94 patients had removal for mesh exposure (36 partial and 58 complete) and 151 had removal for pain (25 partial and 126 complete). All patients had a short-term follow-up with a mean time of 5.9 ± 2.8 weeks and 69% patients had long-term follow-up with a mean time of 29.1 ± 17.7 weeks. No differences were seen in preoperative reports of stress incontinence, urgency, or pain in either group. In the patients with revision for mesh exposure with no preoperative stress incontinence, there was greater postoperative stress incontinence with complete vs partial removal of sling at short-term (14% vs 42%, P = .03) and long-term (7% vs 59%, P = .003) follow-up. In the patients with revision for pain with no preoperative stress incontinence, there was no statistically significant difference in recurrent stress incontinence with complete sling removal at long-term follow-up (22% vs 56%, P = .07). In the patients with midurethral sling revision for pain, 72% of partial and 76% of complete sling removal had resolution of pain postoperatively (P = .66). No difference was seen in postoperative reports of urgency or pain improvement in either group between partial or complete sling removal.
  
  
  CONCLUSIONS
  In women undergoing midurethral sling revision for mesh exposure, complete sling removal resulted in higher recurrent stress incontinence compared to partial sling removal. For the indication of pain, both partial and complete sling removal improved pain in the majority of patients, but there was no statistically significant difference in recurrent stress incontinence.
authors.affiliation: Division of Female Pelvic Medicine and Reconstructive Surgery, Vanderbilt University Medical Center, Nashville, TN; Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN. Electronic address: ljambusaria@yahoo.com.
authors.forename: Lisa H
authors.initials: LH
authors.lastname: Jambusaria
authors.affiliation: Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN.
authors.forename: Jessica
authors.initials: J
authors.lastname: Heft
authors.affiliation: Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, TN.
authors.forename: W Stuart
authors.initials: WS
authors.lastname: Reynolds
authors.affiliation: Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, TN.
authors.forename: Roger
authors.initials: R
authors.lastname: Dmochowski
authors.affiliation: Division of Female Pelvic Medicine and Reconstructive Surgery, Vanderbilt University Medical Center, Nashville, TN; Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN.
authors.forename: Daniel H
authors.initials: DH
authors.lastname: Biller
mesh_terms: D000328:Adult; D000368:Aged; D015331:Cohort Studies; D020878:Device Removal; D004414:Dyspareunia / Q000209:etiology / Q000601:surgery*; D004868:Equipment Failure; D005260:Female; D006801:Humans; D008875:Middle Aged; D010149:Postoperative Pain / Q000453:epidemiology; D011183:Postoperative Complications / Q000453:epidemiology*; D012086:Reoperation; D012189:Retrospective Studies; D053825:Suburethral Slings / Q000009:adverse effects*; D013526:Surgical Mesh; D014550:Urinary Incontinence, Stress / Q000453:epidemiology*; D053202:Urinary Incontinence, Urge / Q000453:epidemiology*; D013520:Urologic Surgical Procedures
keywords: dyspareunia; mesh exposure; midurethral sling; recurrent incontinence; revision; stress urinary incontinence; vaginal pain