Management of Sling Failures: Recurrent Stress Incontinence, Urethral Obstruction and Overactive Bladder Howard B Goldman MD Center for Female Pelvic Medicine and Reconstructive Surgery Glickman Urologic and Kidney Institute The Cleveland Clinic Lerner College of Medicine Case Western Reserve University
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Management of Sling Failures: Recurrent Stress Incontinence, Urethral Obstruction and Overactive Bladder Howard B Goldman MD Center for Female Pelvic Medicine.
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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