Unsuccessful mid-urethral sling division is associated with development and persistence of pelvic pain: A case series

Introduction:

Voiding dysfunction following mid-urethral synthetic sling surgery is a well-recognized complication with an established treatment algorithm.

Our case series describes patients with clinically significant voiding dysfunction where a decision to proceed to early sling release (<12 months) was made and operatively attempted but subsequent presentation shows the sling was not successfully divided.

Methods:

Retrospective case series of 16 women from a database of 330 women who underwent treatment for mid-urethral synthetic sling (MUSS) complications between 2014 and 2023 in Aotearoa New Zealand and Australia.

Results:

We found 16 patients with unrecognized unsuccessful sling division, from database of 330 mesh complications Initially, after sling implantation, these patients presented with characteristic obstructive symptoms including 8/16 having post-operative retention with failed TROC and prolonged catheterization or CIC.

The median time to first sling division for symptoms of bladder outlet obstruction was 9 months. Median time from implantation to the second (or definitive division) was 82 months.

Urodynamic findings after first unsuccessful division were median Qmax of 12 mls/s and median Pdet@max of 32cmh20.

Comparison of pre- and post-operative findings after delayed successful sling division showed significant improvement in recurrent UTIs (from 10/14 to 1/14). However, there was little improvement in pelvic pain/dyspareunia (from 9 to 7/14) and overactive bladder symptoms (9 to 6/14). One patient had a critical outcome, requiring cystectomy for pelvic pain and bladder pain following successful division.

Discussion:

This case series is the first to describe unrecognized, unsuccessful sling division for post-operative voiding dysfunction documented by subsequent objective radiologic and/or operative findings.

The clinical course shows significant urinary and pelvic pain morbidity after the failed division although it is difficult to ascribe causation with a retrospective lens.

These findings suggest that a high index of suspicion and low threshold for investigation should be maintained where clinical symptoms persist after a sling division.