ORLANDO (FRONTLINE MEDICAL NEWS) – Pain as an indication for midurethral sling revision is associated with an elevated risk of postoperative stress urinary incontinence recurrence, according to a review of 129 cases.

At a mean follow-up of 21 months, the overall rate of recurrent stress urinary incontinence (SUI) among study subjects was 39.5%, which is similar to what has been previously reported in the literature. However, women who underwent revision for the indication of pain, including dyspareunia, pelvic pain, or muscle spasms, had an SUI recurrence rate of 70%, Meagan S. Cramer, MD , reported at the annual scientific meeting of the Society of Gynecologic Surgeons.

The SUI recurrence rates among those undergoing revision for erosion, voiding dysfunction, or incontinence – including stress, urge, or mixed urinary incontinence – were 51.2%, 34.3%, and 20.8%, respectively, said Dr. Cramer, a 3rd-year resident at Christiana Care Health System in Newark, Del.

Women older than 55 years at the time of revision were significantly less likely to recur (adjusted odds ratio, 0.34 vs. younger women), and those whose original slings were placed less than 1 year prior to revision had a significantly lower rate of SUI recurrence, compared with those whose slings were placed more than 1 year prior (23.1% vs. 46.7%), she noted.

“There was no difference in BMI [body mass index], race, or baseline comorbidities between the recurrence vs. no recurrence group. There was also no difference in estrogen use preoperatively, concurrent replacement with another sling, preoperative [pelvic organ prolapse quantification] exam, length of sling excised, or the original type of sling placed between the recurrence versus non recurrence groups,” she said. “On multivariable regression analysis controlling for age, BMI, race, tobacco use, time since original sling, erosion on exam, technique used for revision, and presenting indication, pain as an indication of revision was still associated with an increased risk for recurrent incontinence, with an adjusted odds ratio of 9.08.”

Study subjects were women aged 18 years and older who underwent mesh sling revision from January 2009 to July 2016 at a single center. Women were excluded if they underwent revision or excision of vaginal mesh, or if they underwent sling adjustment for persistent incontinence if the incontinence had never resolved after the original sling placement. Those without postoperative follow-up were also excluded.

“Approximately 2%-4% of women who undergo midurethral sling surgery for stress incontinence will later require revision or excision of the sling due to erosion, pain, and/or voiding dysfunction. Based on current literature, up to 56% of these women can experience postoperative recurrence of stress incontinence following their revision,” Dr. Cramer said, noting that there is no consensus on which women will require future surgeries for stress incontinence after revision.

In the current study, women with pain were significantly more likely to undergo a complete excision of their sling (45.0% vs. 17.9% with other indications).

“We also discovered that of all women who underwent complete excision of a prior sling, those with pain had a higher rate of recurrent SUI, compared with those without pain [66.7% vs. 31.6%], but the difference was not statistically significant,” Dr. Cramer said in an interview.

She noted, however, that partial sling excision has been shown in at least one prior study “to provide just as much benefit as complete sling excision for patients with pain without leading to an increased risk of SUI.”

Though limited by the retrospective study design, the current findings suggest that pain as an indication for sling revision is associated with a higher risk of postoperative recurrent SUI, regardless of the type of revision, she said.

“Future prospective studies investigating the relationship between the indication for revision and postoperative stress incontinence would help to further define the roles of pain in this process,” she said, adding that in the meantime, given the prior findings regarding the benefits of partial sling excision, it may be reasonable to advise patients with pain that undergoing a partial sling excision could reduce the risk of recurrent SUI.

Dr. Cramer reported having no disclosures.

SOURCE: Cramer MS et al. SGS 2018, Oral Presentation 04 .