What to do after a mid-urethral sling fails.

Area of Science:

• Urology
• Gynecology
• Pelvic Floor Disorders

Background:

• Mid-urethral slings (MUS) are an effective treatment for stress urinary incontinence (SUI).
• Use of transvaginal mesh, including MUS, declined after a 2011 FDA notification.
• Management of recurrent SUI after initial sling placement remains a clinical challenge.

Purpose of the Study:

• To review current evidence on the efficacy and safety of MUS for SUI.
• To discuss treatment options for recurrent SUI following primary MUS placement.
• To evaluate strategies for managing patients with failed MUS procedures.

Main Methods:

• Review of long-term follow-up data for primary MUS procedures.
• Analysis of evidence for repeat MUS, pubovaginal slings (PVS), and urethral bulking agents.
• Evaluation of patient subgroups, including those with detrusor overactivity or intrinsic sphincter deficiency (ISD).

Main Results:

• Long-term data confirm the efficacy and safety of primary MUS.
• No Level 1 evidence exists for the optimal next step after MUS failure.
• Repeat MUS shows comparable cure rates between transobturator and retropubic approaches.
• Pubovaginal slings and urethral bulking agents are viable alternatives.
• Polyacrylamide hydrogel demonstrates good short-term success for recurrent SUI after failed sling.

Conclusions:

• Mid-urethral slings are effective for SUI, but recurrent cases require careful evaluation.
• Identifying detrusor overactivity, sling malposition, or ISD is crucial for recurrent SUI management.
• Pubovaginal slings may benefit patients with ISD; repeat MUS is suitable for others with recurrent SUI.