From the Guidelines
A bladder sling revision is typically dictated by complications or unsatisfactory outcomes following the initial sling procedure, and the decision for revision should be made after thorough evaluation including physical examination, urodynamic testing, and possibly cystoscopy to assess the exact nature of the problem, as recommended by the most recent guidelines 1. The indications for revision may include persistent urinary incontinence, indicating the sling is too loose, or urinary retention/voiding difficulties suggesting the sling is too tight. Other indications include mesh erosion into the vagina or bladder, chronic pain (particularly during intercourse or daily activities), recurrent urinary tract infections, or de novo urgency symptoms that significantly impact quality of life. Some key points to consider in the evaluation and management of patients with complications after bladder sling procedures include:
- The use of transvaginal ultrasound (TVUS) for the evaluation of implanted mesh and slings, which has high sensitivity for demonstration of these materials and can be used to assess sling configuration and detect mesh extrusion 1.
- The importance of physical examination, urinalysis, urinary stress testing, voiding diary, and urodynamic testing with cystourethrography in the initial evaluation of patients with urinary dysfunction, as recommended by the American College of Radiology 1.
- The consideration of conservative measures, such as pelvic floor physical therapy, medications like alpha-blockers (tamsulosin 0.4mg daily) for retention, or anticholinergics/beta-3 agonists for urgency symptoms, before proceeding to revision surgery, as suggested by the available evidence 1. The specific revision technique depends on the complication, ranging from partial sling incision for obstruction to complete removal and possible replacement for erosion or severe pain. In terms of timing, revision is typically considered after 3-6 months of failed conservative management, depending on symptom severity. It is essential to prioritize the patient's quality of life and morbidity when making decisions about bladder sling revision, and to consider the potential benefits and risks of revision surgery in each individual case, as emphasized by the most recent guidelines 1.
From the Research
Indications for Bladder Sling Revision
The following are indications for bladder sling revision:
- Obstructive voiding symptoms 2
- Vaginal extrusion of mesh 2, 3, 4, 5
- Urinary retention 2, 5
- Voiding dysfunction 5
- Recurrent urinary tract infection 5
- Mesh erosion 3, 4, 5
- Vaginal pain/dyspareunia 5
- Groin pain 5
Risk Factors for Midurethral Sling Revision
The following are risk factors for midurethral sling revision:
- Previous SUI surgery 5
- Concomitant vaginal apical suspension at the time of sling placement 5
- Younger age (18-29 years) 4
Surgical Approaches for Sling Revision
The following surgical approaches may be necessary for sling revision: