NEUROUROLOGY & FEMALE UROLOGY

Outcomes following repeat mid urethral synthetic sling after failure of the initial sling procedure: rediscovery of the tension-free vaginal tape procedure
Lee KS, Doo CK, Han DH, Jung BJ, Han JY, Choo MS
Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
J Urol. 2007; 178: 1370-4; discussion 1374

• Purpose: We evaluated outcomes of the repeat mid urethral sling to treat recurrent or persistent stress urinary incontinence after failure of an initial mid urethral sling.
• Materials and Methods: We retrospectively analyzed data on patients who underwent the repeat mid urethral sling procedure due to persistent or recurrent stress urinary incontinence. Repeat slings were placed without removal of the previous sling. All patients were followed at least 1 year after the second mid urethral sling.
• Results: Of the 31 female patients with a repeat mid urethral sling 29 were followed, including 13 with a retropubic and 16 with a transobturator sling. For the first mid urethral sling 17 patients received a retropubic sling (tension-free vaginal tape) and 12 received a transobturator sling (6 inside out and 6 outside in procedures). Cure and improvement rates irrespective of the approach were 75.9% (22 of 29 patients) and 6.9% (2 of 29), respectively. Cure rates for the retropubic and transobturator slings were 92.3% (12 of 13 patients) and 62.5% (10 of 16), respectively, a difference that did not quite attain statistical significance (p = 0.089).
• Conclusions: The repeat mid urethral sling for persistent or recurrent stress urinary incontinence has a lower cure rate than the initial sling. However, the retropubic approach tends to have a higher cure rate than the transobturator approach in repeat sling cases.
  
  
• Editorial Comment
  The authors review their very large experience with suburethral slings and report on patients who underwent a repeat suburethral sling. The study group included retropubic suburethral slings as well as the transobturator approaches. The surgeons noted that their repeat suburethral sling procedure that was a re-do operation had a lower success rate than the initial operation success rate. This has been noted as well for patients undergoing re-do pubovaginal slings using autologous fascia for operative failures (1). The trend towards a lesser cure rate with a repeat transobturator procedure versus a retropubic approach could potentially be explained by both the urethral angle theory as discussed by the authors as well as the level of suburethral support that can be provided by the different techniques. The diminished efficacy of transobturator slings in patients with lower Valsalva leak point pressures is currently being explored in the literature (2).

References
1. Petrou SP, Frank I: Complications and initial continence rates after repeat pubovaginal sling procedure for recurrent stress urinary incontinence. J Urol. 2001; 165: 1979-81.
2. Guerette NL, Bena JF, Davila GW: Transobturator slings for stress incontinence: using urodynamic parameters to predict outcomes. Int Urogynecol J Pelvic Floor Dysfunct. 2007, Jun 5; [Epub ahead of print].

Dr. Steven P. Petrou
Associate Professor of Urology
Chief of Surgery, St. Luke’s Hospital
Associate Dean, Mayo School of Medical Education
Jacksonville, Florida, USA