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Contents: Systematic Review

Surgical Removal of Midurethral Sling in Women Undergoing Surgery for Presumed Mesh-Related Complications

A Systematic Review

Doyle, Paula Jaye MD; Grimes, Cara L. MD, MAS; Balk, Ethan M. MD, MPH; Wieslander, Cecilia MD; Richardson, Monica MD; Mamik, Mamta M. MD; Sleemi, Ambereen MD; Alas, Alexandriah MD; Kudish, Bela MD; Walter, Andrew J. MD; Aschkenazi, Sarit MD; Mama, Saifuddin MD; Foda, Mohamed MD; Meriwether, Kate V. MD

Author Information
doi: 10.1097/AOG.0000000000004646

Since the U.S. Food and Drug Administration’s approval of the use of mesh midurethral slings for the surgical treatment of female stress urinary incontinence (SUI) in 1996, these devices have gained worldwide popularity owing to the simplicity of use, equal or superior continence outcomes to more invasive anti-incontinence procedures,1 and decreased recovery time. Synthetic midurethral sling procedures are the most commonly performed surgery for SUI, with more than 200,000 slings placed every year in the United States. Reported success for relief of incontinence ranges between 70% and 91%. Synthetic midurethral slings are considered to be the procedure of choice for treatment of SUI.2

Midurethral slings for SUI have an overall complication rate of less than 5%,3 with readmission and reoperation rates of 0.6–0.8%.4 Complications can present in the short- or long-term and include mesh exposure, urinary retention, persistent postoperative pain, and persistent or worsening SUI. The management of mesh complications depends on patient symptomatology and ranges from expectant management to surgical interventions. Surgical management differs based on the indication, approach (abdominal vs vaginal), timing, and amount of mesh removed (partial mesh removal vs total mesh removal).

The Society of Gynecologic Surgeons (SGS) Systematic Review Group performed a systematic review and formulated evidence-based clinical practice guidelines that address the risks and benefits of partial mesh removal compared with total mesh removal to address complications of previously placed anti-incontinence midurethral slings. These guidelines considered the quality and scope of evidence in the current literature, focusing on preservation of stress-related continence and minimizing adverse events.

SOURCES

The SGS Systematic Review Group includes practicing gynecologists and surgeons who specialize in female pelvic medicine and reconstructive surgery, in addition to a methodology expert in systematic review. MEDLINE, Cochrane, and clinicaltrials.gov databases were searched through May 1, 2021, using terms for anti-incontinence mesh surgery and revisions. The heterogeneity of mesh removal terms in addition to American Urogynecologic Society's (AUGS) recommended language5 to describe midurethral mesh removal were searched.

STUDY SELECTION

Based on an a priori criteria, we included studies of women with previous mesh sling for SUI who were undergoing surgical mesh removal for any reason. We excluded studies that had concomitant vaginal mesh removal for pelvic organ prolapse. We did not exclude studies that preformed a colporrhaphy or apical suspension in fewer than 25% of the patients at the time of mesh removal. Our intervention of interest was total mesh sling removal, which was defined as the removal of the entire vaginal portion of the sling, with or without the removal of the retropubic or obturator arms, through vaginal, abdominal, or both surgical approaches. Comparators included partial midurethral mesh excision, transection of the sling, or early mobilization through vaginal or abdominal approach. No studies included urethral dilations. We included studies of surgeries conducted for any presumed mesh-related complications. Specific outcomes were identified during data extraction and were not predefined or limited. To be included as relevant, outcomes had to relate to mesh-related symptoms, lower urinary tract symptoms, or surgical adverse events.

We included randomized controlled trials (RCTs) and nonrandomized studies that compared surgeries and single-group studies. Studies had to report both preoperative and postoperative outcomes (except operative outcomes and adverse events) for each surgical technique and with a minimum of 10 patients in each group. Studies could be published in any language and any format.

Abstracts were screened independently in duplicate by 12 researchers. Discrepancies were resolved by the lead author. Abstract screening was conducted in Abstrackr software (http://abstrackr.cebm.brown.edu), which incorporates machine learning to facilitate the abstract review process. The full texts of all accepted abstracts were screened in duplicate for eligibility, with discrepancies resolved by a third team member. From each study, a single researcher extracted data on study and participant characteristics, surgery and outcome descriptions, results, and risk of bias. At least one other researcher reviewed extracted data for accuracy.

Each study was assessed based on the Cochrane Risk of Bias tool (designed for RCTs)6; selected questions from the ROBINS-I tool (designed for nonrandomized comparative studies) addressing patient selection bias, confounding bias, and use of intention-to-treat principals7; and questions about reporting adequacy. Each study was then classified as being of overall methodologic quality good (A), fair (B), or poor (C). As appropriate, specific outcomes within studies were further downgraded.

Outcomes were categorized as: 1) lower urinary tract symptoms that include urinary urgency, frequency, urgency urinary incontinence, and subjective irritative voiding symptoms; 2) mesh erosion or exposure, such as symptomatic and asymptomatic mesh in the vagina, bladder, or urethra; 3) pain, defined as dyspareunia, penile pain during vaginal intercourse, groin pain, suprapubic pain, or pelvic pain; 4) bladder outlet obstruction, defined as an elevated postvoid residual measurement, urodynamics, or intermittent self-catheterization; 5) SUI, including objective and subjective reporting of urine leakage with activity, urodynamics, and questionnaires; and 6) adverse events.

For each outcome, a summary table was assembled to summarize and evaluate the strength of the evidence comparing total mesh removal and partial mesh removal. Concordant with GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology,8 we evaluated study quality (risk of bias), consistency across studies, directness of the evidence, sufficiency of evidence, and related features. Each outcome was graded to be of high, moderate, low, or very low strength of evidence.

Guideline statements were developed and given a level of strength based on the strength of the supporting evidence. Strong recommendations were made if the benefits (primarily clinical outcomes) outweighed the harms (adverse events, costs), with at least a moderate strength of evidence level. Weak recommendations were made based on strength of evidence and an uncertainty that benefits outweigh harms.

This review and associated clinical recommendations were presented at the SGS annual scientific meeting on July 9, 2020. On completion of the manuscript, comments were petitioned for 2 weeks, and the manuscript was approved by the membership.

RESULTS

Our database searches yielded 11,887 citations, of which 205 articles were retrieved in full text. Forty-eight eligible studies were found; however, four originated from the same database, hence the largest and most current article was used. Of the 45 eligible studies, 35 were single-group studies that evaluated partial mesh removal; five single-group studies that evaluated total mesh removal, and five studies that compared total mesh removal compared with partial mesh removal (Fig. 1). We found no eligible RCTs. None of the five nonrandomized comparative studies attempted to control for preoperative difference between groups or potential confounders. All studies were of retrospective design, with two retrospectively reviewing prospectively collected data. Time from initial surgery to mesh removal surgery was a median of 9 (range 2–153) months across all studies.

F1
Fig. 1.:
Results of study selection and characteristics. RCT, randomized controlled trial.Doyle. Removing Midurethral Sling for Mesh-Related Complications. Obstet Gynecol 2022.

Among the five9–13 nonrandomized comparative studies that evaluated partial and total mesh removal, three11–13 evaluated SUI rates before and after surgery, two9,12 evaluated the effect of surgery on pain, and two10,11 evaluated multiple symptoms before and after surgery, including vaginal and urethral mesh erosion, urinary tract infections, pain, and lower urinary tract symptoms. Two studies compared different types or timing of partial sling removal: One article14 evaluated the difference between sling mobilization and transection, and another15 looked at early mesh transection (less than 1 year since the index surgery) compared with late transection (more than 1 year since the index surgery).

Of the 35 single-group studies that report partial mesh removal surgeries,14–41 nine assessed the outcomes of sling transection15–17,19,20,24,28,31,32 and four studied mesh mobilization.27,29,39,42 The five total mesh removal studies3,43–46 looked at a combination of retropubic and transobturator slings, with the exception of Coskun,42 who report only on mini-slings.

Across studies, the reasons for mesh removal included lower urinary tract symptoms, mesh erosion or extrusion, pain, and bladder outlet obstruction. The overall quality of the studies was fair to poor. No studies were classified as good quality, because they were lacking in a prospective study design or control for potential confounders. A summary of the main study outcome measures, levels of evidence, number of patients evaluated for each study, and whether partial or total mesh removal was performed is presented in Appendix 1, available online at https://links.lww.com/AOG/C531.

Four7–10 fair-to-poor–quality studies with a total of 486 women compared total mesh removal and partial mesh removal and report on lower urinary tract symptom-related outcomes. Reported outcome measures for lower urinary tract symptoms in these four studies included an incontinence severity index questionnaire, urodynamic or uroflowmetry results, voiding diary, or subjective documentation on chart review. One study saw no association when comparing preoperative and postoperative lower urinary tract symptoms, two demonstrated an association in symptom improvement postoperatively but no difference between groups, and one demonstrated an association favoring partial mesh removal for improvement in lower urinary tract symptoms.

More specifically, Misrai et al11 report no symptom change in either group, with 13.3% (10/75) experiencing lower urinary tract symptoms postoperatively compared with 12.0% (9/75) preoperatively. Although they report an equal number of lower urinary tract symptoms preoperatively and postoperatively, they do not identify whether this is de novo or persistent urgency. In contrast, Drain12 et al report that new onset lower urinary tract symptoms developed more frequently in total mesh removal patients (21.4%) when compared with partial mesh removal patients (7.3%, P=.039). Jambusaria et al13 report an associated improvement in lower urinary tract symptoms in both groups, with 54.3% (82/151) having lower urinary tract symptoms preoperatively and 24.7% (37/150) having lower urinary tract symptoms postoperatively, but no difference between groups, with 29% (7/24) in the partial mesh removal group and 38% (12/32) in the total mesh removal group (P=.52). Even though their article reports a relationship between preoperative lower urinary tract symptom improvement with either mesh removal techniques, there was an increase in urgency after total mesh removal in 80% (44/55) of patients compared with 20% (11/55) in the partial mesh removal group. They hypothesized that this was the result of a more extensive periurethral dissection. This outcome was consistent at a mean short-term follow-up of 5.9 weeks and a mean long-term follow-up of 29.1 weeks.

Goodall et al9 report associated symptom improvement in both groups, with 55% of patients (31/56) reporting preoperative urgency or subjective voiding difficulties, compared with 21% of patients (12/56) postoperatively.

For mesh transection for lower urinary tract symptoms, two15,21 poor-quality studies looked at the timing of transection. South et al15 associate an overall improvement in lower urinary tract symptoms in patients who had mesh transected less than 1 year (early lysis group) and more than 1 year (late lysis group) after the index surgery. They report a greater associated improvement in the early lysis group compared with the late lysis group (91% vs 71%; P=.01). Agnew et al21 also show an overall associated improvement in lower urinary tract symptoms with mesh transection but did not demonstrate an association between early or late mesh transection, with 6 of 45 (13%) of participants in the less-than-1-year revision group and 2 of 18 (11%) of those in the more-than-1-year revision group experiencing persistent voiding dysfunction.

Three of the comparative studies associated symptom improvement in preoperative lower urinary tract symptoms after mesh removal in both the total and partial mesh removal subgroups. A meta-analysis was not performed owing to the heterogeneity of outcome measures.

Overall, 2314–23,25–27,30–32,36,38–41,47,48 single-group studies that evaluated partial mesh removal, four3,44–46 single-group studies that looked at total mesh removal, and four comparative studies support an association between improvement in lower urinary tract symptoms after surgery, regardless of mesh removal amount.

A total of 15 single-cohort studies of fair and poor quality evaluated mesh erosion preoperatively and postoperatively; 1117–19,22,33–38,49 report on partial mesh removal, and four3,43,45,50 report on total mesh removal. The single-group studies all implied resolution of mesh erosion postoperatively, but very few considered this a primary outcome, and postoperative statistics were lacking. Two studies,7,9 with a total of 320 patients, compared total and partial mesh removal on patients with mesh erosion or extrusion. However, neither study reports postoperative outcomes related to mesh erosion. Forde and Creagh33 suggest that clinicians are poor at diagnosing erosive complications after midurethral sling placement. With a lack of comparative studies or homogenous outcomes, no meta-analysis was performed.

Overall, 11 single-group studies that evaluated partial mesh removal, four single-group studies that looked at total mesh removal, and two comparative studies suggest an association with improvement in mesh erosion or exposure after surgery regardless of mesh removal amount.

Four9,11–13 comparative studies of poor to fair quality evaluated a total of 486 patients. Outcome measures for pain included visual analog scale, chart review, and Douler Neuropathique 4 questionnaire. The studies all found no difference in pain resolution between total and partial mesh removal. Jambusaria et al13 described resolution of pain in 72% of patients undergoing partial mesh removal and 76% of complete sling removal for the indication of pain (P=.67). Goodall et al9 report a cohort of 56 women undergoing midurethral mesh removal for pain presumed to be caused by the sling. Of women who completed the questionnaire (visual analog scale), there was an associated median 6-point decrease in pain scores postoperatively compared with preoperative findings (P<.001) independent of partial or total mesh removal techniques. Drain et al12 associate a 72.7% improvement in postoperative pain with total mesh removal and an 89.7% associated improvement with partial mesh excision (P=.15); however, women with pain and mesh erosion were categorized together, possibly distorting evaluation of pain. Similarly, Misrai et al11 report an associated total decrease in pain in all patients. Although four comparative studies looked at mesh removal for pelvic pain, we were unable to perform meta-analysis of these data because different specific outcomes are reported across studies and outcomes are either reported as a combination of symptoms, such as pain and erosion together,8 or the outcomes for pain and mesh erosion do not differentiate between partial removal and total mesh removal. Nevertheless, overall, there was no difference found between partial or total mesh removal in regard to improvement in pain outcomes in all four studies. Nine16–18,38,40,47,51–53 single-group studies that evaluated partial removal all demonstrated an associated improvement in pain outcomes; these outcome measures were varied and included the FSFI (Female Sexual Function Index), the UDI-6 (Urogenital Distress Index), subjective reports, and a numeric pain scale. Two45,46 single-group studies looking at total mesh removal also report an associated improvement in pain outcome measures.

Overall, nine single-group studies that evaluated partial mesh removal, two single-group studies that looked at total mesh removal, and four comparative studies suggest an associated improvement in pain after surgery regardless of mesh removal amount.

Two11,12 studies that evaluated 185 patients compared partial mesh removal and total mesh removal and report on bladder outlet obstruction outcomes from presumed midurethral mesh obstruction. Outcome measures include urodynamics and elevated postvoid residual measurements. Drain et al12 report that 76.5% of patients who underwent total mesh removal and 85.7% who underwent partial mesh removal as improved or cured of obstruction (P=.51). Misrai et al11 did not report a difference in obstructive voiding outcomes between surgeries but noted that bladder outlet obstruction was associated with improved outcomes in 82% of women overall (with either surgery). One29 single-group study of fair quality that evaluated mesh mobilization within the first 2 weeks after midurethral sling placement for outlet obstruction found 87.9% (29/33) resolution. Of the four patients with persistent bladder outlet obstruction, mesh sling transection was performed 4–8 months later with 100% resolution. Comparative and single-group studies3,14,17,19,20,23,26–32,39,41,43–45,52,54 demonstrated no difference in bladder outlet obstruction outcomes between total and partial mesh excision; both techniques showed an associated improvement in bladder outlet obstruction symptoms.

Overall, 16 single-group studies that evaluated partial mesh removal, four single-group studies looking at total mesh removal, and two comparative studies suggest an associated improvement in bladder outlet obstruction after surgery regardless of mesh amount removed.

Three11–13 studies with a total of 430 women compared total and partial mesh removal and report on postoperative SUI. Outcome measures included urodynamic testing, voiding diaries, chart review for subsequent interventions for SUI, or documentation of patient-reported SUI. All three studies report a higher rate of postoperative SUI with total mesh removal when compared with partial mesh removal. For example, Jambusaria et al13 report a statistically significant difference between the two groups with 21% of patients in the partial sling removal group developing postoperative SUI compared with 69% in the total mesh removal group (P<.001). Drain et al12 report postoperative SUI in 21.6% after partial mesh removal and 25.0% after total mesh removal. Misrai et al11 report postoperative SUI in 45% (18/40) undergoing partial mesh removal and in 60% (21/35) undergoing total mesh removal. The three studies11–13 were sufficiently similar to allow meta-analysis. The risk of postoperative SUI was lower after partial mesh removal than total mesh removal (odds ratio 0.46, 95% CI 0.22–0.96, P=.037, I2=0.23; Fig. 2).

F2
Fig. 2.:
Meta-analysis of postoperative stress urinary incontinence (SUI) in three studies that compare total mesh removal with partial mesh removal. The risk of postoperative SUI was lower after partial mesh removal than total mesh removal.Doyle. Removing Midurethral Sling for Mesh-Related Complications. Obstet Gynecol 2022.

When we further evaluated postoperative SUI in the partial mesh removal studies, we found four27,29,39,42 studies that specifically looked at sling mobilization. Three of the studies27,29,39 described surgical techniques as being a vaginal “pull down” method to loosen the sling. One study,42 described it as “tape loosening”. Postoperative SUI was 3.7% with this technique, and the time from initial sling placement to intervention was 9.3 days. The remaining study27 described a vaginal and abdominal sling urethrolysis technique that mobilized the urethra off of the sling and created mobility at the proximal urethra. In this study, postoperative SUI was 30%, and the time from sling placement to intervention was 38 months.

Regarding mesh transection, one study15 looked at postoperative SUI after early transection (less than 1 year) and late transection (more than 1 year) and found that early transection of the sling resulted in 9.5% of patients having SUI and late transection resulted in 7.9% of patients having SUI, although the difference was not statistically significant. Conversely, another21 did not find a difference between early (13%) and late (11%) transection in their study.

Overall, 26 single-group studies that evaluated partial mesh removal, four single-group studies that looked at total mesh removal (Table 1), and three comparative studies suggest low rates of SUI after surgery (19.2% partial vs 48.7% total) with partial mesh having significantly less SUI (odds ratio 0.46, 95% CI 0.22–0.96). It should be noted that a potential difference in participant baseline characteristics and follow-up times were not accounted.

T1
Table 1.:
Postoperative Stress Urinary Incontinence Rates After Partial and Total Anti-incontinence Mesh Excision

Of the 45 studies included in this systematic review, 33 (25 single-group, partial removal; five single-group, total removal; three comparative) commented on adverse events over 2,721 surgeries. Among these 33 studies, 18 noted no adverse events in 1,805 surgeries. None of the comparative studies report a statistically significant difference in complications based on surgical method.

Among eight studies (n=688) that report adverse events with total mesh removal, there were reports of one case of urinary retention, one urethral obstruction, one urethral stricture, one infected retropubic tape, one vaginal hematoma, one cystotomy, four retropubic hematomas, one groin hematoma, five patients who needed additional surgery, one gluteal abscess, five port site hernias, and one port site fibroma. This was a total of 23 adverse events out of 688 surgeries, or 3.34%. It should be noted that one study9 reports 26% of the complications related to abdominal retropubic mesh removal, and this could be skewing the total mesh removal safety profile.

Among 28 studies (n=2,033) that report adverse events with partial mesh removal, there were 32 adverse events out of 2,033 surgeries, or 1.57%. Adverse events after surgery for partial removal of midurethral mesh included 12 urinary tract infections, one seroma, three wound infections, two vaginal infections, one extended catheter placement, three fistulas, five hematomas, one blood transfusion, one urethrotomy, and three cystotomies.

DISCUSSION

The results of this systematic review confirm that both partial and total mesh removal are associated with improved symptoms for the majority of patients. We specifically evaluated lower urinary tract symptoms, mesh erosion or exposure, pain, bladder outlet obstruction, postoperative SUI and adverse events. Postoperative SUI was present with partial and total mesh removal; however, postoperative SUI is lower in partial mesh removal surgeries compared with total mesh removal. It is a reasonable plausibility that leaving part of the midurethral sling intact, a portion of the sling's functionality would also remain intact. However, it should be noted that of the three comparative studies that evaluated postoperative SUI, follow-up time varied and the study with the shortest follow-up time demonstrated the most significant difference.

Data for postoperative mesh erosion or extrusion outcomes were of very low strength evidence. The majority of studies inferred a resolution in mesh erosion or extrusion, but this was not statistically reported.

All studies demonstrated an associated improvement in pain outcomes independent of the amount of mesh removed. However, we were unable to break down the data into type of midurethral sling being removed (tension-free vaginal tape vs transobturator tape). Nevertheless, we believe it is reasonable to individualize surgical approach when removing mesh for pain related complications as there may be a difference related to the type of sling being removed. Fuentes et al51 suggest performing partial sling excision for pain followed by total mesh removal in the subset of patients whose pain does not improve with partial mesh removal.

Bladder outlet obstruction outcomes were associated with improvement irrespective of amount of mesh removal or even by mesh transection. Of note, one study15 looked at early transection (less than 1 year) and late transection (more than 1 year). It showed more postoperative SUI in the early lysis group compared with delayed transection. The presumed mechanism is more tissue ingrowth and scarring from a longer healing period, resulting in more midurethral support after sling transection.

Although adverse events were uncommon in both partial and total mesh removal, the types of complications were different. For example, with total mesh removal procedures, there was commonly a retropubic or transobturator dissection. This resulted in hematomas, abscesses, and port site complications. It should be noted that one study9 reports 26% of the complications related to abdominal retropubic mesh removal, and this could be skewing the total mesh removal safety profile. It is unclear whether this surgical approach has an increase in complications or if the researchers used a lower reporting threshold. Additional complications included fistulas and a blood transfusion. It would be anatomically logical for fistula formation to be a risk regardless of surgical approach, but none were reported with total mesh removal. Incidental cystotomies, which were repaired intraoperatively, were reported with both types of mesh removal surgery. Overall, the adverse event rate shows an acceptable safety profile for both types of sling excision.

The strengths of this article are in the inclusive study design and a research team composed of female pelvic medicine and reconstructive surgery specialists and a systematic review content expert. Rigorous systematic review processes were used. The review was vetted by a professional society of gynecologists, and the clinical practice guidelines were agreed on.

The limitations of the article include the overall quality of the studies—the majority were considered to be poor- to fair-quality. Given the overall design of retrospective single-cohort studies, there were data gaps on relevant outcomes. There were no prospective or randomized studies available. Despite fundamental differences between the women for whom total or partial mesh removal is performed, none of the studies accounted for these or adjusted for potential confounders. Furthermore, data are limited by heterogeneity of measuring outcomes, differing definitions of lower urinary tract symptoms, bladder outlet obstruction, or postoperative pain between studies.

The results of this study allow preoperative counseling in women who are contemplating partial or total mesh removal for complaints presumed to be related to a previously placed midurethral sling. This study found postoperative SUI is higher with total mesh removal than with partial mesh removal, and early mobilization for bladder outlet obstruction resulted in the lowest amount of postoperative SUI (3.7%). With the exception of postoperative SUI, all outcomes studied in this review were associated with improved outcomes after partial and total mesh removal of a midurethral sling. Only postoperative SUI is lower with partial mesh removal, compared with total mesh removal, after a midurethral sling. This supports a more conservative approach to mesh sling removal that use approaches such as early mobilization, transection, and targeted excision. The evidence did not support better outcomes with total mesh removal on pain, bladder outlet obstruction, lower urinary tract symptoms, or mesh erosion. These outcomes resolved equally well with total or partial mesh excision, and adverse outcomes were low for both mesh excision strategies.

In addition, the heterogeneity of mesh removal terms used in research publications made it difficult to analyze techniques and outcomes despite AUGS recommended language5 to describe midurethral mesh removal. As the evidence is of moderate to low quality, we hope for more rigorous and prospective studies to this clinical question in the coming years.

Based on our systematic review and meta-analyses, the SGS Systematic Review Group makes the following clinical practice guideline recommendations:

  1. We suggest counseling patients preoperatively that the rate of postoperative SUI is lower with partial mesh removal compared with total mesh removal, with no difference in other outcomes or adverse events (weak recommendation).
  2. We recommend that future research incorporate AUGS/International Urogynecologic Association5 terminology to describe midurethral mesh removal (strong recommendation based on preferred reporting standards).

REFERENCES

1. Trabuco EC, Linder BJ, Klingele CJ, Blandon RE, Occhino JA, Weaver AL, et al. Two-year results of burch compared with midurethral sling with sacrocolpopexy: a randomized controlled trial. Obstet Gynecol 2018;131:31–8. doi: 10.1097/AOG.0000000000002415
2. Imamura M, Hudson J, Wallace SA, MacLennan G, Shimonovich M, Omar MI, et al. Surgical interventions for women with stress urinary incontinence: systematic review and network meta-analysis of randomised controlled trials. BMJ 2019;365:l1842. doi: 10.1136/bmj.l1842
3. Ramart P, Ackerman AL, Cohen SA, Kim JH, Raz S. The risk of recurrent urinary incontinence requiring surgery after suburethral sling removal for mesh complications. Urology 2017;106:203–9. doi: 10.1016/j.urology.2017.01.060
4. Hokenstad ED, Glasgow AE, Habermann EB, Occhino JA. Readmission and reoperation after midurethral sling. Int Urogynecol J 2018;29:1367–70. doi: 10.1007/s00192-017-3551-9
5. Joint position statement on the management of mesh-related complications for the FPMRS specialist. Female Pelvic Med Reconstr Surg 2020;26:219–32. doi: 10.1097/SPV.0000000000000853
6. Higgins JPT, Green S. Cochrane handbook for systematic reviews of interventions, version 5.0.0. Cochrane Collaboration; 2008.
7. Sterne JA, Hernán MA, Reeves BC, Savović J, Berkman ND, Viswanathan M, et al. ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ 2016;355:i4919. doi: 10.1136/bmj.i4919
8. Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, et al. Cochrane handbook for systematic reviews of interventions. 2nd ed. John Wiley & Sons; 2019.
9. Goodall EJ, Cartwright R, Stratta EC, Jackson SR, Price N. Outcomes after laparoscopic removal of retropubic midurethral slings for chronic pain. Int Urogynecol J 2019;30:1323–8. doi: 10.1007/s00192-018-3756-6
10. Shaw J, Wohlrab K, Rardin C. Recurrence of stress urinary incontinence after midurethral sling revision: a retrospective cohort study. Female Pelvic Med Reconstr Surg 2017;23:184–7. doi: 10.1097/SPV.0000000000000338
11. Misrai V, Rouprêt M, Xylinas E, Cour F, Vaessen C, Haertig A, et al. Surgical resection for suburethral sling complications after treatment for stress urinary incontinence. J Urol 2009;181:2198–203. doi: 10.1016/j.juro.2009.01.036
12. Drain A, Enemchukwu E, Shah N, Syan R, Rosenblum N, Nitti VW, et al. Current role of urethrolysis and partial excision in patients seeking revision of anti-incontinence sling. Female Pelvic Med Reconstr Surg 2019;25:409–14. doi: 10.1097/SPV.0000000000000596
13. Jambusaria LH, Heft J, Reynolds WS, Dmochowski R, Biller DH. Incontinence rates after midurethral sling revision for vaginal exposure or pain. Am J Obstet Gynecol 2016;215:764.e1–5. doi: 10.1016/j.ajog.2016.07.031
14. Segal J, Steele A, Vassallo B, Kleeman S, Silva AW, Pauls R, et al. Various surgical approaches to treat voiding dysfunction following anti-incontinence surgery. Int Urogynecol J Pelvic Floor Dysfunct 2006;17:372–7. doi: 10.1007/s00192-005-0018-1
15. South MM, Wu JM, Webster GD, Weidner AC, Roelands JJ, Amundsen CL. Early vs late midline sling lysis results in greater improvement in lower urinary tract symptoms. Am J Obstet Gynecol 2009;200:564–5. doi: 10.1016/j.ajog.2008.11.018
16. Baekelandt F, Van Oyen P, Ghysel C, Van der Aa F, Ampe J. Long-term functional results after unilateral mid-urethral sling transection for voiding dysfunction. Eur J Obstet Gynecol Reprod Biol 2016;207:89–93. doi: 10.1016/j.ejogrb.2016.10.020
17. Viereck V, Rautenberg O, Kociszewski J, Grothey S, Welter J, Eberhard J. Midurethral sling incision: indications and outcomes. Int Urogynecol J 2013;24:645–53. doi: 10.1007/s00192-012-1895-8
18. Kowalik CG, Cohn JA, Kakos A, Lang P, Reynolds WS, Kaufman MR, et al. Road to recovery after transvaginal surgery for urethral mesh perforation: evaluation of outcomes and subsequent procedures. Int Urogynecol J 2018;29:887–92. doi: 10.1007/s00192-018-3563-0
19. Laurikainen E, Kiilholma P, A nationwide analysis of transvaginal tape release for urinary retention after tension-free vaginal tape procedure. Int Urogynecol J Pelvic Floor Dysfunct 2006;17:111–9. doi: 10.1007/s00192-005-1330-5
20. Crescenze IM, Abraham N, Li J, Goldman HB, Vasavada S. Urgency incontinence before and after revision of a synthetic mid urethral sling. J Urol 2016;196:478–83. doi: 10.1016/j.juro.2016.01.091
21. Agnew G, Dwyer PL, Rosamilia A, Edwards G, Lee JK. Functional outcomes for surgical revision of synthetic slings performed for voiding dysfunction: a retrospective study. Eur J Obstet Gynecol Reprod Biol 2012;163:113–6. doi: 10.1016/j.ejogrb.2012.04.005
22. Oh TH, Ryu DS Transurethral resection of intravesical mesh after midurethral sling procedures. J Endourol 2009;23:1333–7. doi: 10.1089/end.2009.0098
23. Molden S, Bracken J, Nguyen A, Harvie HS, White A, Hammil SL, et al. A retrospective multicenter study on outcomes after midurethral polypropylene sling revision for voiding dysfunction. Female Pelvic Med Reconstr Surg 2010;16:340–4. doi: 10.1097/SPV.0b013e3181f5ac07
24. Shakir NA, Wang C, Singla N, Alhalabi F, Christie A, Lemack GE, et al. Challenges of multidimensional outcome reporting after suburethral mid urethral sling removal. J Urol 2018;199:1577–83. doi: 10.1016/j.juro.2017.12.059
25. Goujon E, Jarniat A, Bardet F, Bergogne L, Delorme E. Retrospective study on the management and follow-up of 18 patients with a mid-urethral sling penetrating the urethra or bladder. J Gynecol Obstet Hum Reprod 2018;47:289–97. doi: 10.1016/j.jogoh.2018.05.007
26. Moksnes LR, Svenningsen R, Schiøtz HA, Moe K, Staff AC, Kulseng-Hanssen S. Sling mobilization in the management of urinary retention after mid-urethral sling surgery. Neurourol Urodyn 2017;36:1091–6. doi: 10.1002/nau.23046
27. Rautenberg O, Kociszewski J, Welter J, Kuszka A, Eberhard J, Viereck V. Ultrasound and early tape mobilization--a practical solution for treating postoperative voiding dysfunction. Neurourol Urodyn 2014;33:1147–51. doi: 10.1002/nau.22459
28. Kasturi S, Hale DS. "J" cut of sling for postoperative voiding dysfunction following synthetic midurethral slings. Int Urogynecol J 2011;22:933–6. doi: 10.1007/s00192-011-1404-5
29. Price N, Slack A, Khong SY, Currie I, Jackson S. The benefit of early mobilisation of tension-free vaginal tape in the treatment of postoperative voiding dysfunction. Int Urogynecol J Pelvic Floor Dysfunct 2009;20:855–8. doi: 10.1007/s00192-009-0858-1
30. Brennand EA, Tang S, Birch C, Robert M, Kim-Fine S. Early voiding dysfunction after midurethral sling surgery: comparison of two management approaches. Int Urogynecol J 2017;28:1515–26. doi: 10.1007/s00192-017-3302-y
31. Castellani D, Galica V, Saldutto P, Biferi D, Paradiso Galatioto G, Vicentini C. Unilateral sling transection for patients with postoperative voiding dysfunction after transobturator sling surgery, Int J Gynecol Obstet 2015;131:313–4. doi: 10.1016/j.ijgo.2015.06.037
32. Wu SY, Kuo HC, Long-term outcomes of anti-incontinence surgery and subsequent transvaginal sling incision for urethral obstruction. Int Urogynecol J 2019;30:761–6. doi: 10.1007/s00192-018-3733-0
33. Forde JC, Davis NF, Creagh TA Evaluation of presenting symptoms and long-term outcomes of patients requiring excision of a transobturator tape (TOT). Ir Med J 2015;108:270–2. doi: 10.1007/s00192-018-3733-0
34. Baracat F, Mitre AI, Montellato NI, Endoscopic treatment of vesical and urethral perforations after tension-free vaginal tape (TVT) procedure for female stress urinary incontinence. Clinics (Sao Paulo) 2005;60:397–400. doi: 10.1590/s1807-59322005000500008
35. Basu M, Gorti M, Onifade R, Franco A, Fynes M, Doumouchtsis SK. Continence outcomes following partial excision of vaginal mesh exposure after mid-urethral tape insertion. Eur J Obstet Gynecol Reprod Biol 2013;167:114–7. doi: 10.1016/j.ejogrb.2012.11.013
36. Töz E, Sahin C, Apaydin N, Ozcan A, Taner CE. Functional outcomes of polypropylene midurethral sling resection for treatment of mesh exposure/extrusion: does it lead to a relapse of incontinence? Ginekol Pol 2015;86:531–6. doi: 10.17772/gp/57816
37. Frenkl TL, Rackley RR, Vasavada SP, Goldman HB. Management of iatrogenic foreign bodies of the bladder and urethra following pelvic floor surgery. Neurourol Urodyn 2008;27:491–5. doi: 10.1002/nau.20558
38. Forzini T, Viart L, Alezra E, Saint F. Erosive complications of mid urethral slings (MUS): 10 years of surgical experience [in French]. Prog Urol 2015;25:240–8.doi: 10.1016/j.purol.2014.12.007
39. Glavind K, Shim S. Incidence and treatment of postoperative voiding dysfunction after the tension-free vaginal tape procedure. Int Urogynecol J 2015;26:1657–60. doi: 10.1007/s00192-015-2756-z
40. Kuhn A, Eggeman C, Burkhard F, Mueller MD. Correction of erosion after suburethral sling insertion for stress incontinence: results and related sexual function. Eur Urol 2009;56:371–6. doi: 10.1016/j.eururo.2008.07.001
41. Mouracade P, Lang H, Jacqmin D, Saussine C. Transvaginal tape lysis for urinary obstruction after suburethral tape placement. When to do an immediate replacement? Int Urogynecol J Pelvic Floor Dysfunct 2008;19:1271–4. doi: 10.1007/s00192-008-0626-7
42. Offiah I, Rachaneni S, Dua A, Management of mid-urethral tape complications: a retrospective study. J Obstet Gynaecol India 2020;70:152–7. doi: 10.1007/s13224-019-01269-5
43. Syan R, Peyronnet B, Drain A, Enemchukwu E, Malacarne DR, Rosenblum N, et al. Exploring stress urinary incontinence outcomes after sling excision for perforation or exposure. Low Urin Tract Symptoms 2019;11:206–10. doi: 10.1111/luts.12263
44. Fabian G, Kociszewski J, Kuszka A, Fabian M, Grothey S, Zwierzchowska A, et al. Vaginal excision of the sub-urethral sling: analysis of indications, safety and outcome. Arch Med Sci 2015;11:982–8. doi: 10.5114/aoms.2014.42305
45. Coskun B, Lavelle RS, Alhalabi F, Lemack GE, Zimmern PE. Mini-slings can cause complications. Int Urogynecol J 2015;26:557–62. doi: 10.1007/s00192-014-2530-7
46. Hou JC, Alhalabi F, Lemack GE, Zimmern PE. Outcome of transvaginal mesh and tape removed for pain only. J Urol 2014;192:856–60. doi: 10.1016/j.juro.2014.04.006
47. Shakir NA, Wang C, Singla N, Alhalabi F, Christie A, Lemack GE, et al. Multidimensional outcomes of suburethral synthetic midurethral sling removal. World J Urol 2020;38:2005–12. doi: 10.1007/s00345-019-02987-1
48. Tepe NB, Bayrak Ö, Şen H, Uğur MG, Erturhan S, Seçkiner İ. Comparison of the efficiency of partial versus subtotal mesh removal on urogenital distress and sexual functions after stress urinary incontinence surgery. Turk J Urol 2020;46:140–5. doi: 10.5152/tud.2019.19113
49. Karmakar D, Dwyer PL, Nikpoor P, Mid-urethral sling revision for mesh exposure-long-term outcomes of two surgical techniques from a comparative clinical retrospective cohort study. BJOG 2020;127:1027–33. doi: 10.1111/1471-0528.16149
50. Dillon BE, Gurbuz C, Zimmern PE Long term results after complication of "prophylactic" suburethral tape placement. Can J Urol 2012;19:6424–30. doi: 10.1007/s00192-018-3733-0
51. Fuentes JL, Finsterbusch C, Christie AL, Zimmern PE. Mesh sling arm removal for persistent pain after an initial vaginal suburethral mesh sling removal procedure. Female Pelvic Med Reconstr Surg 2021;27:e522–7. doi: 10.1097/SPV.0000000000000981
52. Shapiro R, Dueñas-Garcia OF, Vallejo M, Trump T, Sufficool M, Zaslau S. Recurrent incontinence after transvaginal partial sling excision in patients with prior mid-urethral sling. Res Rep Urol 2021;13:9–15. doi: 10.2147/RRU.S281697
53. Wang CN, Christie AL, Zimmern PE, Sensitivity to change of subdomain question 6 of the urogenital distress inventory short form after sling removal for pain. Urology 2021;147:104–8. doi: 10.1016/j.urology.2020.10.029
54. Ngo YG, Huang KH, Kung FT, Wu LY, Chu LC, Yang TH, et al. The effects of "unilateral midurethral sling cut down" in women with voiding dysfunctions after anti-incontinence surgery. Int Urol Nephrol 2019;51:1501–6. doi: 10.1007/s11255-019-02219-w

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