Midurethral slings (MUS) are a commonly used treatment for stress urinary incontinence (SUI).  Though the success rate is high, some patient may develop complications necessitating repeat surgery, such as voiding difficulties, pain, or mesh exposure. Limited evidence describes long term outcomes of MUS revision/removal surgery among three different operative techniques: Transvaginal Sling Incision (TVSI), Transvaginal Sling Excision (TVSE) and Complete Sling Excision (CSE). Our primary objective was to describe the long term lower urinary tract symptoms after MUS revision/removal using the UDI-6 questionnaire, as an objective assessment. Our secondary objective was to describe the symptom profile of patients and the subjective improvement after MUS revision. Our hypothesis was that the postoperative UDI-6 scores would be highest (worst) in the CSE group.

A retrospective chart review of consecutive patients who underwent (MUS) revision, between September 2013 and December 2021, by a single tertiary care surgeon. The patient’s medical record was reviewed for demographic details, comprehensive clinical history, surgical report, and pre and post MUS revision subjective symptoms. At the final follow up, patients completed the Urogenital Distress Index questionnaire (UDI-6). The UDI-6 is a validated measure of lower urinary tract symptoms and pelvic pain. Patients were divided into three groups based on type of mesh revision done. TVSI was defined as transection of sling without removal of mesh (usually for isolated voiding dysfunction). TVSE was defined as removal of the vaginal portion of the sling up to the pubic rami. CSE was defined as removal of the entire sling, with both a transvaginal and retropubic dissection through a Pfannenstiel incision. 
Data is presented as frequency, median and interquartile range. The UDI-6 scores are presented as median and interquartile ranges (IQR). The total raw UDI-6 score for each of the three groups was transformed into a score from 0 to 100. Similar to prior research, a UDI-6 value below 33 was considered asymptomatic. SAS 9.4 was used, and a p<0.05 was considered significant.

We identified 48 patients who underwent MUS revision, of which 8 underwent a TVSI, 27 underwent TVSE, and 13 underwent a CSE. The type of MUS procedure was Retropubic sling (TVT, n=26), Transobturator Sling (TOT/TVT-O, n=19), a Mini sling (n=2) and unknown (n=1). The index MUS surgery was done in another center for 92% patients (44/48). Among the 48 patients, the mean age was 55 years. Of these, 62.5% were menopausal, 50% had a previous hysterectomy and 40% were current/ever smokers. Twelve women (25%) had a previous mesh revision surgery before referral. The median time from mesh placement to removal was 72 [36-116]  months for all subjects, 80.5 [38-128] months TVSI group, 79 [33-123] months for the TVSE and 49 [39-95] months for the CSE.
The most common preoperative symptoms were Urge Urinary Incontinence (UUI, 69%), voiding dysfunction (60%), recurrent SUI (60%), pain (56%), mixed incontinence (MI) (48%), mesh exposure (46%) and recurrent urinary tract infection (UTI, 31%). For the TVSI, the most common symptoms were voiding dysfunction (100%), UUI (63%), and recurrent UTIs (38%). For the TVSE group the most common symptoms were incontinence (SUI 74%, UUI 70%, MI 59%), mesh exposure (63%) and pain (56%). The most common symptoms in the CSE group were pain (92%), UUI (69%), and voiding dysfunction (62%). The mean number of pads used at the time of referral for the group overall was 3.0 (TVSI group 1.6, TVSE group 3.3 and CSE group 3.0).  
Nine women had concurrent anti-incontinence surgery at the time of mesh revision; of those 7 were fascial pubovaginal slings and 2 were Burch Urethropexy. Seven women had fascial pubovaginal slings at a later date. Intraoperatively, 39.5% of subjects needed a transurethral incision to remove the mesh due to erosion, and 4% needed a transvaginal bladder incision. 
After the MUS revision was done, 23 out of the 48 subjects continued to have SUI and 13% developed new SUI. In the TVSI group 50% reported SUI, in the TVSE 52% reported SUI, and in the CSE group 38% reported SUI. UUI decreased from 69% to 50% overall, and in each of the individual groups (to 50% in the TVSI group, 56% in the TVSE and 38% in the CSE group). The mean change in pad use among all subjects was -1.5. Among the TVSI group the mean change in pad use was -1.5; both the TVSE and CSE groups had a mean change in pad use of -1.4. 
Self-reported pain decreased from 56% to 26%. In the TVSE group, the rate of pain decreased from 56% to 22% and in the CSE group it decreased from 92% to 46%. Pain resolved in 31% of the total subjects (specifically in 37% of the TVSE group and 38% of the CSE group). Narcotic use decreased from 10% to 6% in the overall group.
The UDI-6 score was completed by 37/48 patients (77%). The median time from sling revision to completion of UDI-6 questionnaire was 33 [14-61] months overall, (23.5 [8–37.5] months in the TVSI group, 39 [15–70]  months in the TVSE group and 29 [13.5–48.5]months in the CSE group). The median total UDI-6 score for all the patients was 44 [IQR 28.0–56.0]. (details in table 1).

Our results demonstrate that mesh related complications can have variable clinical presentation and that MUS revision can improve subjective and objective urological symptoms in the long term. Our results show that there is an improvement in subjective symptoms of UUI, mean change in pad use, pain, narcotic medication use, voiding dysfunction, and use of clean intermittent catheterization (CIC) over the long term. An objective assessment of urological symptoms, using the validated UDI-6 score demonstrated that certain symptoms do persist and can vary depending on the operative technique used, however in general all three surgical groups had similar UDI-6 scores. It is important to realize that even with active management through medical therapy and further non-mesh-based SUI surgery, only about 37% of these patients reach an “asymptomatic” or normal UDI-6 score of <33. The TVSI high score was driven by the high scores in both the frequent urination and UUI questions. Baekelandt et al. investigated the long-term outcomes of unilateral MUS transection and found that 26.1 % of patients were incontinent, mainly with UUI [1]. The key contributor to the high TVSE score was the high score in the UUI questions. Comparable to our study, Crescenze et al., demonstrated that regardless of type of transvaginal mesh revision, patients with UUI had higher UDI-6 scores and worse patient satisfaction scores, reflecting the clinical impact of UUI [2]. In our study, the CSE group’s high scores were due to elevated scores in the SUI and degree of incontinence questions. Shaw et al., also found that SUI symptoms recurred in 56% of patients after mesh excision versus only 13% after sling division. [3] Limitations of our work include the small sample size, and the selection bias that results in a patient undergoing either TVSI, TVSE, or CSE.

Our results demonstrate that after MUS revision, there are improvements in subjective and objective urological symptoms. However, with a median follow up of almost 3 years, the majority of patients still have urinary symptoms. This information can help in patient counselling and managing patient’s expectation after MUS revision surgery

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 Dec;207:89-93. doi: 10.1016/j.ejogrb.2016.10.020. Epub 2016 Oct 26. PMID: 27833061.
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 Aug;196(2):478-83. doi: 10.1016/j.juro.2016.01.091. Epub 2016 Jan 25. PMID: 26820550.
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 May/Jun;23(3):184-187. doi: 10.1097/SPV.0000000000000338. PMID: 27748665.