BERKELEY, CA (UroToday.com) - The mid-urethral synthetic sling (MUSS) has become the gold standard treatment of female stress urinary incontinence associated with urethral mobility, and it has become the most commonly performed surgical procedure to treat urinary incontinence. However, there are still considerable caveats regarding short- and long-term complications of MUSS.
While MUSS has a favorably low intraoperative morbidity rate, it requires thorough surgical training and skill to ensure safety and also to decrease mesh-related complications. MUSS, when not properly performed, may lead to severe morbidity, and even mortality. It should be kept in mind that unfavorable results are not published in any journal. Published studies with good results in the literature are coming from tertiary excellence centers, performed by experienced surgeons, and do not represent the true reality.
Voiding dysfunction after MUSS is an under-reported complication that can be seen within a broad spectrum of symptoms starting from increased frequency and ending with retention. De novo voiding dysfunction is believed to be related to the obstructive effect of the sling, however the exact pathophysiology is not understood. Voiding dysfunction after MUSS may happen even in experienced hands and may affect the quality of life worse than SUI.
Reliable urodynamic criteria for the diagnosis of female infravesical obstruction are lacking. Thus, the diagnosis of mesh-related obstruction is based on the temporal relationship between surgery and onset of symptoms. Fortunately, timely tape cut or urethral release successfully cures retention or emptying difficulty in the majority of cases. However, the outcome of urethral release surgery is not always predictable in patients with de novo storage symptoms such as urgency. Unmasked detrusor overactivity is suggested to be responsible for de novo urgency in cases of patients who are not obstructed. Unfortunately, de novo storage symptoms may appear even years after surgery and can be challenging to treat.
MUSS is proven to cure female stress urinary incontinence equally or more successfully and safely than any surgical procedure described previously. Besides surgical technique, a good outcome after MUSS surgery depends on correct surgical indication with proper preoperative evaluation. Many women empty their bladders with the relaxation of their pelvic floor without a sustained detrusor contraction. These women are more prone to voiding dysfunction after surgery, and detrusor function appears to be an independent predictor of de novo voiding problems.
Last, but not least, we believe that management of patients’ expectations preoperatively is of utmost importance for patient-reported favorable outcome, especially in patients with mixed UI. Patients should be thoroughly informed about possible complications of MUSS, preoperatively, and should be followed carefully after surgery. As recent warnings of the U.S. Food and Drug Administration regarding mesh complications have clearly underlined, a high index of suspicion is needed to diagnose and treat complications after MUSS.
Written by:
Tufan Tarcan, MD, PhDa and Bülent Çetinel, MDb as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.
aProfessor of Urology at Marmara University School of Medicine
bProfessor of Urology at Istanbul University Cerrahpaşa Medical Faculty
Management of complications after tension-free midurethral slings - Abstract
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