Synthetic mid-urethral slings (MUS) were used as the gold standard surgical management of stress urinary incontinence (SUI) (1). However, there has been growing evidence about potential serious delayed and under-reported mesh-complications associated with them (2). Management of these complications involves partial or complete excision of the sling, with different risks associated with different options (3).

We present a case series of  Total Trans-Obturator Tape (TOT) removal,  including vaginal and extra-vaginal (groin) approaches to achieve total removal, performed in a tertiary mesh-complications unit over the past 3 years. We aim to assess post-operative pain improvement and recurrence of incontinence following total mesh excision.

Retrospective cohort study of women who underwent total TOT removal: complete vaginal and bilateral extra-vaginal (groin) between 2018 - 2020. Patients were excluded if they had previous mesh excision, more than one mid-urethral mesh sling or mesh-implant or urinary tract perforation.

Our primary outcomes were improvement of pain score and incidence of recurrence stress urinary incontinence after mesh excision. Secondary outcomes included intra-operative complications, return to theatre, post-operative complications and re-admission rates.

Data on demographics, investigations, intra-operative and post-operative care were collected, as was follow-up data.

All explanted mesh specimens are photographed with a measuring tape and uploaded onto patients electronic case records, prior to insertion into histopathology transport medium for further analysis.  From this total tape length was calculated.

19 patients had undergone total TOT removal during this time period. 
Due to COVID-19 suspension of elective services , there was minimal surgical activity during 2020.
Mean patient age was 52 years (range 45-68yrs). Mean BMI was 31(range 21-44). 

Indication for mesh removal was chronic pain, that had not responded to non-surgical management,  in 95% (18/19) of cases, mesh exposure in 37% (7/19) of cases and  pelvic sepsis extending into the  right buttock in one case (5%). 

Peri-operative

Intra-operative urethral injury only occurred in 1/19 (5%) case with pelvic sepsis, during  the removal of the infected sub-urethral sinus tract, which extended into the right buttock. It was repaired with a Martius-graft with no persistent defect on follow-up.

The average estimated blood loss during surgery was 202 mls (50 – 750).  None of the patients had return to theatre. The mean length of the mesh excised was 22 cm (19-29). All excised mesh and tissue were sent for histopathological examination. The most common histopathological finding was  “fibrous tissue with foreign material embedded in it and signs of giant cell reaction”. 

Time to discharge was sometimes delayed secondary to transport requirements due to the geographic nature of our tertiary service. The average  hospital stay however, post-operatively was 2-3 days.

Follow-up

16/19 (84%) patients have attended for follow-up to date.  Due to COVID-19 restrictions and suspension of elective services, the follow-up period was variable , with follow-up taking place between 4-12 months postoperative (average: 7.5 months).

Pain:

Most women reported significant improvement in chronic pain, with 15/19 (79%) of patients reporting significant drop in their VAS score (approximately 50%).  (fig 1). There was significant decrease in the mean pain score from 8.313 (95% CI 7.252, 9.373) pre-operatively to 3.5 (95% CI 1.685, 5.315) within the first week
All 16 patients completed the 10-points visual analogue pain at follow-up. The significant decrease in the mean pain score from 8.313 (95% CI 7.252, 9.373) baseline appeared to persist with Vas scores of  4.188 (95% CI 2.456, 5.919) at Follow-up which is clinically and statistically significant (p-value: 0.0013)  (Figure 1)

Overall, 75% of patients reported “significant” improvement or “complete resolution of pain”, 19% reported “no change” in their mesh-related pain and 6%  “worsening” of their pain. 

Urinary Symptoms:

13/16 (82%) of patients reported worse or de-novo stress urinary incontinence: 38% of patients having previously been dry and  44% reported worsening of their pre-existing SUI. Only 18% of patients did not suffer from worsening urinary incontinence within the first year after mesh removal. 

32% of patients suffering from worsening SUI  have to date gone on to have further surgical management of their SUI , following further failed conservative treatments 

56% (9/16) of patients reported worsening of their pre-existing over-active bladder symptoms (OAB), 6% (1/16) of patients reported de-novo over-act OAB symptoms, 25% (4/16) reported no change and 13% (2/16) reported improvement of their pre-existing OAB symptoms.

We report a case series of patients having total TOT mesh removal. Indication of removal was predominantly due to pain (95%). In the absence of sepsis, significant intra-operative complications are rare during total TOT removals.

75% of patient reported significant improvement or complete resolution of their mesh-related pain at 4-12 months, however, 25% still suffered from ongoing or worsening pain despite total mesh excision. 

Nearly 82% of patients developed significant worsening incontinence in the first  year after  mesh removal, which was significant enough to require further management in over a third to date.

While most of patients reported improvement of their pain after total mesh removal, patient should be counselled that symptoms may persist or worsen. Recurrence or worsening of urinary incontinence is high after total mesh removal.

Rogo-Gupta L, Litwin MS, Saigal CS, Anger JT, Urologic Diseases in America P. Trends in the surgical management of stress urinary incontinence among female Medicare beneficiaries, 2002-2007. Urology. 2013;82(1):38-41.
Ross S, Tang S, Eliasziw M, Lier D, Girard I, Brennand E, et al. Transobturator tape versus retropubic tension-free vaginal tape for stress urinary incontinence: 5-year safety and effectiveness outcomes following a randomised trial. Int Urogynecol J. 2016;27(6):879-86.
Carter EC, Cartwright R, Goodall E, Jackson S, Price N. A laparoscopic technique for excision of retropubic midurethral sling arms eroding into the bladder. Int Urogynecol J. 2019;30(6):1013-5.