There has been increasing reports of complications with implanted synthetic mid-urethral sling meshes including extrusion, exposure, pain and/or de novo lower urinary tract bothersome symptoms(1). These complications may warrant removal of the mesh either partially or fully(2). Although previous reports documented the results of mesh removal, such as pain improvement, recurrence of lower urinary tract symptoms (LUTS), especially stress urinary incontinence, there is a scarcity of data regarding functional outcomes, sexual quality of life, and quality of life assessment after mesh removal(3). 
The aim of our current study was to assess short-term functional and quality of life outcomes after transobturator tape removal surgeries.

A retrospective quality improvement project was conducted of all women who had full removal, partial or completion removal of their mid-urethral transobturator mesh tape (TOT) in a tertiary referral center from March 2013 to November 2020.  Choice of surgery and extent of mesh removal was made via a joint decision between the patient and the surgeon.

Functional outcomes and quality of life using a bespoke composite questionnaire (UDI-6, EQ-5D-5L, and ICIQ-S) with additional questions on sexual life, was undertaken by telephone and post. R-Software has been used for statistical analyses.

77 women with a mean age of 53 years (range 34-78) were enrolled in the study. The mean body mass index (BMI) was 33 (28-37). Among them, 10 patients had a history of two tape insertions (5 retropubic TVT and 5 TOT). 25% of the patients had previously undergone one tape removal attempt in another center and attended for completion removal of the rest of the mesh for persistent pain or bothersome LUTS. The mean interval between tape insertion and its removal was 8 years (1-15). 

Indications for removal surgery are detailed in figure 1. 

Post-mesh insertion chronic pelvic pain was the main indication for mesh removal in 44% of cases (34/77). Surgery was also performed for erosion in 25% of cases (19/77) (n=6 urethral, n=10 vaginal and 3 bladder erosion). Other indications were LUTS (n=24, 31%), mainly related to urgency or voiding dysfunction.

A total full removal or a completion removal was performed in 67 patients (87%). Among them,  61 (91%) underwent vaginal and bilateral groin/paralabial incisions. A partial removal of the tape was undertaken in 10 cases (13%), with 6 cases performed through an endoscopic approach to treat bladder extrusion with stones.

The average length of mesh removed was as follows: 17 cm (6- 26) for full removals, 15.8 cm (5-25) for full completions, and 5 cm (1-9) for partial removal. Concomitant autologous fascial sling (AFS) was performed in 9 patients (12%), in whom bothersome urodynamically-proven recurrent stress urinary incontinence (SUI) was identified prior to mesh removal. Among them, 2 had a concomitant Martius labial fat-pad flap and urethral repair.

Length of catheterisation was ≤3 days in 40% of cases (n=31), and length of stay was ≤5 days in 63% of cases (n=49). There was a 9% complication rate (n=7), with all being Clavien-Dindo ≤2.

Post-operative outcomes are detailed in Table 1. Functional outcomes were available for 43 patients, with a mean follow up of 20 months (2-93). Among the patients who underwent mesh removal for chronic pelvic pain, (48%) reported pain improvement (≤2 on question 6 UDI-6). One patient required an additional surgery for completion removal 3 years after the initial surgery for persistant pain. Bothersome urgency or recurrent SUI were reported in 37% (n=16) and in 32% (n=14) respectively. Persistent voiding dysfunction was observed in 12% of patients (n=5).

Satisfaction rate was high (86%, n=37); 81% (n=35) of the patients considered the surgery successful, 73% (n=33) felt a bit better or much better, 93% (n=40) would still have the surgery if they were in the same situation again, and 95% would recommend this surgery.

Among the 43 patients who answered the questionnaire, 30 (70%) returned to having a sexual life after surgery, with 24 patients (80%) considering it about the same, a bit better or much better than before the surgery. 
Eighteen patients (30%) have been experienced post-operative sexual dysfunction, such as pain during intercourse, reduced sexual desire or difficulties reaching climax.

This case series in one of the few to report functional outcomes, in particular quality of life and sexual quality of life, after tape removal and has one of the highest numbers of TOT removals with tissue-sparing groin dissection. It also highlights that groin dissection has low morbidity and should be offered to patients with mesh complications especially if they have pain.
  
Despite the fact that more than one third of the patients were still bothered by LUTS or pain, or experienced recurrence of SUI, more than 80% of them considered the surgery successful and the satisfaction rate was very high (86%). Moreover, a high rate of patients returned to sexual life after tape removal.

Despite a high rate of post operative bothersome urgency or SUI recurrence, TOT mesh removal with bilateral groin dissection improves patients’ pain and quality of life, and is associated with a high rate of overall satisfaction. Joint and shared decision making is crucial when offering mesh removal to patients.

Keltie K, Elneil S, Monga A, Patrick H, Powell J, Campbell B, et al. Complications following vaginal mesh procedures for stress urinary incontinence: an 8 year study of 92,246 women. Sci Rep. 2017;7(1):12015
Welk B, Al-Hothi H, Winick-Ng J. Removal or Revision of Vaginal Mesh Used for the Treatment of Stress Urinary Incontinence. JAMA Surg. 2015;150(12):1167-75
Bergersen A, Hinkel C, Funk J, Twiss CO. Management of vaginal mesh exposure: A systematic review. Arab J Urol. 2019;17(1):40-8