Urethral Exposure of Mid-urethral Sling: Diagnosis, Management and Functional Outcomes

Objective To identify symptoms leading to urethral mesh exposure diagnosis, describe the surgical management and evaluate post-operative functional and urodynamic outcomes. Materials and Methods Retrospective observational monocentric study of 15 patients treated by mid-urethral sling removal for urethral exposure, between December 2005 and February 2021, in a pelviperineology centre. Results Fifteen patients were included. The mean time to diagnosis of urethral exposure was 43 months. This diagnosis delay was caused by a non-specific symptomatology. Surgical management consisted of partial removal of the eroded mid-urethral sling fragment by vaginal approach in all cases, with low peri-operative morbidity. At 3 months follow-up, 87% of the patients had stress urinary incontinence vs 54% at 2 years. 13 patients had a urodynamic assessment after their mid-urethral sling removal, they all had sphincter insufficiency with a urethral closure pressure lower than 30 cm H2O. Nine patients underwent a second urinary incontinence management procedure, leading to 77% of complete remission and 23% of partial improvement. Conclusion Clinical presentation of urethral erosion after mid-urethral sling is heterogeneous. Surgical management is complex; after a good preoperative evaluation, a two-step management strategy including minimally invasive mid-urethral sling removal and treatment of recurrent urinary incontinence leads to good results with 77% of patients cured. Sphincter insufficiency is one of the mechanisms that may explain the high rate of stress urinary incontinence after urethral mesh erosion surgery.