Midurethral slings are the standard of care for the surgical treatment of stress urinary incontinence. It is the most extensively studied anti-incontinence procedure, with an incidence of failure of 15%. Despite the fact that there are over 2000 publications describing slings, failure remained poorly understood due to multiple factors and etiologies that are hard to control and study with no consensus for the management. In this video, we will review risk factors, etiologies, and management of sling failure and present a novel technique for repeat slings. Preoperative detrusor overactivity affects negatively the success of both transvaginal and transopterator tape. In a Danish nationwide registry of 8600 women who had slings, preoperative anti-muscarinic use and mixed urinary incontinence had less chance of cure, and the severity of urinary incontinence was a strong predictor of failure. Other risk factors include center and surgeon volume, along with intrinsic sphincter deficiency, especially with hypomobile urethra. There are multiple options for the management of failed slings with no consensus, including urethral bulking agents, birch-gulpo suspension, and pubovaginal slings. Repeat midurethral sling is the most common treatment for sling failure. Evaluation includes physical examination to check for vaginal erosion and point of tenderness. Period dynamics to check for obstructive voiding dysfunction and urethral function. Cystoscopy is essential to rule out urethral and bladder erosion. We advocate to excise vaginally the previous midurethral sling. Erosions can be subtle, that's why we always advocate removal of the sling rather than leaving it in place. Dissection of the vaginal portion of the sling have been previously described. Care should be taken not to injure the urethra or the bladder. After making a midline incision, sharp dissection is proceeded to release the sling from the periurethral tissues and the vaginal epithelium. Alice clamp is useful to hold the sling to provide traction. Traction-counter-traction and push-spread technique are helpful to dissect the adherent sling of the tissues. The procedure is repeated on the other side. It's important to keep the operative field dry to improve visualization. The dissection is carried laterally to the inferior pubic ramus or as much as feasible vaginally. Removal of the previous sling alleviate dyspareunia and pelvic pain and address obstructive voiding dysfunction. After the removal of the previous midurethral sling, we proceed by placing a new retropubic midurethral sling in the usual fashion. 70 degree lens cystoscopy is superior to 30 degree to identify bladder perforation. The trocar on that side is removed and replaced more laterally. We adjust the tension by placing a midline suburethral back cock. It helps with laying the sling flat under the urethra and prevent inadvertent extra tensioning. The most important step is fixing the suprapubic arms of the new TVT to the abdominal fascia and the vaginal portion to the periurethral tissues. We make a 1.5 cm skin incision with a knife at the site of the suprapubic arms on each side and dissect the subcutaneous fat with cautery in order to reach the fascia and use a 2-oproline to suture the suprapubic arm to the abdominal fascia. The same procedure is repeated on the other side. The excess mesh is cut. We can visually see how the suprapubic arm is sutured to the abdominal fascia. Skin is closed with interrupted sutures of 4-O-monocle. The back cock clamp is removed after we finish manipulating the suprapubic arm to prevent an advert tensioning. The sling is tagged suburethrally with 2-ovicrol to prevent migration. The periurethral tissues are imbricated with 2-ovicrol to cover the sling. We believe it will decrease the risk of erosion. A variation to the technique of fixing the suprapubic arm is holding the abdominal fascia with the back cock to facilitate suturing and to keep the incision small. This is a patient with previous midurethral sling presenting with stage 4 prolapse and we can see the sling about 10 cm away from the urethral meatus and about 5 cm away from the vaginal apex. She was managed by coprochlysis, excision of the previous sling and repeat midurethral sling with fixed suprapubic arms. Theoretically, the true reason for failed sling over time is the chronic increase in abdominal pressure that will dislodge the sling whether due to advanced prolapse like in this case or with increase in BMI over time or chronic increase in abdominal pressure with straining during defecation or cough. If other etiologies for failed sling are excluded like we previously mentioned in the video, namely preoperative detrusor overactivity, urgency component, vaginal erosion, urethral bladder erosion, fixing the sling can potentially decrease the long-term risk of failure. We recommend future studies for validation.

midurethral slings

sling failure

surgical technique

management options

repeat midurethral sling