My Midurethral Sling Failed, So Now What?

I was recently at a party, talking to friends.  The kind of friends that you may not see that often but are always happy to see.  It was a group of vibrant, beautiful, amazing women.  One of these fabulous women confided in me that she had had a sling that didn’t work.  I was completely surprised because I never knew she had a bladder issue (my friends are rarely my patients).  Plus, I try really hard to talk about other things at parties (my husband frequently asks me to stop saying vagina).  And because it is really rare for a sling to fail immediately.  I realized I’ve never written anything about what happens when our treatments don’t work.  And the reality is that nothing is perfect.  So here we go.  Why might a midurethral sling fail?

What is a midurethral sling?

A midurethral sling is a surgical treatment for stress urinary incontinence.  It involves putting a piece of material underneath the urethra.  There are different types of material that you can placed, including mesh, your own tissue (or fascia), or a non-mesh graft.  When we use mesh, we call the procedure a midurethral sling.  There are three ways to place a midurethral sling: retropubic, transobturator, and single incision.  Generally speaking, studies show that these different methods have similar cure rates for most women.  We expect long-term success rates (longer than five years) of up to 92%. So, while this is a very effective treatment, it doesn’t work for everyone.  Why?

Wrong diagnosis

This may sound silly reason, but it happens.  A midurethral sling corrects stress urinary incontinence.  In some patients, frequency symptoms will also improve.  This does not always happen.  It will not correct urgency urinary incontinence.  Sometimes the diagnosis can be hard to make and is not straightforward.  Every now and then, I will have a patient who has a cough-induced bladder contraction- they leak when they cough, but it is urgency incontinence.  This can be a very confusing clinical picture.  Sometimes the incorrect diagnosis is made.

Mixed urinary incontinence

When I perform a midurethral sling, my patient always expects to be completely dry.  Suppose she has mixed urinary incontinence (both stress and urgency incontinence). In that case, I always tell her that the stress will improve, but the urgency and any associated leaking will likely still be present.  This is something that we always discuss and usually several times.  But after going through surgery for leaking, you expect to be dry, and you forget these details.

So, if you have had a midurethral sling and you still have bladder urgency and frequency, that “gotta go” feeling, it isn’t a failure.  That is the other reason that you leak.  A sling should really only correct leaking with coughing, sneezing, and exercise.  It just means that it is time to try a treatment for the urgency urinary incontinence that you have.

Type of sling

When you are designing a research study looking at two different types of slings, you have to decide how to compare them.  This helps you figure out how many women need to be in the study.  Research studies are expensive, and large studies are super expensive.  One way to decrease the number of women required for a study is to ask if the two slings have the same cure rate within a named percentage, which is usually what is done.  This statistical manipulation changes the number of women need in a study,

So, all of this math means that I can tell you that the different types of slings have roughly the same cure rates or usually within 10%.  It doesn’t mean that the cure rates are completely the same.  If you do a lot of slings and try different ones, you will notice that some perform better.  The retropubic slings generally have higher cure rates.  And sometimes, slings that are new to the market do not perform as well as more established slings.

I have used the same sling for most of my career.  I’ve tried to switch a few times.  I work at a few different places, and each institution has different contracts with different companies.  There are financial reasons why the institutions push me to change.   But I always come back to the same midurethral sling because it works the best in my hands.  It is important to look at the type of sling that was done because this may be associated with a lower cure rate.

It is too loose

When a sling is placed, it has to be tensioned.  There are different ways to do the tensioning.  Different types of slings need to be tensioned in different ways.  There is no way to check in their operating room to make sure it works well.  We need you to be up and moving to do the best testing.  This means that you can leave the operating room, and the sling may be too tight or loose.  Each surgeon should know their own failure rate (too loose) and retention rate (too tight).  And this is a reasonable thing for you to ask before surgery.  I know that when I switched sling types, my retention and failure rates have changed.  And I am a very experienced surgeon.

Your urethra is fixed.

A midurethral sling works when your urethra is mobile or moves.  This is the case for most women.  But for women who have little movement, slings work poorly.  We see this most commonly in women with scarring from other surgeries or who have had radiation.  This is a key part of the initial physical exam before surgery.

Your urethra is damaged.

Your urethral sphincter muscle has to work normally for a sling to correct your leaking.  If the sphincter is damaged, a sling is less likely to work.  Damage can happen during a delivery, a traumatic accident, or because of other medical conditions.

We don’t know

Sometimes a sling won’t work even when it seems like it was the perfect surgery for the perfect patient.  Our understanding of the body grows and changes all of the time.  Right now, a retropubic sling is the most common surgical treatment for stress urinary incontinence.  Over time, we will hopefully develop ways to subtype stress incontinence and treat the different subtypes in more specific ways.  The goal is to keep improving.

What can you do?

When a sling fails, it is important to re-evaluate everything.  Was the diagnosis correct?  Was there a technical difficulty?  What type of sling was used?  Was the tensioning correct?  Are there any anatomical issues that need to be addressed?

These things all need to be sorted out.  But if it seems that the anatomy is normal, there are no confounding factors, and the diagnosis is stress urinary incontinence, here is what I would do.

1. Rediscuss all treatment options. Discuss physical therapy and weight loss if appropriate.  I would not skim over conservative treatments.
2. Evaluate carefully how my patient wants to proceed.
3. If the sling was not a retropubic sling, I would offer a retropubic sling.
4. If a retropubic sling was placed, I would move forward with a bulking procedure.

Everyone feels differently when something like this happens.  I also usually offer a second opinion.  It isn’t that I don’t think I can fix it.  Sometimes you need a fresh start.  Surgery involves trusting the surgeon.  Things work best if you can have open conversations about expectations, results, and next steps (when needed).

Lucasz ES JAMA 2017