(Poster 11) Outcomes After Vaginal Excision of Transobturator Sling Mesh

Objectives: While transobturator mid-urethral slings (TOMS) and single-incision mid-urethral slings (SIMS) have been demonstrated as safe and effective procedures for the treatment of stress incontinence (SUI), adverse functional outcomes can occur, including urgency/frequency, voiding dysfunction, pelvic pain, dyspareunia, and mesh exposures. Clinical decision-making can be challenging when determining who will benefit from sling removal, versus treating associated symptoms. This study was performed in an academic urogynecologic practice with high referral rates for post-sling adverse symptoms. Our objective is to evaluate indications for excision of TOMS and SIMS, as well as post-excision outcomes. Prior smaller studies focused on outcomes after total excision of TOMS including groin dissection, but not on outcomes after transvaginal excision alone.

Methods: This was a retrospective cohort study which included 54 patients who underwent excision of TOMS or SIMS sling mesh from 2021-2025. The same surgical technique was used, removing all vaginal sling mesh spanning between the bilateral obturator fascia from a vaginal approach without groin mesh dissection. Trigger point injections (bupivacaine/epinephrine/triamcinolone) were performed in patients with pelvic pain. Categorical variables were compared using Fisher’s exact tests, continuous variables were compared using Mann-Whitney U tests.

Results: Demographics, sling related symptoms, and main outcomes are listed in table 1. Median time from sling placement to excision was 54.5 (6-180) months. The most frequent symptoms noted after initial sling placement included dyspareunia (79.6%), urgency/frequency (74.1%), voiding dysfunction (64.8%), pelvic pain (62.9%). Pre-excision exam findings included hypertonic levators (75.9%), obturator internus tenderness (74.1%), suburethral tension band (72.2%), and levator tenderness (59.3%). When comparing TOMS to SIMS, the only significant difference in adverse symptoms was for voiding dysfunction, which was seen more in SIMS (p=0.018). Pre-existing endometriosis or pelvic pain was significantly associated with post-sling pelvic pain (P=0.038, 0.039). After sling excision, 90.7% of patients noted at least some overall subjective improvement (46.3% noted dramatic or complete overall improvement). Subjective improvement was noted in pelvic pain (94.1%), voiding dysfunction (91.4%), and urgency/frequency (87.5%). Incontinence improved in 71.1% of patients, remained stable in 21.2%, and worsened in 7.9%, with interval SUI procedure occurring in 18.5% of patients. There were no significant associations between time to excision and improvement in symptoms.

Conclusions: This study showed high rates of subjective symptomatic improvement after excising the vaginal portion of sling mesh in patients with post-sling pelvic pain, voiding dysfunction, and urgency symptoms after TOMS and SIMS, with low complication rates. All slings were removed several months to years after placement. Consistent exam findings of vaginal tension band, pelvic hypertonicity, and levator tenderness insinuate that sling over-tensioning may lead to pelvic floor dysfunction and associated symptoms. These patients may benefit from excision of sling mesh.