Editing Functional: Female SUI (section)

====== <span style="color:#ff0000">Adverse events ======
* '''Patient counselling'''
**'''Permanent nature of these products since''' MUS surgery involves the implantation of a synthetic, prosthetic material
**'''Unique and sometimes serious complications related to their use'''
**'''Risk of''' '''transient and permanent voiding dysfunction after surgery, including''' '''postoperative difficulty emptying the bladder and de novo urgency and frequency'''
*'''<span style="color:#ff0000">Overall, relatively low rates of complications (10)'''
*# '''<span style="color:#ff0000">Bladder trocar injury: 2.7-3.8%; higher with retropubic'''
*# '''<span style="color:#ff0000">Voiding dysfunction: 7.6%'''
*# '''<span style="color:#ff0000">Wound healing problems: 1%'''
*# '''<span style="color:#ff0000">Vaginal mesh exposure</span>: 0.5-8.1%'''
*# '''<span style="color:#ff0000">Mesh perforation of urethra</span>''' (transobturator and retropubic): '''0-0.6%'''
*# '''<span style="color:#ff0000">Mesh perforation of bladder</span>: 0.5-0.6%'''
*# '''<span style="color:#ff0000">Sexual dysfunction'''
*# '''<span style="color:#ff0000">Groin pain; higher with transobturator</span>'''; conservative therapy with NSAIDs should resolve the majority of symptoms. If pain persists after 6-8 weeks, consider referral to a pain clinic for trigger point injections and physical therapy.
*# '''<span style="color:#ff0000">Bleeding, vascular injury; higher with retropubic'''
*# '''Infection, bowel perforation, and death'''
* '''<span style="color:#ff0000">Bladder Trocar Injury'''
** '''<span style="color:#ff0000">Rate of trocar injury is higher with retropubic vs. trans-obturator MUS'''
*** '''The rate of bladder or urethral trocar injury:'''
**** '''Retropubic MUS surgery: 2.7-23.8%'''
**** '''Trans-obturator MUS surgery: 0-1.3%'''
** '''<span style="color:#ff0000">Management'''
***'''<span style="color:#ff0000">If occurs intra-operatively, remove trocar and pass trocar again more laterally and leave foley catheter in 3-7 days.'''
****'''Trocar injury is generally thought of as a benign condition.''' 
* '''<span style="color:#ff0000">Vaginal Mesh Exposure'''
** '''Most cases manifest within a few weeks to a few months after the MUS procedure'''
** '''Risk factors (5):'''
**#'''Diabetes'''
**#'''History of smoking'''
**#'''Older age'''
**#'''>2 cm vaginal incision length'''
**#'''Previous vaginal surgery'''
**'''<span style="color:#ff0000">Diagnosis and Evaluation'''
***'''<span style="color:#ff0000">History and Physical Exam'''
****'''<span style="color:#ff0000">Signs and Symptoms (6):'''
****# '''<span style="color:#ff0000">Vaginal discharge</span>''' (with variable constituents and different amounts of blood and inflammatory components)
****# '''<span style="color:#ff0000">Palpable rough surface in the vagina'''
****# '''<span style="color:#ff0000">Sexual discomfort</span>''' (including partner related)
****# '''<span style="color:#ff0000">Pelvic pain'''
****# '''<span style="color:#ff0000">Inguinal discomfort'''
****# '''<span style="color:#ff0000">LUTS (urgency, frequency, persistent incontinence, hematuria)'''
** '''<span style="color:#ff0000">Management'''
*** The management of this complication is not standardized, composition of mesh is particularly important in the event of mesh exposure
***'''<span style="color:#ff0000">Options (2)'''
****'''<span style="color:#ff0000">Conservative management with conjugated estrogen and possibly antibiotic creams''' 
*****'''<span style="color:#ff0000">Option in well-selected patients who are relatively asymptomatic and have small-caliber exposures (<1 cm)'''
**** '''<span style="color:#ff0000">Excision should be reserved for failure of conservative therapy or when local symptoms mitigate against observational management (e.g., bothersome dyspareunia).''' 
*****'''Limited excision and trimming with vaginal closure can be attempted.''' 
******'''Even with partial excision of the mesh, continence is maintained in the majority of patients.'''
***** '''If these options fail, excision of most of the mesh from a transvaginal approach should be pursued in most cases.'''
****** '''Operative management typically involves excision of the exposed mesh''', thorough irrigation with antibiotic solution, and closure of vaginal flaps. Good results have also been observed in selected patients with vaginal advancement flaps and suture approximation of the debrided vaginal mucosa over the exposed mesh.
* '''<span style="color:#ff0000">Mesh Perforation of the Urethra'''
** '''<span style="color:#ff0000">Diagnosis and Evaluation'''
***'''History and Physical Exam'''
****'''History'''
*****'''Presenting symptoms are variable'''
*****'''Voiding dysfunction is predominant'''
** '''<span style="color:#ff0000">Management'''
*** Management of this complication is extremely challenging
*** '''<span style="color:#ff0000">Observation should never be considered when there is urethral perforation'''
*** '''Options (2)'''
***#'''Endoscopic management of small areas of mesh perforation'''
***#'''Transvaginal surgical excision'''
***#* '''For slings that perforate into the urethra an inverted-U incision is best''' because this allows for exposure of the proximal urethra, bladder neck, and endopelvic fascia as well as providing a vaginal epithelial flap that avoids overlapping suture lines
***#* An autologous fascial sling or a Martius labial fat pad graft can be used for repair, at the discretion of the surgeon.
***#** '''An autologous fascial sling can be placed at the time of surgery to augment the repair or in a delayed fashion to treat recurrent SUI.'''
* '''<span style="color:#ff0000">Mesh Perforation of the Bladder'''
** '''Pathogenesis'''
***'''Most likely the result of an unrecognized cystotomy or placement of the mesh within the urinary bladder at the time of surgery'''.
** '''<span style="color:#ff0000">Diagnosis and Evaluation'''
***'''History and Physical Exam'''
****'''Signs and Symptoms'''
****#'''Lower abdominal pain'''
****#'''Intermittent gross hematuria'''
****#'''Recurrent UTI'''
****#'''Urgency'''
****#'''Frequency'''
****#'''Dysuria'''
****#'''Urinary incontinence'''
** '''<span style="color:#ff0000">Management'''
*** '''<span style="color:#ff0000">Observation should never be considered when there is intravesical perforation'''
***'''Options (2)'''
***#'''If small area of mesh perforation: endoscopic management (excision with scissors or ablation with the holmium laser) is an appropriate initial step if complete excision of all exposed material can be achieved'''
***# '''If endoscopic excision fails or as initial treatment for large areas of mesh perforation, transvaginal or retropubic excision'''
***## Reconstruction should involve nonoverlapping suture lines and interposition of tissue such as a labial fat pad or greater omentum.
***## An autologous fascial sling can be placed at the time of surgery to augment the repair or in a delayed fashion to treat recurrent SUI.
* '''Pain and Infection after MUS Surgery'''
** '''Groin and suprapubic pain are potential problems after MUS placement.''' 
***'''Thigh and groin pain appear to be more commonly associated with the transobturator approach'''
** '''Severe infection is a rare complication after MUS surgery'''
***Diagnosis of this complication is variable and can take as long as several years
*** '''Obesity, diabetes, and hypertension are associated with fasciitis after pelvic surgery.'''
** '''Management of MUS Severe Infection or Pain'''
*** '''In most cases, postoperative groin or leg pain after MUS surgery can be managed with NSAIDs, rest, and physical therapy.''' 
****'''Most groin pain resolves after postoperative day 2'''
*****Pain persists longer after the transobturator midurethral slings
*** In instances of chronic mesh pain and severe infection when nonoperative therapy has failed, it may be necessary to attempt a complete mesh excision from both sides of the bone.
*** For the complete excision of transobturator mesh we typically consult an orthopedic surgeon to aid with lateral dissection of the sling.
* '''<span style="color:#ff0000">Voiding Dysfunction after MUS Surgery'''
** '''Epidemiology'''
***De novo urgency occurs with postoperative voiding dysfunction in as many as 12% of patients
***'''Voiding dysfunction after MUS is substantially less than with PVS (bladder neck) slings'''
**'''Usually transient'''
***Long-term urinary retention and obstructive voiding dysfunction are rare after the MUS procedure
**'''Pathogenesis'''
***'''Typically the result of obstruction'''
****'''From the sling being placed too tightly or in the wrong location (too proximally)'''
****'''Associated with pelvic organ prolapse (unrecognized preoperatively or de novo)'''
*****Some patients may have voiding dysfunction without evidence of obstruction
** '''Risk factors'''
***'''Type of MUS'''
****'''In general, similar rates of de novo urgency and perioperative urinary retention among the different types of MUSs'''
****'''However, an RCT found significantly higher rate of voiding dysfunction necessitating surgery (or permanent catheter) after a retropubic MUS compared with a transobturator sling procedure (3% vs. 0%)[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4367868/ §]'''
**** In addition, the rate of urinary retention (catheter for longer than 6 weeks) was also higher in the retropubic MUS group (3.7% vs. 0.7%).
** '''<span style="color:#ff0000">Diagnosis and Evaluation'''
***'''<span style="color:#ff0000">History and Physical Exam'''
****'''<span style="color:#ff0000">History'''
*****'''<span style="color:#ff0000">Most common symptoms of obstruction are''' 
******'''<span style="color:#ff0000">Inability to void (urinary retention)'''
******'''<span style="color:#ff0000">Incomplete emptying'''
******'''<span style="color:#ff0000">De novo urgency and frequency'''
*****Over several weeks to a month, the storage symptoms (urgency and frequency) and pain become more prevalent as the bladder attempts to adjust to the obstruction.
****'''<span style="color:#ff0000">Physical Exam'''
*****'''<span style="color:#ff0000">Pelvic organ prolapse'''
******'''A key factor in assessing voiding dysfunction is the presence of prolapse that was either uncorrected at time of surgery or that occurred postoperatively.''' Prolapse of sufficient size may kink or angulate and externally compress the urethra. '''After surgery, apical, anterior, and posterior prolapse must be ruled out as a cause of the urethral obstruction'''
***'''<span style="color:#ff0000">Cystoscopy'''
****'''<span style="color:#ff0000">Useful to rule out bladder pathology, urethral mesh perforation, and a hypersuspended bladder neck'''
***The optimal evaluation for patients with postoperative voiding dysfunction is poorly defined in the literature. The decision to perform urethrolysis is usually based on a clear temporal relationship between onset of symptoms and the surgical procedure.
** '''<span style="color:#ff0000">Management''' 
*** '''<span style="color:#ff0000">Urinary obstruction after MUS surgery is usually transient and can be managed with short-term intermittent catheterization'''
*** '''<span style="color:#ff0000">If persistently elevated residual urine, bothersome symptoms refractory to conservative management, and within first 3 months of surgery, then perform transvaginal sling release'''
**** '''Cutting the MUS in the midline through a single vertical vaginal incision using minimal dissection is the preferred method to manage persistent voiding dysfunction that results from an obstructive sling within the first 3 months after surgery'''
*****'''Transvaginal sling release consistently provide resolution of symptoms with maintenance of continence in the majority of patients'''
******The entire sling does not need to be excised; majority of patients maintain continence with single incision
**** '''Timing'''
*****'''The exact timing of sling incision is variable; however, most recommend waiting at least 2 weeks; the sling should be incised within 4 weeks of surgery'''
*** '''<span style="color:#ff0000">If after 3 months, perform a more formal sling excision and urethrolysis'''
****'''Sling may be fixed along its entire course, and midline sling incision may not achieve enough sling relaxation to resolve voiding dysfunction'''
***'''<span style="color:#ff0000">Urethral dilation is of limited usefulness and, if used too aggressively, may be detrimental.'''
* '''<span style="color:#ff0000">Sexual Dysfunction after MUS'''
** '''Contradictory evidence in the literature that MUS surgery improves and worsens sexual function'''
*** Some attribute improved sexual function after MUS surgery to a significant decrease in coital incontinence
*** '''The rate of de novo dyspareunia after MUS surgery is between 3-14%; sling removal can improve dyspareunia'''
* '''Other Complications after MUS Surgery'''
** Infection, bleeding, vascular injury, bowel perforation, and death.
*** '''<span style="color:#ff0000">Risk of major vascular injury higher with retropubic vs. transobturator'''
*** '''The majority of postoperative hematomas resolve without intervention'''
** '''<span style="color:#ff0000">UTI is the most common and easily treatable complication of MUS surgery.'''