Urethral erosion after synthetic and nonsynthetic pubovaginal slings: differences in management and continence outcome

PURPOSE: We present a series of urethral erosion following a pubovaginal sling procedure due to synthetic and nonsynthetic materials and discuss their management and continence outcome. MATERIALS AND METHODS: During a 3-year period 57 patients underwent urethrolysis for urethral obstruction after receiving a pubovaginal sling. Urethral erosion, defined as sling material entering the urethral lumen, was present in 9 patients and this cohort comprises the focus of our review. In 3 patients the eroded material was synthetic, that is ProteGen (Boston Scientific, Natick, Massachusetts) in 2 and polypropylene in 1. This condition was treated with removal of the whole sling, multilayer closure of the erosion and selective use of a Martius flap. In 6 patients the eroded material was nonsynthetic, that is allograft fascia in 5 and autograft fascia in 1. This condition was treated with sling incision and multilayer closure of the urethra. Preoperative assessment included a urogynecologic questionnaire, measurement of pad use, a voiding diary, cystourethroscopy and videourodynamics. Postoperatively similar parameters were used to assess continence outcomes and the need for subsequent procedures. RESULTS: Nine patients were followed 30 months after urethrolysis. All 9 women had some manifestation of voiding dysfunction following the pubovaginal sling procedure, including urinary retention in 4, urge incontinence in 3 and mixed incontinence in 2. Urinary retention resolved in 3 patients and urge incontinence resolved in 4. Stress urinary incontinence (SUI) persisted in 2 of the 3 patients in the synthetic group, while no patient in the nonsynthetic group had recurrent SUI. There were no recurrent urethral erosions or fistulas in either group. CONCLUSIONS: Urethral erosion after a pubovaginal sling procedure can occur irrespective of the sling material. However, recurrent SUI is not an invariable outcome of the management of urethral erosion following the pubovaginal sling procedure.