Female Incontinence: What to Do When Synthetic Mid-Urethral Sling Fail

Le Phuc LienVietnam Speaker Female Incontinence: What to Do When Synthetic Mid-Urethral Sling FailSurgical failure rates following midurethral sling (MUS) procedures vary widely, with reported rates ranging from approximately 8% to 57% at five years of follow-up. This variability is largely attributed to inconsistent definitions of surgical failure and a general lack of long-term follow-up data. A recent Cochrane review highlights the absence of high-quality evidence to support or refute specific management strategies for recurrent or persistent stress urinary incontinence (SUI) following failed MUS procedures. A thorough clinical evaluation is essential and should include a detailed patient history, comprehensive physical examination, and clarification of the patient’s treatment goals. Conservative management options encompass pelvic floor physiotherapy, the use of an incontinence pessary, commercially available intravaginal devices (e.g., Uresta®, Impressa®), and pharmacologic therapy. Minimally invasive interventions include periurethral bulking agent injections (bladder neck injections) and sling plication. Surgical alternatives involve repeat MUS—with or without removal of the existing mesh—salvage pubovaginal sling using autologous fascia, Burch colposuspension, or, in select cases, insertion of an artificial urinary sphincter. In this article, we review the current evidence supporting each of these treatment modalities and describe the management algorithm adopted by our expert panel for patients presenting with SUI following failed midurethral sling surgery.