Which factors influence success of recurrent surgical treatment of stress urinary incontinence?

Objectives: Identify factors associated with and increased risk of treatment failure following recurrent surgical treatment of SUI.

Methods: A retrospective cohort of all patients who had a secondary surgery for SUI between January 2002 and December 2012 at our institution were included regardless of primary surgery type. The International Consultation on Incontinence Questionnaire (ICIQ) was mailed between February and December 2016. The electronic medical record was reviewed to obtain pre-, intra-, postoperative, and demographic data. Primary surgery was categorized into 3 groups: midurethral slings [retropubic, transobturator (TO), and single incision sling (SIS)], bulking agent, and “other” [allograft sling, Burch, MMK, bladder neck suspension, and other bladder repairs]. Treatment failure was defined as ICIQ score >5 or occurrence of third anti-incontinence procedure. Cox proportional hazards models, adjusted for age, were fit to evaluate factors for an association with treatment failure after the secondary surgery.

Results: Among 352 women who met the study inclusion criteria, 162 were identified as treatment failures (including 52 with a third procedure and 110 with ICIQ score >5). The 5-year Kaplan-Meier estimate of the cumulative incidence of treatment failure was 32.2 (95% CI, 26.3-37.6) after secondary surgery.

Among 120 women whose primary surgery was midurethral sling, the risk of treatment failure following the second surgery was not associated with type of procedure (age-adjusted p=0.78).

However, among the 47 women whose primary procedure was a bulking agent the risk of treatment failure was significantly associated with type of secondary surgery (Figure 1; age-adjusted HR 3.85, 95% CI 1.12-13.30 for TO/SIS, HR 15.16, 95% CI 4.03-57.02 for bulking agent vs. retropubic).

Similarly, among the 185 women whose primary surgery was “other” the risk of treatment failure was also significantly associated with type of secondary surgery (Figure 2; age-adjusted HR 2.07, 95% CI 1.14-3.76 for TO/SIS, HR 3.66, 95% CI 1.70-7.92 for bulking agent, HR 1.83, 95% CI 1.05-3.18 for bladder neck sling vs. retropubic).

Conclusions: Women who had a primary bulking agent or “other” procedure are at increased risk of treatment failure if they undergo a secondary TO/SIS or bulking agent. Patients who underwent “other” primary procedures also had a higher failure rate after a secondary bladder neck sling. Retropubic midurethral slings provide more favorable secondary surgical outcomes.