Diagnosis and treatment of synthetic mid-urethral sling complications

Synthetic Mid-Urethral Slings (SMUS) have been widely used with benefit to many women. Complications arise in a small proportion, occurring acutely in the perioperative stage, post-operatively and in a delayed fashion many years after implantation. Clinical trials provide data on selected patients who are as homogeneous as possible. Real world studies rarely provide detail on the denominator population from which the sample originates. Mature clinical quality registries (CQR) provide long term data on a non selected population who have undergone a procedure for a given condition. Near complete case ascertainment is the goal and there are many examples in other clinical areas. Due to the serious and potentially life changing nature of some of the complications that may arise following SMUS, health agencies instigated action on behalf of patients to promote improvements in care. The International Continence Society (ICS) assembled a multidisciplinary working group to forge this guidance. The working group includes 2 consumer advocates and relevant medical expertise. The management of complications following SMUS placement is discussed and algorithms are provided for each of the common complications of SMUS. The recommendations are based on an expert consensus derived from experience and limited data from a multiple narrative and systematic reviews of the literature. Due to a retrospective design, low cohort numbers, short follow-up and inconsistent definitions, all the studies were at high risk of bias (Figure 1). This overview of SMUS complications commissioned by the ICS aims to provide background literature and algorithms for management of common problems that may present, though it is not exhaustive. Problems such as recurrent urine infection and overactive bladder may have their root cause in an obstructive SMUS. The temporal link between sling implantation and onset of symptoms is not always evident and patients are not always aware that an SMUS was implanted as part of a pelvic floor procedure. Clinicians need to be assiduous in their history taking and physical examination to determine the likely root cause using imaging or other tests judiciously. Multi-disciplinary teams (MDT) are required particularly where chronic pain has developed