Success of Autologous Pubovaginal Sling after Failed Synthetic Mid Urethral Sling

Purpose: There is no consensus on the management of persistent or recurrent stress incontinence after a failed synthetic mid urethral sling. After a mesh complication or sling failure many women and surgeons prefer to avoid a repeat mesh procedure and choose an autologous pubovaginal sling. However, little empirical work has been performed to assess the efficacy. Materials and Methods: We performed a retrospective review of 66 women who underwent autologous pubovaginal sling with rectus fascia after 1 or more failed synthetic mid urethral sling from 2007 to 2012. Results: Mesh removal was performed before autologous pubovaginal sling in 21 patients (31.8%) while 6 (9.1%) had mesh removed simultaneously with autologous pubovaginal sling. Indications for the autologous pubovaginal sling were pure stress urinary incontinence in 16 patients (24.2%) and mixed incontinence in 50 (75.8%), 8 of whom were deemed complex with a prior urethral diverticulum or urethrovaginal fistula/urethral mesh erosion. At a mean of 14.5 months after autologous pubovaginal sling 46 (69.7%) patients reported cure of stress urinary incontinence. Of these patients 25 (37.9%) had complete cure with no stress or urgency incontinence, 17 had cure of stress urinary incontinence but had persistent urgency incontinence, and 4 had cure of stress urinary incontinence but experienced do novo urgency incontinence. Requiring a mesh excision did not predict worse outcomes compared to cases in which mesh was not removed (p=0.13). Patients with pure stress urinary incontinence were significantly more likely to be cured of all incontinence (62.5%) than those women with preoperative mixed incontinence (30.0%) (p=0.006). Conclusions: Even after a failed synthetic mid urethral sling, autologous pubovaginal sling is effective and cured stress urinary incontinence in 69.7% of cases.