Stress urinary incontinence (SUI) is a very prevalent voiding disorder among adult women, with rates that reach 34%. The mid-urethral sling (SMU) is the surgical treatment of choice worldwide [1]. It has become the standard technique for treating SUI, and one of the most common complications is urinary obstruction. The literature estimates that 1 to 10% of patients require the use of an indwelling catheter up to 28 days of surgery [2, 3]. The lack of standardized mid-urethral sling placement, the concern of possible persistent incontinence, and the widespread use of the technique among low-volume surgeons can explain such rates of obstruction. Despite constant discussions regarding the use of synthetic mesh versus autologous fasciae for the SMU, none of them is free from the risk of urethral obstruction and urinary retention. 

The classical urethrolysis with tape removal has good results but is related to high urinary incontinence recurrence rates. Among the treatment options for urethral loosening with urinary continence maintenance, the double opposite tape incision rises as an alternative as an early urinary retention salvage technique. This video demonstrates an alternative treatment for urinary retention after SMU implantation,  which aims to release the urethral compression and keep urethral support.

We present a video of a 43-year-old patient with acute urinary retention after transobturator sling for stress urinary incontinence. She presented complete urinary retention after the procedure and started clean intermittent self-catheterization for 28 days. Once there was no improvement, she performed the uroflowmetry exam that showed a maximum flow rate of 4.3 ml/s, a voided volume of 130 ml, and a post-voiding residual of 273 ml. She had a urodynamic exam before the sling procedure in which there was no sign of detrusor dysfunction. Also, the urethrocystoscopy showed extrinsic urethral compression and reduced urethral mobility. Then,  the double opposite tape incision was proposed to release the urethra and keep some urethral support, trying to maintain continence. 

The surgery started with an inverted “U” incision along the anterior vaginal wall to allow total access to the sling. It was identified and mobilized from the urethra by blunt dissection,  followed by the section of the adhesions around the tape. A partial incision of the tape was made, laterally to the urethra, starting from the right side upwards. The extension of the cut was more than half of the tape’s width, and it is crucial to achieving tape elongation. However, it is essential to take care and not cut the sling completely. Then we did a similar incision at the left side, but from top to bottom at this one. Finally, the vaginal wall was closed with absorbable interrupted sutures of 2.0 polyglactin. We placed a vaginal pack embedded with neomycin and bacitracin cream and a 16Fr Foley catheter. We removed both on the first postoperative day when she left the hospital.

After one week from the surgery, the patient resumed her usual activities, while sexual intercourse and physical activities were allowed after six weeks. She is satisfied without low urinary tract symptoms. Uroflowmetry confirmed improvements with a higher maximum flow rate and no post-voiding residual. The two opposite tape incisions allowed a slight elongation, sufficient to relieve urethral compression, but still kept the urethral support, maintaining the sling function.

This video demonstrates a surgical treatment for urinary obstruction due to mid-urethral sling without sling excision. To our knowledge, this method has not been described before and also showed to be feasible and effective. Concerning our unique case at tape mobilization and opposite partial section, further studies are required to compare this technique to other surgical treatment options

Bazi T, Kerkhof MH, Takahashi SI, Abdel-Fattah M; IUGA Research and Development Committee. Management of post-midurethral sling voiding dysfunction. International Urogynecological Association research and development committee opinion. Int Urogynecol J. 2018;29(1):23-28.
Malacarne DR, Nitti VW. Post-Sling Urinary Retention in Women. Curr Urol Rep. 2016;17(11):83.
Blaivas JG, Purohit RS, Benedon MS, et al. Safety considerations for synthetic sling surgery. Nat Rev Urol. 2015;12(9):481-509.