Study design, materials and methods
We performed a retrospective cohort study of 148 female patients who underwent sling explantation due to complications. All patients underwent comprehensive evaluation, including urodynamic testing, cystoscopy, and standardized questionnaires (UDI-6, ICIQ-SF); pain intensity was quantified using the Visual Analog Scale (VAS). Data were analyzed using descriptive statistics and by comparing the findings with published literature.
Results
The mean age was 56 years (range 31–82), a mean body mass index of 29.4 (IQR 24–31) and 93 women were postmenopausal. The average interval from sling placement to explantation was 3 years, and the mean time to symptom onset was ~14 months postoperatively. The primary indications for sling explantation were chronic pain (29.1%), obstructive voiding symptoms (26.4%), and vaginal mesh extrusion (16.2%). Overactive bladder symptoms were observed in 12.8% of patients, dyspareunia in 8.1%, mesh erosion into the urethra or bladder in 4.7%, recurrent urinary tract infections in 2%, and urethrovaginal fistula in 0.7%.
In the majority of cases (68%), patients presented with overlapping symptoms. Frequent combinations included pelvic pain with dyspareunia (21%), obstructive voiding with OAB (18%), dyspareunia with mesh extrusion (12%), pelvic pain with urgency (9%), complicating diagnosis and requiring a multidisciplinary approach. In 22% of cases the sling was placed concurrently with pelvic organ prolapse repair, notably, 59% of these patients had no documented SUI symptoms preoperatively. Additionally, 8 patients underwent sling implantation based solely on overactive bladder symptoms, without documented SUI. Furthermore, 87.8% of surgeries were performed in low-volume centers, correlating with higher complication rates.
Improper sling positioning was found in 11 cases, with tape located outside the mid-urethral zone (e.g., under the bladder neck or in the proximal urethra), correlating with early (median onset: 6 months) bladder outlet obstruction, extrusion and increased chronic pain. Mesh erosion into the urethra or bladder was occasionally (4 cases) an incidental finding—discovered during difficult catheterization or routine cystoscopy, which also indicates the hidden nature of this complication. This underscores the need for thorough evaluation in patients with atypical or persistent symptoms.
Interpretation of results
The study highlights that complications associated with mid-urethral sling implantation are multifactorial, frequently overlapping, and often remain undetected for extended periods. Diagnostic complexity is evident, with common symptom combinations such as pelvic pain and dyspareunia, obstructive voiding and overactive bladder, or dyspareunia with mesh extrusion complicating patient evaluation. Improper patient selection—particularly sling implantation without documented stress urinary incontinence—significantly contributed to complications. A majority of problematic procedures were performed in low-volume centers, underscoring the importance of surgical experience and standardized techniques. Additionally, incorrect sling placement correlated with early complications like obstruction and extrusion. Incidental discovery of mesh erosion highlights the necessity of thorough postoperative surveillance and routine cystoscopy in symptomatic patients. Prospective studies are warranted to further confirm these findings.
Concluding message
Our study demonstrates that complications leading to sling removal are multifactorial. The findings highlight the importance of surgical expertise, standardized procedures, and careful patient selection — especially when a sling is placed concurrently with pelvic organ prolapse repair — in reducing adverse outcomes. Despite the retrospective design, the large patient cohort lends significant clinical value to the results. Further improvements in sling materials and surgical techniques, as well as prospective studies, are needed to confirm these findings and ultimately improve patient outcomes.