Continence Outcome and Management Following Urethral Erosion of the Paravaginal Sling
Drs. Cindy Amundsen, Brian J. Flynn, George D. Webster
Duke University Medical Center
Durham, North Carolina

Purpose: Urethral erosion of a pubovaginal sling is most commonly reported following use of synthetics and the anticipated outcome is that following sling removal incontinence will recur.  We present a series of sling erosions including erosions following autograft and allograft use and discuss their management and their continence outcome.
Methods: Between May 1998 and May 2001, 57 patients underwent surgical treatment of urethral obstruction after a pubovaginal sling.  Nine patients (16%) had urethral erosions in addition to their urethral obstruction and required urethral repair.  Preoperatively, patients were evaluated with a urologic history, pad usage, cystoscopy, and urodynamics. Post operatively, patients were evaluated for continence status, voiding dysfunction, and subsequent procedures.
Results: Of the eroded slings, 5 were allograft fascia lata , one was autologous rectus fascia, 2 were woven polyester slings treated with bovine collagen and one patient had a prolene mesh sling.  Preoperatively, 50% of the patients were in total retention, the other half had urge incontinence requiring an average of 3 pads/ day. The average followup was 23 months,(range 4-40). Patients with allograft or autologous graft erosion were treated with a midline incision of the sling  and primary repair of the underlying urethral injury by local debridement and suture. Of these 6 patients, none have recurrent stress urinary incontinence; however 2 patients have persistent urge incontinence requiring 1.5 pads/ day.  The 3 patients with synthetic material were treated with removal of the sling and 2 patients required Martius labial flaps to support the urethral repair.  Two of the three patients developed recurrent stress incontinence requirinq management. No patient developed a urethrovaginal fistula.
Conclusion:   Urethral erosion after sling placement may occur with allograft, autologous or synthetic material.  Addition techniques may be required in the initial surgical management when synthetics were used and patients may require subsequent procedures to maintain continence. The incidence and magnitude of recurrent stress incontinence is surprisingly low considering the injury to the urethra.
Key words: urethral erosion, incontinence, pubovaginal sling