Pre-operative Evaluation Before TOT Removal for Pain

Mid urethral slings had become the predominant procedure for stress urinary incontinence, although their use is falling in many countries now and paused completely in some. It is evident that a proportion of patients with TOT slings have complications that necessitate their removal. However, there is a paucity of data on outcomes after excision to aid with counselling patients on their expected benefits. We will provide a review on literature guiding pre-operative workup required for excision of transobturator tape (TOT) slings for pain. 

A systematic review of excision of all mid urethral slings found a higher risk of recurrent SUI after complete excision compared with partial excision. Similar rates of incontinence were found with staged versus concurrent SUI procedure after complete TOT excision. Multiple studies have observed pain as the most common indication for excision of TOT slings, and complete excision may be associated with better improvement in pain scores compared to partial excision. Multiple case series in the last 5 years have demonstrated improvement in pain after excision of TOT slings, though with very heterogenous methods of measuring pain. 

Counselling patients to the possible outcomes after excision of TOTs is crucial in management. Persistent pain with TOTs may necessitate excision, though may not resolve the pain. The risk of recurrent incontinence needs to be considered against the possible benefits of improvement in pain with partial or complete excision. Ultimately patients need to be empowered to make evidenced based decisions on their own treatment.