38 To date, however, there are insufficient data to determine whether cure rates differ significantly between the repeat retropubic and transobturator routes, and whether complication rates are higher after secondary than primary MUS procedures. Use of a re-adjustable sling for recurrent SUI with sphincteric deficiency is currently under investigation. Use of the Remeex (Neomedic, Barcelona, Spain) re-adjustable sling (Fig. 1) showed that, after

3 years, 109 of 125 (87.2%) women were continent under stress after initial surgery, including 49 of 55 (84%) with recurrent SUI and 60 of 70 (85.7%) with ISD.44 Moreover, 19 of these patients showed additional benefit from JAK inhibitor a subsequent re-adjustment. The rate of infection of the re-exposed varitensor during adjustment was lower, while the development of de novo overactivity (8%) was similar to results observed with the other sling type. A prospective study of the AMI adjustable suburethral sling (Agency for Medical Innovation GmbH, 6800 Feldkirch, Austria) (Fig. 245) implanted through the retropubic route in 25 patients with recurrent urodynamic SUI showed that 21 of the patients were urodynamically continent after 12 months.46 A recent study described the use of a transobturator

crossover re-adjustable sling as a salvage procedure for failed anti-incontinence Inhibitor Library cell assay procedures (Fig. 3).47 This SAFYRE t plus sling (Promedon, Cordoba, Argentina) consists of a monofilament polypropylene mesh between two self-anchoring Alanine-glyoxylate transaminase columns. The procedure is performed by creating a spiral sling for better circumferential coaptation

of the urethra. Moreover, silicone washers are used in the genitofemoral fold at the level of the clitoris, both to improve fixation and facilitate later adjustments. Re-adjustments were easily performed under local anesthesia by moving the washers until there was no urine leakage during valsalva maneuver. After 12 months, the overall cure rate was 93.7% (15/16), with only one patient requiring re-adjustment. During surgery, however, one patient experienced a urethral perforation, which was resolved by closing the urethral operation. The adjustable continence therapy (ACT) device consists of two adjustable balloons, each attached to an injection port placed subcutaneously in the labia majora (Fig. 4).48 After 6 years, 68% of patients remained dry.49 The pubovaginal sling has shown success rates ranging from 50 to 90% in the treatment of women with persistent or recurrent SUI. A trial of the pubovaginal sling in patients with all types of SUI divided patients into simple and complex groups, with mean numbers of prior incontinence surgeries of 0.78 and 3.1, respectively.50 After 1-year follow-up, SUI was cured in 183 women (73%) and improved in 48 (19%). After a >10-year follow-up in 20 women, the success rate was 95%.