LAUSR

Dear Editors, We thank Dr Petros for his interest in and comments on our study [1]. To clarify, the paper compared early intervention of midurethral sling (MUS) loosening after 7 days for postoperative voiding dysfunction (VD) with a plan of continued catheterization with intervention only if the VD did not resolve. Timing of any intervention was determined by the patient, and not delayed to 6 months for all women. A recommendation to intervene Bwithin 48–72 h at most^ [2] is surprising, given that studies suggest that most cases of VD might resolve within the first week or two post-MUS insertion [3]. Therefore, it seems reasonable to delay any intervention until after post-operative day 7. The ethics of each management approach were considered in the design of our study. It is easy to criticize Bthe ethics of women going through... catheterization with its hazards of infection, discomfort, expense^ [2], but at the time of the study development, a scenario of true equipoise existed. It was not known if either technique was superior at resolving VD without compromising the cure of SUI. Additionally, women in our study selected their ownmanagement approach. Participants made informed choices about their care after being counseled with the best available evidence at the time. Any suggestion of unethical care is unfounded. Dr Petros raises the discussion of tape elasticity properties. We are in agreement that any attempts to stretch a tape would be expected to fail owing to the elastic recoil of polypropylene. In our experience, elasticity is not actually a concern when a sling is loosened properly because with mobilization the MUS is not being stretched, but rather one distal arm is entirely moved en bloc from the original insertion position. The statement that understanding the Bcontribution of... variables^ that determine optimal sling tension Bdoes not matter. Somehow the surgeons get it right for the most part^ [2] merits scientific examination rather than simply being taken as an article of faith. Women deserve a more scientific approach to their surgical care. Recognizing that voiding dysfunction is a highly distressing outcome after MUS, our group developed a randomized clinical trial comparing two tensioning techniques with the primary outcome of abnormal bladder function at 12 months post-surgery [4]. The study has recently concluded enrollment, results are anticipated in early 2019. Dr Petros’ suggestion that women in the catheterization group may be at risk of tape contraction over time, leading to slow development of lower urinary tract symptoms, is very interesting. Investigation of this idea using a new prospective study would be difficult because of the proposed slow, insidious rate of mesh contraction. However, perhaps those groups who conducted large, detailed studies ofMUS procedures ≥10 years ago could consider long-term follow-up to compare if healthcare utilization is higher for those women who had Belevated, but normal^ post-void residuals after surgery. We are excited that evidence for the best management of early VD continues to accumulate, including a large registry study by Moksnes et al. [5], which echoes our findings. Research regarding quality improvement of MUS outcomes and complications is urgently needed. This reply refers to the comment available at https://doi.org/10.1007/ s00192-018-3589-3