Transvaginal Retropubic Versus Transobturator Midurethral Sling in the Treatment of Recurrent Stress Urinary Incontinence.

Introduction: Transvaginal retropubic (TVT-R) and transobturator (TVT-O) midurethral slings are the main surgical options for stress urinary incontinence (SUI). Surgical indications for each of them are defined by clinical and history presentation. These techniques play a particular role in SUI recurrence after a previous urinary incontinence surgery, although there are few studies comparing their efficacy. This study aims to compare the outcomes of TVT-R versus TVT-O sling procedures in patients with recurrent/persistent SUI who were submitted to a previous incontinence surgery.

Methods: Retrospective and comparative study including all patients submitted to a repeated midurethral sling procedure due to recurrent/persistent SUI between January 1st 2019 and December 31st 2023 at the Gynecology Department of Unidade Local de Saúde (ULS) of Coimbra, Portugal. Demographic and clinical characteristics, surgical efficacy, and intra and postoperative complications were collected through medical records. At least eight months of follow-up were accomplished. Statistical analysis was performed using SPSS software, version 26.0 (IBM Corp., Armonk, NY), considering a significant p-value <0.05.

Results:  Overall, 860 women were submitted to a midurethral sling procedure, of which 806 (93.7%) placed a transobturator sling and 54 (6.3%) a retropubic sling. Of these, 42 underwent repeated incontinence surgery due to recurrent/persistent SUI, of which 28 (66.7%) TVT-R and 14 (33.3%) TVT-O. No statistically significant differences were found between patients undergoing TVT-R vs TVT-O, considering the median age, body mass index, parity, and postmenopausal status (p=non significant (n.s.). There was a significant difference in urethral mobility prior to surgery between groups, with most TVT-R patients having fixed urethra and most TVT-O patients having mobile urethra (p<0.001) The rate of intraoperative and immediate postoperative complications was similar in both groups (10.7% vs 7.1%, p=n.s.. Bladder laceration was the most common complication, reported only in the TVT-R group. There was a complete resolution of SUI complaints after surgery in 75.0% and 85.7% of cases, respectively (p=n.s. Long-term complications were also similar in both groups (21.4% vs 14.3%, p=n.s., with a worsening/appearance of urge urinary incontinence in 17.9% 21.4% of cases (p=n.s.).

Conclusion: In the present study, retropubic midurethral sling was the most performed procedure in the treatment of SUI recurrence after previous incontinence surgery. Efficacy rates in SUI treatment were high in both groups, with no statistically significant differences between the two surgical techniques. Although it was expected that TVT-R would result in a higher rate of complications given its greater surgical complexity, there were no differences between both groups in terms of intra and postoperative complications. Therefore, we should select the surgical option that provides the best conditions for the treatment of recurrent/persistent SUI, avoiding major complications and in accordance with the clinical assessment and the patient's preference.