Long-Term Outcomes After Transobturator Sling Placement by a Single Surgeon

Objectives: Minimally invasive mid-urethral slings (MUS) are standard treatment for stress urinary incontinence (SUI). The majority of studies on MUS focus on retropubic slings. Transobturator mid-urethral slings (TO-MUS) were introduced with the goal of minimizing adverse events, but data on long-term efficacy and safety are limited. Few studies report TO-MUS outcomes beyond five years. To date, only three studies have a mean follow up greater than ten years. Our objective was to report long-term outcomes of TO-MUS placed by a single surgeon.

Methods: We conducted a retrospective review of all patients who underwent TO-MUS placement by a single surgeon at a large academic center between 2010 and 2014. Our primary outcome was rate of reoperation. Secondary outcomes included patient-reported success, reason for reoperation, and risk factors for recurrent SUI.

Results: There were 329 patients who underwent TO-MUS placement during the study period. Patients with no follow up or who had prophylactic sling placement at the time of prolapse surgery were excluded, yielding 295 patients for final analysis. See Table 1 for patient characteristics. Median follow up time from date of surgery was 3.0 [interquartile range (IQR) 0.15-4.82] years, with 56 (19.0%) patients following up for more than 10 years. The majority of patients were white, non-Hispanic, post-menopausal, overweight (average body mass index (BMI) 25.6 kg/m2), and had a history of two vaginal deliveries.

In total, there were 20 (6.8%) patients who had a reoperation. Of these, 12 (4.1%) had reoperation due to recurrence of SUI (4 with repeat sling placement and 8 with urethral bulking), 7 (2.4%) due to mesh exposure, and 1 (0.3%) for urinary retention. Median time to reoperation was 3.9 [IQR 1.0-6.8] years. See Table 2 for outcomes stratified by follow up time. Among the 56 patients with greater than ten years of follow up, 43 (76.8%) had no recurrence of SUI, 6 (10.7%) had reoperation, 3 (5.4%) reported recurrence but did not have subsequent procedures, and 4 (7.1%) reported mild SUI that was not bothersome. Patients with recurrent SUI had no significant difference in race, menopausal status, use of vaginal estrogen, number of prior vaginal deliveries, or BMI compared to patients without recurrent SUI.

Conclusions: Following TO-MUS placement, 76.8% of patients reported no SUI at follow up more than ten years after placement. Only 10.7% of patients required reoperation for recurrent SUI after ten years. These findings support long-term TO-MUS efficacy and risk of reoperation and may help with preoperative counseling of patients.

Table Legend:
Table 1: numbers are mean ± standard deviation or n(%)
Table 2: numbers are n(%)