Stress urinary incontinence (SUI) is a very common condition in women, associated with physical morbidity, sexual dysfunction, loss of independence and psychosocial well-being. Currently, the gold standard in treatment is the placement of midurethral sling (MUS), with different approaches, however, the decision criteria for the many types of approach are debatable, without reaching a universal consensus (3). The primary aim of the study was to determine the efficacy of the "mobile application" model as a tool in the surgical decision to select a midurethral sling for SUI.

A historical cohort was performed, as inclusion criteria: women >18 years of age with a diagnosis of stress urinary incontinence (SUI) and/or mixed urinary incontinence (MUI), undergoing anti-incontinence surgery with midurethral sling at Urogynecology service of a third level medical center in Mexico City from January 2016 to March 2023.

A web app was developed using the eBavel tool, which creates dynamic form capture applications, the following 3 forms were created:
Patient registration where the following variables are recorded: Age, Scholarship, Occupation, Height, Weight, Body Mass Index, Gestations, Births, Ectopic, Maximum birth weight, Complications during delivery, Episiotomy, Tears, Forceps, Menopause, Prolapse, Sandvick Index.

Calculation of surgery where the following variables were recorded: Urodynamic study, ALPP, Cough stress test (CST), McGuire´s type of SUI, UUI, Recurrence, Immunological alteration and Chronic pelvic pain. When all these variables are answered, an automatic calculation is performed where it recommends the type of surgical approach recommended for each patient: TOT (transobturator), TVT (retropubic) or Remeex® (external mechanical regulator) female system  placement.

Postoperative records, this section is subdivided into immediate postoperative period, recording variables: date of surgery, surgery recommended by calculation, surgery performed, concomitant prolapse surgery, type of prolapse surgery, time on surgery, bleeding, days of hospital stay, complications. In the postoperative follow-up sections at one month and one year, the following variables were recorded: Urgency prior to the procedure, Urgency de novo, IUU prior to the procedure, IUU de novo, SUI, Voiding Symptoms, Postoperative Pain, CST, Residual Urine and Healing.

We examined 298 records, of which only 243 patients met the inclusion criteria and were included in this study. The mean age was 63.18 years (± 9.9 years). The mean BMI was 28.69, The mean maximum gestational weight was 3451.85 (± 559.999) and the use of forceps, tears and episiotomy 5.3% and 8.2%, 0.1% of the patients were in menopause and immunological alterations were rare, being only in 0.8%, complications at delivery were rare (0.8%), also we found a prevalence of MUI in 54.3% of the present sample. A recurrence of SUI was found in 11.5 %.
Out of 243 patients, 127 (52.3%) had urodynamic study. The type of incontinence was classified according to McGuire: type 0 (25%), type I (12.3%), type II (7.4%) and type III (7%), CST: positive empty bladder (18.9%), negative CST with 200-300 ml (17.3%), positive CST with 200-300 ml (11.5%). 

Subjective success rate at 1 month postoperatively was 97.9% with a 2% persistence of SUI, objective success rate was 97.9% and persistence of SUI of 2.1%. At 1-year subjective success rate was 97.1% with 2.9% recurrence of SUI, for objective success rate was 97.9% with recurrence of SUI at 2.1%. The subjective success rate at 1 year for each type of approach was 100% for TOT, 95.8% for TVT and 80% for the Remeex® female system, and the objective success rate was 99.3%, 97.2% and 90%.

The mobile app final recommendation was mostly TOT (63.4%), followed by TVT/REMEEX® (17.7%), TVT (16.9%) and REMEEX® (2.1%) (Figure 1).  The effectiveness of the mobile app in predicting the surgery recommended by experts was analyzed. A concordance 205% cases (84.4%) was found (Figure 2). Secondly, the app results and the experts were classified as: 0 TOT approach 1 TVT approach. With this classification, the Cohen's Kappa value was calculated, finding a value of .745 (95% CI: 0.65876-0.83124) with a p <0.001.

The mobile app developed in the present study proved to be a great tool, which, based on the characteristics of each patient, suggests a specific type of approach, obtaining a high concordance with the decisions made by the experts, as well as a high cure rate.
The results of our study show a subjective cure rate of 100% for the TOT approach technique, 95.8% for TVT, with objective cure rates of 99.3% for TOT, 97.2% for TVT, subjective and objective cure rate of 80% and 90% with Remeex® female system, concordant with that reported by M. Plata et al. 2018 (2), which reports a subjective and objective cure rate of 90% and 84%. 
These findings are consistent with those reported by Ford et al.2017 (1) in their systematic review, who reported subjective cure rates of 62-98% and 71-97% for the TOT and TVT approach, as well as objective cure rate of 85.7% for TOT and 87.2% for TVT, evaluated at 1 year.

The association between the concordance between the recommendation of surgery by the App and the decision made by the experts and the proportion of urinary incontinence at one month, 1 year, complications, and the cure at one month and one year was analyzed. We emphasize that our success rates are in line with the results previously documented in the literature, and, moreover, show a trend towards the upper end of this range, suggesting a remarkable efficacy of the approach techniques used in our study, This cohen value of .745 reports a substantial agreement between the mobile App and the decision made by the experts.

The selection of the surgical approach to treat SUI with MUS should not be based exclusively on statistical criteria, but should take into account the type of incontinence, her medical history, individual characteristics of each patient and comorbidities, in order to determine the best therapeutic alternative.
Although our study has shown favorable results for the choice of surgical approach using the mobile app as a selection tool, it is crucial to emphasize that this tool should not replace the clinical judgment of the surgeon.

Ford, A. A., Rogerson, L., Cody, J. D., Aluko, P., & Ogah, J. A. (2017). Mid-urethral sling operations for stress urinary incontinence in women. Cochrane Database of Systematic Reviews, 2017. https://doi.org/10.1002/14651858.CD006375.pub4
M. Plata. (2018). Effectiveness of the Remeex systemTM in Colombian women with recurrent stress urinary incontinence or intrinsic sphincter deficiency. International Urogynecology Journal.
Imamura, M., Hudson, J., Wallace, S. A., Maclennan, G., Shimonovich, M., Omar, M. I., Javanbakht, M., Moloney, E., Becker, F., Ternent, L., Montgomery, I., Mackie, P., Saraswat, L., Monga, A., Vale, L., Craig, D., & Brazzelli, M. (2019). Surgical interventions for women with stress urinary incontinence: Systematic review and network meta-analysis of randomised controlled trials. The BMJ, 365. https://doi.org/10.1136/bmj.l1842