Pelvic organ prolapse (POP) and stress urinary incontinence (SUI) are prevalent pelvic floor disorders that can significantly affect a woman's quality of life. While these conditions frequently coexist, they may require separate surgical interventions for optimal management. However, in specific cases, simultaneous transobturator tape (TOT) placement with classical repair of POP and uterosacral ligament (USL) augmentation may be considered as a comprehensive approach to address both POP and SUI concurrently. This integrated surgical strategy aims to provide robust pelvic floor support, improve continence outcomes, and streamline the treatment process for patients. Schematic representation showing postoperative tape position can be seen in Figure 1. In this study, we explore the specific indications, benefits, and considerations surrounding the simultaneous approach to TOT placement with classical repair of POP and USL augmentation.

The study retrospectively evaluated the efficacy and safety of simultaneous transobturator tape (TOT) placement with classical repair of pelvic organ prolapse (POP) and uterosacral ligament (USL) augmentation in patients with stage II-IV POP. Conducted at a monocentric institution by a single experienced surgeon, the study reviewed medical records and outcomes of 78 female patients (median age 61 years [38-80 years]) undergoing the procedure between January 2017 and February 2023 (shown in Figure 2). Patients had stage II-IV POP-Q (pelvic organ prolapse quantification system) with anterior and central compartment prolapse. Surgical interventions involved TOT placement with self-cut tape-implants for USL augmentation using non-absorbable polypropylene tape. Ethical approval was obtained, adhering to the Declaration of Helsinki. The surgical technique evolved based on previous experience, with tape size reduction and modification of the operative approach. Clinical outcomes were assessed using the International Continence Society (ICS) staging system and questionnaires for continence and sexual function, and postoperative complications monitoring.

The study outcomes underscored the efficacy and safety of the simultaneous TOT placement with classical repair of POP and USL augmentation. Anatomical restoration, assessed using the International Continence Society (ICS) staging system, revealed remarkable success rates, with 98% of patients achieving ICS stage zero at both 3 and 12 months postoperatively. This indicates robust pelvic floor support and effective management of POP. Additionally, the procedure exhibited a low incidence of complications, with only one serious complication observed, involving peritonitis with ileus and subsequent removal of tissue implant. Intraoperative complications were notably absent, and there were no instances of POP recurrence during the study period. The study reported three minor postoperative complications, accounting for 5% of the cases. These included two cases of implant material exposure and one case of de-novo overactive bladder symptoms with borderline urine retention. All minor complications were effectively managed, further highlighting the procedure's safety and efficacy. Patient satisfaction rates were high, emphasising the positive impact of the comprehensive surgical approach on quality of life.

The innovative surgical approach of TOT placement with classical repair of POP and USL augmentation, described in this study offers a notable departure from traditional methods of treating POP. By employing tension-free insertion of apical tapes directed towards the USL, the technique minimises the risk of postoperative dyspareunia and reduces complications associated with tape materials, akin to TVT-O procedures. Notably, the procedure's aesthetic advantage is evident through discreet skin incisions in the femoral-genital folds, enhancing patient satisfaction. Furthermore, simultaneous TOT placement with classical POP repair and USL augmentation presents a comprehensive solution for patients with mixed urinary incontinence or moderate to severe POP with associated stress urinary incontinence, offering anatomical support across pelvic compartments. It can be tailored to individual patient needs, addressing both apical and anterior prolapse while improving urethral support and continence mechanisms. However, the approach demands careful consideration due to increased surgical complexity, potential tape-related complications, and the need for long-term monitoring to address recurrence risks. Patient selection and thorough counselling emerge as pivotal factors in achieving optimal outcomes and patient satisfaction.

Simultaneous TOT placement with classical repair of POP and USL augmentation is a safe and effective surgical approach for addressing both SUI and POP concurrently. While the procedure offers numerous benefits, careful patient selection, thorough counselling, and obtaining informed consent are essential. Further research is needed to assess long-term effectiveness and safety outcomes. This study contributes to the growing body of evidence supporting the use of simultaneous procedures for pelvic floor disorders and highlights the importance of individualised treatment approaches in optimising patient outcomes and satisfaction.