To evaluate the long-term reoperation rates for recurrent stress urinary continence (SUI) after primary retropubic and transobturator sling procedures.

We previously published a retrospective cohort study of women who underwent midurethral sling procedures at a single institution for primary SUI between 2002 and 2012. Reoperation for recurrent SUI and sling-related complications (incomplete bladder emptying or mesh exposure requiring surgical excision) was assessed by review of the EMR with follow-up extended from December 2013 (original paper) to December 2022 for the present analysis. Because sling type was not randomly assigned, women in both groups were matched using a greedy algorithm on age, BMI, isolated compared with combined procedure, and preoperative diagnosis to obtain a less-biased comparison of outcomes.

Median time to reoperation was 2.8 years (interquartile range 0.7–5.8) and 1.5 years (interquartile range 0.7–5.0) for the retropubic and transobturator groups, respectively. Median follow-up for the remaining patients without reoperation was 11.8 years (interquartile range 6.7–14.7 years) for retropubic sling and 10.1 years (interquartile range 3.4–14.0 years) for the transobturator slings.

Within the full cohort, 98 women underwent reoperation for recurrent SUI (4.4% (69/1,551) with a retropubic sling and 8.8% (29/330) with a transobturator sling). This represents 23 new cases of reoperation within the 9 years of extended follow-up. The cumulative incidence rates of reoperation for SUI at 6, 12, and 18 years were 4.9% (95% CI 3.0-6.8%), 6.5% (95% CI 4.2-8.7%), and 6.5% (95% CI 4.2-8.7%) in the retropubic group and 8.4% (95% CI 5.0-11.7%), 11.6% (95% CI 7.4-15.7%), and 12.5% (95% CI 7.9-16.8%) in the transobturator group. This increased risk of undergoing reoperation for SUI for women with a transobturator sling (vs retropubic sling) was higher among the women with a combined procedure (full cohort: HR 6.34, 95% CI 3.09–13.02, P<.001; covariate-matched cohort: HR 3.96, 95% CI 1.35–11.58, P=.01) than among the women with an isolated procedure (full cohort: HR 1.58, 95% CI 0.91–2.72, P=.10; covariate-matched cohort: HR 1.51, 95% CI 0.84–2.74, P=.17).

Women who had a retropubic sling continued to be at an increased risk of needing a subsequent surgery for urinary retention (covariate-matched cohort: HR 8.39, 95% CI 1.11–63.22, P=.04) compared with women in the transobturator group. Subsequent surgery for mesh exposure was still similar between groups. The cumulative incidence of sling revision for urinary retention in the covariate-matched cohort plateaued at 3.1% by 5 years and remained higher in the retropubic group compared with the transobturator group for the duration of follow-up (3.1% vs 0.4%, respectively, by 15 years).

Women who underwent a transobturator sling are at significantly greater risk of needing a reoperation for recurrent SUI than those who had a retropubic sling. Interestingly, the majority of the increased reoperation risk is attributed to transobturator procedures combined with prolapse repairs and occurred within 4 to 6 years from the index repair. Within the covariate-matched cohort, women who were continent after 6 years remained free of reoperation for remaining 12years of follow-up. There is a continuous low reoperation rate for isolated procedures.

We evaluated a homogenous cohort of women undergoing their first operation for SUI, with and without concomitant prolapse repairs. Ajustment for known confounders enabled us to provide long-term reoperation rates for recurrent SUI and for surgical complications associated with the two contemporary and most relevant surgical treatments of SUI with minimized bias. Patients should be counseled about increased risk of reoperation if undergoing a transobturator sling combined with prolapse repairs.

Trabuco EC, Carranza D, El Nashar SA, Weaver AL, McGree ME, Elliott DS, et al. Reoperation for Urinary Incontinence After Retropubic and Transobturator Sling Procedures. Obstet Gynecol. 2019;134(2):333-42.
Kenton K, Stoddard AM, Zyczynski H, Albo M, Rickey L, Norton P, et al. 5-year longitudinal followup after retropubic and transobturator mid urethral slings. J Urol. 2015;193(1):203-10