Midurethral sling are widely regarded as a standard surgical treatment for women with urinary stress incontinence (USI) because of their minimally invasive nature, durable success rates, and favourable safety profile. The retropubic midurethral sling, a revolutionized surgical management by providing an effective synthetic suburethral support placed through the retropubic space. Although highly effective, the retropubic approach carries known risks related to trocar passage behind the pubic bone—such as bladder perforation, vascular injury, and bowel injury—which prompted the development of alternative approaches. To address these concerns, the transobturator midurethral sling provides a lateral trajectory through the obturator foramen, avoiding the retropubic space altogether. While transobturator slings demonstrate comparable efficacy, the efficacy of transobturator sling was showed to be lower in women with intrinsic sphincter deficiency (ISD) than retropubic sling. A mixed model of using both slings for women with USI: retropubic tape for women with ISD while transobturotor sling for women without ISD were evaluated on the intermediate efficacy and complications.

This is a retrospective analysis of the prospectively collected database from 2020-2021 in a territory referral center. Women who received a mid-urethral sling for USI in our urogynaecological unit were included in the analysis. Their basic demographics, pre-operative urodynamic diagnosis including Valsalva leak point pressure (VLPP), tape of midurethral sling, post operative urinary symptoms and any complication were documented. ISD is defined as VLPP< 60cmH2O.  Urinary symptoms including stress incontinence and urge symptoms were rated by women during the 1-year and 3-year follow up visit.

Over the study period, total of 74 women were included for analysis, with the mean age was 61.5 (SD: 10.3) years old, median parity of 2 (range 1-5). 10.8% (8/74) of them had ISD and received retropubic slings while the other had transobturator slings. The intermediate outcome after the midurethral slings operation was listed in Table 1. There were no major intra-operative complication including major bleeding or visceral injury. Within 3 years of postoperative period, there were 4 women complicated with tape material erosion in vaginal required estrogen cream application and excision of exposed tape under local anaethesia. Their symptoms all resolved after the procedures. There was one woman with significant urinary urge incontinence required anti-cholinergic for 1 year with symptoms improved.

In this model of performing retropubic tape for women with ISD while transobturator tape for women without ISD, the subjective cure rate was high with 82.4% at 1 year and 90.5% at 3 year. The de novo urinary urgency incontinence was low at 9.5% at 3 year. The subjective cure rates seem to be better than in our previous publications in women who received transobturator tape and with lower rate in de novo urge incontinence. And the overall complication was also low.

The model of performing retropubic sling for women with USI and ISD and transobturator sling for women without ISD is a highly efficient and safe approach to address women with different VLPP as shown in intermediate 3 years’ time.

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