5-Year Longitudinal Follow up after Retropubic and Transobturator Mid Urethral Slings - Commentary

The most commonly performed surgical procedure done for stress urinary incontinence (SUI) is mid urethral slings (MUS)1, with approximately 200,000 SUI surgeries performed annually in the United States, increasing 27% from 2000 to 20092,3. However, there are no long-time studies evaluating the effectiveness of MUS, only 1-2-year outcome data from a randomized clinical trial of retropubic and transobturator MUS in women with SUI4,5. This is important because it has been shown that failure rates for SUI procedures increase time6,7, and complications of SUI surgery, such as urgency urinary incontinence, urinary tract infections, and mesh related problems, may have long-term impact on patient satisfaction and quality of life (QOL). The purpose of this study is then to report long-term outcomes, 5-years, in women who completed the TOMUS (Trial of Mid-urethral Slings).

Women who were in the 1-year and 2-year outcomes of the randomized equivalence trial of retropubic and transobturator MUS were invited to enroll in the observational study. In total, 404 women from the original study (out of 597, 68%) consented and enrolled in the study. Women who underwent surgical retreatment were excluded from the study. The primary outcome, or treatment success, was defined as no retreatment or self-reported stress incontinence symptoms. Secondary outcomes included urinary symptoms, QOL, satisfaction, sexual function, and adverse events of MUS.

The results of the study showed that women assigned to the retropubic sling have higher five year surgical treatment success (7.9%) as compared to the transobturator sling (51.3% vs 43.4%, 95% CI – 1.4, 17.2). In both slings, satisfaction decreased during the 5 years, urinary symptoms and QOL worsened with time (p<0.001). Women with retropubic sling reported greater urinary urgency (p=0.01), more negative impact on QOL (p=0.02), and worse sexual function (p=0.001). However, there was no significant difference in proportion of women experiencing at least 1 adverse event. Similar to their 2-year findings5, long-term treatment success after retropubic MUS was slightly higher than transobturator MUS, while urinary urgency incontinence, sexual function, and overall impression of improvement was better after transobturator MUS. This suggests that treatment success in the retropubic group comes at the cost of QOL and other symptom improvement, which transobturator did much better.

Some limitations of the study included slightly lower retention rate (67%) from the original study. Because of this, mesh exposures may be slightly higher than reported, which may not be overrepresented in the study population. In conclusion, long-term treatment success and satisfaction decreased with time in both retropubic and transobturator MUS. Women in the study reported higher satisfaction for the transobturator study even though it had lower treatment success rate. The findings from the study may assist physicians and patients in suggesting slings be offered as first line treatment for SUI8.

Written by: Jaime Landman Professor of Urology and Radiology Chairman, Department of Urology University of California, Irvine

Authors: Kimberly Kenton, Anne M. Stoddard, Halina Zyczynski, Michael Albo, Leslie Rickey, Peggy Norton, Clifford Wai, Stephen R. Kraus, Larry T. Sirls, John W. Kusek, Heather J. Litman, Robert P. Chang, and Holly E. Richter

Affiliations: Northwestern University, Chicago, Illinois (KK), New England Research Institutes, Watertown (AMS, RPC), and Boston Children’s Hospital, Boston (HJL), Massachusetts; University of Pittsburgh, Magee-Women’s Research Institute, Pittsburgh, Pennsylvania (HZ); University of California San Diego, San Diego, California (MA); Yale University, New Haven, Connecticut (LR); University of Utah, Salt Lake City, Utah (PN);University of Texas Southwestern, Dallas (CW), and University of Texas Health Sciences Center at San Antonio, San Antonio (SRK), Texas; William Beaumont Hospital, Royal Oak, Michigan (LTS); National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland (JWK); and University of Alabama at Birmingham, Birmingham, Alabama (HER)

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Reference:

1. Anger JT, Weinberg AE, Albo ME et al: Trends in surgical management of stress urinary incontinence among female Medicare beneficiaries. Urology 2009; 74: 283
2. Oliphant SS, Wang L, Bunker CH et al: Trends in stress urinary incontinence inpatient procedures in the United States, 1979-2004. Am J Obstet Gynecol 2009; 200: 521.
3. Erekson EA, Lopes VV, Raker CA et al: Ambulatory procedures for female pelvic floor disorders in the United States. Am J Obstet Gynecol 2010; 203: 497.
4. Richter HE, Albo ME, Zyczynski HM et al: Retropubic versus transobturator midurethral slings for stress incontinence. N Engl J Med 2010; 362: 2066.
5. Albo ME, Litman HJ, Richter HE et al: Treatment success of retropubic and transobturator mid urethral slings at 24 months. J Urol 2012; 188: 2281.
6. Brubaker L, Richter HE, Norton PA et al: 5-Year continence rates, satisfaction and adverse events of Burch urethropexy and fascial sling surgery for urinary incontinence. J Urol 2012; 187: 1324.
7. Ward KL and Hilton P: Tension-free vaginal tape versus colposuspension for primary urodynamic stress incontinence: 5-year follow up. BJOG 2008; 115: 226.
8. Labrie J, Berghmans BL, Fischer K et al: Surgery versus physiotherapy for stress urinary incontinence. N Engl J Med 2013; 369: 1124.
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