Highlight
This study presents key long-term data comparing retropubic and transobturator midurethral sling procedures for primary stress urinary incontinence (SUI). Major highlights include:
- Low overall failure rates for both sling types over an extended follow-up (median >9 years).
- Significantly higher risk of reoperation for recurrent SUI after transobturator slings compared to retropubic slings.
- Women undergoing transobturator sling placement combined with prolapse repair carry an especially elevated risk of reoperation.
- Retropubic slings are associated with a higher risk of reoperation due to urinary retention requiring intervention.
Study Background
Stress urinary incontinence (SUI) affects a substantial proportion of women worldwide, significantly impairing quality of life by leading to involuntary leakage during physical exertion, coughing or sneezing. Midurethral sling procedures have become the gold standard surgical treatment for primary SUI, owing to their minimally invasive nature and durable efficacy.
Two predominant sling placement approaches are widely used: the retropubic route (involving passage behind the pubic bone) and the transobturator route (passing through the obturator foramen). Both methods have demonstrated favorable short to mid-term success rates in reducing SUI symptoms but differ in their complication profiles.
Long-term data comparing their durability, failure rates, and complication risks, particularly over a decade or more, remain limited. Moreover, the impact of concurrent pelvic organ prolapse repair on sling outcomes is unclear. This retrospective cohort study addresses these knowledge gaps by assessing reoperation rates and complications following these procedures over an extended follow-up period.
Study Design
This retrospective review evaluated a previously described cohort of 1881 women undergoing midurethral sling placement for primary SUI at an academic medical center from 2002 to 2012. For the long-term follow-up analysis, a covariate-matched subset was created, including 570 women who received retropubic slings and 317 with transobturator slings.
Patient health records were reviewed, extending follow-up through December 31, 2022, capturing a median (interquartile range) follow-up duration of 11.1 years overall (retropubic 11.4 years, transobturator 9.6 years).
Main outcome measures were treatment failure defined as reoperation for recurrent SUI, and the incidence of procedure-associated complications, notably reoperations for urinary retention.
Key Findings
The study found notably low failure rates for both sling types but with important differences:
- Failure and Reoperation Rates: Overall, 8.8% of women with transobturator slings required reoperation for recurrent SUI, compared to 4.4% in the retropubic group. The unadjusted hazard ratio (HR) for reoperation with transobturator versus retropubic sling was 2.29 (95% CI, 1.49-3.54; p < 0.001), with covariate-matched analysis affirming heightened risk (HR 1.91; 95% CI, 1.15-3.17; p = 0.01).
- Influence of Concurrent Prolapse Repair: The increased risk of reoperation for transobturator slings was particularly pronounced when the sling procedure was combined with prolapse repair surgery. Unadjusted HR was 6.34 (95% CI, 3.09-13.02; p < 0.001), and after matching, the HR remained elevated at 3.96 (95% CI, 1.35-11.58; p = 0.01).
- Urinary Retention Complications: Women who underwent retropubic sling placement demonstrated higher rates of reoperation for urinary retention compared to those with transobturator slings. Matched analysis yielded a HR of 8.39 (95% CI, 1.11-63.22; p = 0.04) for urinary retention-related interventions in the retropubic group.
These findings highlight a distinct trade-off in risk profiles between the two sling approaches: transobturator slings carry greater risk of recurrent SUI necessitating reoperation, particularly when paired with prolapse repair, while retropubic slings impose higher risk of obstructive urinary complications.
Expert Commentary
Midurethral slings remain the cornerstone in surgical management of primary SUI, benefiting from minimal invasiveness and good long-term efficacy. Guidelines recommend individualized selection of retropubic versus transobturator approaches based on patient anatomy, comorbidities, and concomitant procedures.
The significantly elevated reoperation risk associated with transobturator slings combined with prolapse repair observed here may reflect biomechanical or inflammatory factors influencing sling integration and urethral support. Conversely, the higher incidence of urinary retention after retropubic placement aligns with known risks of retropubic approaches due to urethral obstruction or voiding dysfunction.
Study limitations include its retrospective nature, potential coding or documentation bias, and single-center design, which may affect generalizability. Nonetheless, the large cohort size and extended follow-up enhance reliability of these important findings.
Conclusion
In conclusion, this comprehensive long-term evaluation confirms that midurethral slings for primary SUI have sustained low failure rates. However, the choice of sling type should consider distinct complication risks: transobturator slings are associated with greater reoperation for recurrent SUI, especially when combined with prolapse repair, while retropubic slings confer a greater risk of urinary retention requiring surgical intervention.
These results underscore the importance of personalized surgical planning and informed patient counseling regarding potential long-term outcomes. Further prospective studies are warranted to optimize sling selection strategies and improve durability and safety in women with SUI.
References
- Trad ATA, El Nashar SA, Linder BJ, et al. Long-Term Outcomes After Retropubic and Transobturator Sling Procedures: Reoperation for Recurrent Stress Urinary Incontinence. BJOG. 2026 Jul 2; PMID: 42392760.
- Blaivas JG, et al. Midurethral Slings for Stress Urinary Incontinence: A Review of Complication Rates and Management Strategies. Int Urogynecol J. 2019;30(12):1849-1859.
- Ford AA, Rogerson L, Cody JD, et al. Mid-urethral Sling Operations for Stress Urinary Incontinence in Women. Cochrane Database Syst Rev. 2015 Jul 7;(7):CD006375.