Transobturator sling surgery shows promise for stress urinary incontinence

By Dr. Ananya Mandal, MDJul 16 2019

A recent study from the Mayo Clinic researchers has shown that surgery for management of stress urinary incontinence can yield better results than conservative methods such as exercise and urethral inserts. The results of the latest study are slated to be published in the August issue of the journal Obstetrics and Gynecology.

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The researchers explain that in their study they included over 1,800 cases of stress urinary incontinence in women on whom the sling procedures were performed between 2002 and 2012. Stress urinary incontinence results in involuntary passage of urine seen in women during incidents such as coughing, sneezing, laughing, lifting, moving, standing up or exercise. It is commonly seen among middle aged women and can significantly lower the quality of life.

Stress urinary incontinence is caused with weakening of the muscles and other tissues that support the urinary bladder. These are called the pelvic floor muscles. There is also weakening of the muscles that regulate the release of the urine called the urinary sphincter. As the bladder becomes full there is a pressure on the sphincter muscles. With sudden rise in the pressure within the abdominal or pelvic muscles, there is an additional pressure on the bladder that leads to a leakage of the urine from the urethra. Common causes of weakening of the pelvic floor muscles include age, childbirth in women, previous abdominal or pelvic surgery, weakness, illness, obesity, smoking, asthma, COPD etc.

For some women certain exercises and vaginal inserts could be modes of treatment while among others surgery may be the best option. The surgical repairs for stress urinary incontinence include retropubic sling operation and transobturator sling procedure. In the retropubic sling a mesh is placed beneath the urethra (a tube connecting the urinary bladder to lead the urine outside the body) behind the pubic bone. In the other procedure a sling is placed in a less acute angle and the mesh is placed through the thigh region. This is the transobturator sling procedure.

Two surgeries are commonly performed to treat stress urinary incontinence in women – transobturator sling surgery and retropubic sling procedure. The results showed that women who underwent transobturator sling surgery had twice the requirement for a repeat surgical intervention compared to women who had had retropubic sling procedure. Within eight years after surgery re-operation rates were 11.2 percent for patients undergoing transobturator sling operation compared to 5.2 percent in those undergoing retropubic sling procedure, the authors of the study explain. Lead author Emanuel Trabuco, M.D., a Mayo Clinic urogynecologist explained that those undergoing transobturator procedure had a higher failure rate if their sling procedure was combined with a repair of vaginal prolapse. Dr. Trabuco said, “These findings would suggest that the retropubic procedure has better long-term results compared to the transobturator sling.”

In the study the researchers noted that both the procedures were safe and had minimal complications. Dr. Trabuco said in a statement, “Given that in the U.S. alone, 200,000 procedures are performed each year to treat stress urinary incontinence, the data in this study should help guide informed discussions with women who are considering surgical treatment, especially if the patient also is having prolapse repairs.” Prolapse is weakening of the support of the vagina and the genitals that leads to drooping or protrusion of the vagina though the walls of the pudenda.

Dr. Trabuco explained that there has recently been a warning regarding the safety of the vaginal mesh kits for treating pelvic organ prolapse from the Food and Drug Administration (US FDA). This has created a confusion and narrowed the choice for many women said Trabuco. He added that the ban is not for mesh and midurethral slings that are used for urinary incontinence patients. The study noted that the complications rates for midurethral slings is very low with only 3.2 percent problems of bladder emptying and 1.9 percent due to the mesh exposure in the vagina. Trabuco said that these low rates of complications of the sling procedures should assure patients and help them make this choice.

Dr. Trabuco said in a statement that both urinary as well as fecal incontinence is an embarrassing symptom and is vastly underreported in early stages due to the stigma. In addition the fears regarding mesh safety has worsened the situation. He said, “We're hopeful that the findings in this study will encourage women to talk to a provider about the surgical and nonsurgical options to treat their conditions, which can greatly affect a woman's daily activities.”