Retropubic versus Transobturator Midurethral Sling with Concomitant Colpocleisis

Objectives: The purpose of this study is to compare the surgical outcomes of retropubic (RP) versus transobturator (TO) midurethral slings (MUS) MUS in women undergoing concomitant colpocleisis, specifically 2-year MUS failure and 1-year lower urinary tract symptoms (LUTS). A secondary aim is to identify factors associated with these surgical outcomes.

Methods: All cases of concurrent MUS and colpocleisis performed within a closed, integrated healthcare delivery system between 04/01/2010 and 03/31/2020 were reviewed. MUS failure was defined as 1) postoperative stress urinary incontinence (SUI) symptoms and/or 2) additional anti-incontinence surgery. LUTS was defined as 1) MUS lysis and/or 2) de novo or worsening overactive bladder (OAB) symptoms requiring treatment with a new prescription for OAB medication, posterior tibial nerve stimulation, or intradetrusor onabotulinum toxin A.

Results: A total of 558 cases were identified; 454 (81%) RP and 104 (19%) TO. Mean age was 78.3 years, and 62% were White. Subject demographics were similar in both RP and TO cohorts (Table 1). Neither 2-year MUS failure (7% RP, 9% TO) nor 1-year LUTS (7% RP, 12% TO) were significantly different between the cohorts (p=0.450 and 0.171, respectively). In multivariable analysis of surgical outcomes adjusting for subject demographics and comorbidities, advanced age was protective against LUTS (OR 0.29, 95%CI 0.09-0.93, p=0.038 among 70-74 year olds; OR 0.28, 95%CI 0.09-0.83, p=0.022 among 75-79 year olds; Table 2). Near statistical significance, tobacco users had a six-fold increased risk of LUTS (OR 6.01, 95%CI 0.98-36.75, p=0.052) and subjects with class 3 obesity had a four-fold increased risk of MUS failure (OR 4.67, 95%CI 0.97-22.54, p=0.055).

Conclusions: At the time of colpocleisis, both RP and TO MUS were highly successful and associated with a low incidence of lower urinary tract symptoms, including MUS lysis. The findings of this large study support RP and TO MUS as equally effective and safe anti-incontinence options during concurrent colpocleisis, a surgery that is performed for often elderly, medically frail individuals. LUTS did not increase following MUS because the cohort included women undergoing concomitant correction of prolapse, not MUS alone. With an extensive prolapse amenable to colpocleisis, women often have obstructive voiding symptoms from the prolapse, which can then exacerbate LUTS. Correction of prolapse may not fully resolve LUTS, but correction of obstructive voiding symptoms can improve quality of life enough that these women do not seek further treatment for any persistent LUTS.