Comparison of the Long-term Treatment Outcome Between Pubovaginal and Transobturator Suburethral Sling for Stress Urinary Incontinence in Women

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Int Neurourol J. 2025;29(4):248-254

Publication date (electronic) : 2025 November 4

doi : https://doi.org/10.5213/inj.2550078.039

Yi-Hsuan Wu¹, Yuan-Hong Jiang², Sheng-Fu Chen², Hann-Chorng Kuo^,2

¹Department of Urology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan

²Department of Urology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Tzu Chi University, Hualien, Taiwan

Corresponding author: Hann-Chorng Kuo Department of Urology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Tzu Chi University, No. 707, Section 3, Chung Yang Road, Hualien 970, Taiwan Email: hck@tzuchi.com.tw

Received 2025 February 17; Revised 2025 May 27; Accepted 2025 May 31.

Abstract

INTRODUCTION

Stress urinary incontinence (SUI) is defined as involuntary urine leakage that occurs when intra-abdominal pressure increases, such as during coughing, heavy lifting, or physical activity. SUI affects adult women worldwide, with an estimated overall prevalence of approximately 46% [1]. The underlying mechanisms of SUI involve 2 major factors: urethral hypermo-bility, which stems from the loss of support in pelvic-floor musculature or vaginal connective tissue, and intrinsic sphincter deficiency, characterized by reduced urethral resistance that leads to inadequate urethral closure during stress. Several risk factors for SUI have been identified, including age, ethnicity, pregnancy, vaginal delivery, elevated body mass index, and previous pelvic surgery [2-8].

The diagnosis and evaluation of SUI require a comprehensive approach that begins with a detailed history to assess severity, symptom impact, coexisting pelvic-floor disorders, and relevant medical conditions. A pelvic examination provides essential information regarding pelvic organ prolapse (POP) and muscle strength. Conservative management options include weight loss, pelvic-floor muscle training, and the use of vaginal devices such as pessaries [8]. Duloxetine and acupuncture have also been explored as potential interventions [9]. However, surgery continues to play a central role in the management of severe SUI and includes procedures such as Burch colposuspension, pubovaginal sling (PVS), midurethral mesh sling, and urethral bulking. Midurethral mesh sling procedures, including retropubic tension-free vaginal tape and transobturator suburethral sling (TOT), have been widely performed over recent decades because of their minimally invasive nature, high effectiveness, and low complication rates. Each surgical option has distinct advantages and limitations, and selecting the most appropriate intervention requires patient-centered discussion based on individual factors and preferences [10].

The coexistence of SUI and POP is common due to shared etiologic mechanisms related to pelvic-floor injury [11,12]. Women with a history of vaginal delivery face an increased risk of POP compared with those who have undergone caesarean section, with anterior vaginal wall prolapse or cystocele being the most prevalent type [12,13]. Surgical treatments for SUI and POP generally involve different procedures, but simultaneous surgery that incorporates both a suburethral sling for SUI and an anterior colporrhaphy for POP offers a comprehensive solution to improve overall outcomes in women presenting with both conditions. This combined approach may reduce the need for multiple anesthetic exposures and separate surgeries, thereby optimizing treatment effectiveness.

To our knowledge, no direct comparative assessment of outcomes between PVS and TOT procedures has been reported to date. Based on preoperative bladder function, we aim to provide a direct comparison of the long-term effectiveness of these anti-incontinence surgical interventions, including evaluations of perioperative complications and lower urinary tract symptoms (LUTS).

MATERIALS AND METHODS

RESULTS

Baseline Urodynamic Parameters Among Different Patient Subgroups

Table 1 presents a detailed comparison of preoperative urodynamic parameters among the different treatment subgroups. The mean age across the groups did not differ significantly, indicating that the patient populations were age-comparable. Significant differences were noted in FSF and FS, with the TOT with colporrhaphy group demonstrating higher values. In addition, PdetQmax and Qmax showed significant variation among the groups, suggesting meaningful differences in bladder dynamics and voiding performance. PVR also differed significantly, with the PVS with colporrhaphy group exhibiting higher PVR than the other subgroups. In contrast, no significant differences were observed in US, compliance, voided volume, or CBC. VE demonstrated significant variability as well, highlighting potential differences in VE among the surgical groups.

Table 1.

The baseline urodynamic parameters among patients receiving different surgical procedures

Success Rate and LUTS After Suburethral Sling Surgery

The analysis of the success rate and postoperative LUTS after suburethral sling surgery is summarized in Table 2. The PVS with colporrhaphy group exhibited the highest success rate, followed in order by the PVS alone, TOT with colporrhaphy, and TOT alone groups. The TOT alone group showed the lowest rate of absent postoperative LUTS and had the highest proportion of persistent overactive bladder (OAB) symptoms. The highest frequency of dysuria was observed in the PVS with colporrhaphy group (12.1%), although this difference was not statistically significant.

Table 2.

The lower urinary tract symptoms after suburethral sling surgery in patients with stress urinary incontinence with different surgical procedures

Complication Rates Associated With Different Surgical Interventions

Table 3 presents the incidence of various postoperative complications. Pelvic hematoma, bladder perforation, urethral perforation, and wound infection were uncommon across all intervention groups, with only minimal variability in occurrence. Sling erosion, a potential long-term complication, occurred at different frequencies among the subgroups, with the highest rate observed in the TOT with colporrhaphy group. Urethrolysis for postoperative dysuria or urinary retention was slightly more frequent in the PVS groups, with or without colporrhaphy, compared with the TOT groups, although the differences were not statistically significant. The need for repeat sling procedures was similar among all surgical interventions. Overall, despite some variability in complication patterns, the results indicate that these procedures are associated with generally low adverse event rates, with no significant differences between the PVS and TOT groups regardless of concurrent colporrhaphy.

Table 3.

The incidence of various complications associated with different surgical interventions

Long-term Cumulative Success Rate of Different Treatment Subgroups

Overall, the PVS group demonstrated a superior long-term anti-incontinence effect compared with the TOT group. Furthermore, the long-term cumulative success rates of the PVS groups, with or without colporrhaphy, were significantly higher than those of the TOT groups, with or without colporrhaphy (P< 0.001) (Fig. 1).

Fig. 1.

The long-term cumulative success rate of patients with stress urinary incontinence, comparing (A) pubovaginal sling (PVS) versus transobturator suburethral sling (TOT) procedures, including those with concomitant colporrhaphy, and (B) the 4 treatment subgroups (PVS alone, TOT alone, PVS with colporrhaphy, and TOT with colporrhaphy). The success rates of PVS, with or without colporrhaphy, are significantly higher than those of TOT, with or without colporrhaphy (P<0.001).

DISCUSSION

The present study is the first to focus on the anti-incontinence effects of PVS and TOT using the same synthetic suburethral sling, with or without concomitant colporrhaphy, thereby reflecting real-world conditions in which SUI and POP commonly coexist. Our study also provides valuable long-term outcome data, including cumulative success rates over an extended follow-up period.

It is important to recall the anatomical differences between PVS and TOT placement. PVS is positioned at the proximal urethra to address intrinsic sphincter deficiency, whereas TOT supports the midurethral region to counter urethral hypermobility. Although these procedures are based on distinct biomechanical principles, they aim to achieve the same clinical goal of treating SUI. Nonetheless, direct comparative evidence remains limited [16], particularly in settings involving concomitant pelvic-floor repair. Schimpf et al. [17] reported that the midurethral sling demonstrated higher cure rates than the autologous PVS, although only a small proportion of the included participants had undergone TOT. A recent systematic review and meta-analysis comparing long-term outcomes of various anti-SUI surgeries found that PVS achieved the highest surface under the cumulative ranking curve (93.1), followed by TOT (60.1). However, pairwise comparisons between PVS and TOT showed no statistically significant differences in objective cure rate (0.93; 95% confidence interval [CI], 0.80–1.09) or subjective cure rate (0.91; 95% CI, 0.81–1.03). Postoperative complication profiles, including repeat surgery, sling exposure, and urinary tract infection, were also comparable between the 2 techniques [18]. In routine clinical practice, both procedures are widely used and are often selected based on surgeon preference, individual pelvic anatomy, and comorbidities rather than theoretical considerations alone. The present head-to-head assessment therefore offers meaningful insight into their realworld efficacy, durability, and complication patterns.

The association between SUI and POP is well established [11,12], although the necessity of performing concurrent procedures remains a subject of debate. Cross et al. [19] suggested that PVS provides additional support to the bladder base and complements anterior colporrhaphy, and anterior colporrhaphy alone has been reported to cure more than 60% of women with incontinence [20]. In our study, concurrent colporrhaphy resulted in improved long-term cumulative success rates in both sling groups. However, other studies have reported deterioration of urethral closure function following anterior colporrhaphy [21,22]. In addition, a prospective randomized trial by Co-lombo et al. [23] demonstrated that anterior colporrhaphy alone had a low cure rate for stress incontinence among women with SUI and grade 2–3 cystocele. Another recent trial found comparable 1-year success rates and symptom scores between midurethral sling alone and combined midurethral sling with colporrhaphy for correcting incontinence with low-stage cystocele, though simultaneous surgery required longer operative time and resulted in greater blood loss [24].

Persistent urgency or urgency incontinence negatively affects quality of life and reduces postoperative satisfaction. Consistent with our findings, the TOT group had lower cumulative success rates, and the TOT-alone subgroup exhibited the highest incidence of persistent OAB symptoms (31%). This is comparable to prior reports, which indicate that persistent urgency occurs in approximately 40% of patients after anti-incontinence sling surgery [25], and persistent urgency incontinence occurs in 26%–32% [26]. Predictive factors previously discussed—such as preoperative OAB symptoms, anticholinergic medication use, prior incontinence surgery, detrusor overactivity, and advanced age—reflect different underlying mechanisms [27]. Moreover, recent evidence has suggested a potential association between hip adductor muscle strength and urinary incontinence in patients with end-stage hip osteoarthritis, implying that musculoskeletal factors, including hip joint function, may influence continence and contribute to postoperative LUTS in complex cases [28]. Identifying the primary cause of mixed incontinence is therefore essential for reducing postoperative LUTS, reinforcing the importance of thorough urodynamic evaluation prior to anti-incontinence surgery.

This study has several limitations. First, the retrospective design without randomized preoperative allocation resulted in heterogeneous baseline characteristics among the subgroups. Second, a successful outcome was defined as being dry or using fewer than 1 pad per day, and subjective patient-reported LUTS were used as secondary outcomes, without comprehensive objective assessments. Despite these limitations, the large sample size and minimal exclusion criteria reflect real-world clinical scenarios frequently encountered in practice.

In conclusion, the findings of this study indicate that PVS, with or without colporrhaphy, provides a superior long-term anti-incontinence success rate compared with TOT. Simultaneous colporrhaphy further enhances success rates. However, the precise mechanisms underlying the benefit of concurrent colporrhaphy require additional investigation.

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