This retrospective cohort study [1] sought to assess and compare the long-term efficacy and safety of the retropubic (RP) and transobturator (TO) approaches to mid-urethral slings (MUS). Although short-term advantages and disadvantages are well documented, the long-term impact of both approaches has scarcely been reported. These data will allow women to be adequately counselled before undergoing either procedure. All women who received a MUS between 2006 and 2010 were identified from the Swedish National Quality Register of the Gynaecological Society. Patients were contacted 10 years following the index operation and invited to complete questionnaires regarding urinary tract-related symptoms (UDI-6), the impact of incontinence on quality-of-life parameters (IIQ-7) and mesh-related complications.

A total of 2,421 women were included, 1,562 in the RP and 859 in the TO group. Patients receiving RP were found to have higher cure rates, lower urgency incontinence rates and better voiding patterns than those undergoing the TO approach. There was no significant difference regarding complications, re-operations or quality of life. At 10 years, a significant number of patients reported lower urinary symptoms, including retention, urgency, dribbling, stress and urge urinary incontinence. Despite this, 79% of patients reported an improvement in symptoms compared with their pre-operative condition. Post-operative urinary retention at 10 years was the most commonly seen complication reported in 29%. Sling-related re-operation occurred in 5.6% and mesh exposure was seen in 2% at 10 years, consistent with prior reports.

This study provides novel data to support the argument that MUS performs well 10 years after the application, as demonstrated by a sustained improvement in symptoms and low rates of sling-related complications. However, a high percentage of patients still seem to experience ongoing urinary symptoms, regardless of the approach. One of the main limitations of the study is its follow-up questionnaire design, where questions may be subject to interpretation and hence results may vary. Interestingly, 12.7% of responders were unaware that they had received an MUS which questions the effectiveness of the consenting process in this Nordic country. The key strengths of this study include a large sample size and 60% response rate.