The coexistence of SUI and POP is common due to shared risk factors related to pelvic floor injury. Women with a history of vaginal delivery face an increased risk of POP compared to those with a caesarean section history, with the most prevalent type being anterior vaginal wall prolapse or cystocele. Surgical repair for SUI and POP typically involves different procedures, but simultaneous surgery, incorporating the insertion of a suburethral sling for SUI and an anterior colporrhaphy for POP, provides a comprehensive solution to improve overall outcomes for women with both SUI and anterior vaginal wall prolapse. This approach has the potential to minimize the need for separate anesthesia and surgeries, optimizing the effectiveness of the intervention. To our knowledge, there has been no comparative assessment on the outcome between pubovaginal sling and TOT to date. Based on preoperative bladder function, we aim to provide a direct comparison on long-term effectiveness between these anti-incontinent surgical interventions, including various parameters like perioperative complication and lower urinary tract symptoms (LUTS).

We retrospectively reviewed medical records of 533 female patients with mixed urinary incontinence and predominant SUI in a medical center. Patients were divided into four groups: pubovaginal sling (PVS) alone, transobturator suburethral sling (TOT) alone, PVS with colporrhaphy, and TOT with colporrhaphy. The primary outcome was the long-term cumulative success rate in different groups and a successful outcome defined as dry or less than one pad usage per day. The secondary outcomes were subjective postoperative lower urinary tract symptoms and various perioperative complications.

The long-term cumulative success rate of PVS group with or without colporrhaphy are significantly higher than those in TOT group with or without colporrhaphy (p< 0.001). The group of PVS with concurrent colporrhaphy obtained highest success rate, followed by the PVS alone, TOT with colporrhaphy and TOT alone (p=0.003). (Table 1) Furthermore, highest rate of persistent overactive bladder was noted in TOT alone group (p< 0.001). The group of PVS with colporrhaphy retained the highest success rate, and was followed by the PVS alone, TOT with colporrhaphy and TOT alone. The group of TOT alone obtained significant lowest rate of absent postoperative LUTS, and the rate of persistent overactive bladder (OAB) was obviously the highest. Furthermore, the highest proportion of dysuria was noticed in the group of PVS with colporrhaphy (12.1%) among surgical interventions, however, it did not yield significance. In general, the PVS group demonstrated long-term superior anti-incontinent effect than the TOT group. Furthermore, the long-term cumulative success rate of PVS group with or without colporrhaphy are significantly higher than those in TOT group with or without colporrhaphy (p< 0.001). (Figure 1)

The present study was the first research focusing on anti-incontinent effect between PVS and TOT procedure using the same synthetic suburethral sling with or without colporrhaphy, mimicking the real-world where coexistence of SUI and POP is common. Our study also provided a valuable long-term treatment outcome with cumulative success rate. Persistent urgency or urgency incontinence had impact on quality of life and decrease satisfaction after anti-incontinent surgery. As our result, the TOT group had the lower cumulative success rate and the group of TOT alone obtained significant highest rate of persistent symptoms of OAB (31%).

The result of this study showed that the PVS procedure with or without colporrhaphy had a superior long-term anti-incontinent success rate than the TOT groups. The simultaneous colporrhaphy increased the success rate. However, the exact mechanism supporting concurrent colporrhaphy or not needs to be further investigated.

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