The urinary incontinence influence the life quality (QoL) of the
patients. The modern surgical treatment for female stress urinary incontinence (SUI) or for
the stress type of mixed urinary incontinence (MUI) are the tension free mid-urethral slings
(Level of evidence: 1a, Grade of Recommendation: Strong) [1]. They are effective and safe
procedures, however in some cases significant, QL decreasing complications can be occur.
One of them is the postoperative voiding dysfunction (voiding difficulty, residual urine,
bladder urinary retention). Voiding difficulty is mentioned in 4-10 %, urinary retention in 3.2-
9 % in the international literature [2]. Our goal was on one hand to measure the ration of
postoperative voinding dysfunction in our in patients underwent transobturator sling
procedures and on other hand to find any possible perioperative risk factors to predict for
postoperative voiding problems.

We have evaluated the perioperative data of 409
patients, who underwent TOT (surgimesh®, outside-in technique) surgery (n=377, 92.2%) or
in some cases (n=32, 7.8 %) TOT+other additional surgery (anterior or posterior vaginal wall
repair, paraurethral cysta exstirpation) in our department between 01.01.2008 and
31.12.2016, based on clinical documentation during a retrospective assessment. We have
investigated the impact of the studied pre- and intraoperative factors (age in year; body
mass index in kg/m2; type of incontinence: SUI:363 patients (88.8%), MUI:46 patients
(11.2%); details of the surgery: TOT only or TOT with additional operation, intraoperative
stress test; the experience of the surgeon; vaginal status: presence of any type and grade of
pelvic organ prolapse, the wide of the vagina and the presence any urogenital atrophy; child
births; previous anti-incontinence and prolapse procedures; preoperative voiding symptoms
and results of urodynamic exams; intraoperative complications: bleeding, vaginal vault injury
and other possible risk factors such: diabetes, depression in the patient history) on the
postoperative voiding function (post void residual urine and urinary retention requiring
catheterisation and / or surgical revisions). The significant (> 50 ml) post void residuum (PVR)
was considered as the primary endpoint. During the statistical analysis, multivariate analysis
was performed and a 5% significance level was used.

The average patient’s age was: 61.9+/-10.3 year (37-86 years). The average body
mass index (BMI) was: 29+/-4.4 kg/m2 (18.3-44.6 kg/m2). Significant PVR was present in 39
cases (9.5%), 9 (2.2 %) even needed to be catheterized and 2 (0.49 %) patients needed
reoperation. Narrow vagina (vagina diameter <2 cm) was found in 15 patients (3.7 %). The
older age (65.7+/-10.3 year in patients with significant PVR vs 61.5+/-10.3 year in patients
without significant PVR, p=0.016) and a – preoperatively – narrow vagina (6/15 patients
(40%) with narrow vagina had significant PVR vs only 33/394 patients (8.4 %) without narrow
vagina had significant PVR, p=0.001) were considered as independent risk factors for
significant PVR. Significant differences regarding the significant PVR couldn’t shown between
the other examined perioperative factors, p&gt;0.05.

In the case of older age, the supposedly weaker bladder function
and the accompanying urogenital atrophy, and in the case of narrow vagina, the tape
overextension due to the more difficult surgical technique may be the cause of the
significant PVR.

Our results are similar to the published international data according to
the frequency of the voiding dysfunction after female transobturator sling implantations.
Significant, reoperation requiring urinary retention is relative rare after female TOT
procedures. However, based on our findings, it seems like older age and preoperative
narrower vagina prone to postoperative voiding problems – although after processing our
missing preoperative data, other predictive factors may play a role as well. Elderly, non-birth
or urogenital atrophic patients with narrow vaginal status should be carefully considered the
benefit-risk principle before the operation. In this aspect, it is very important to give a
correct patient information before deciding for surgical intervention in this patient
population. The solution in this risk group may offer the more careful patient selection, the
center surgery, the “looser” support and the postoperative re-adjustable tapes.

EAU Guidelines. Urinary Incontinence. Edn. presented at the EAU Annual Congress Barcelona 2019. ISBN 978-94-92671-04-2.
Ford AA, Rogerson L, Cody JD, Ogah J. Midurethral sling operations for stress urinary incontinence in women. Cohrane Database Syst Rev. 2015 (7):CD006375