Re: 5-year longitudinal follow-up after retropubic and transobturator midurethral slings

Re: 5-Year Longitudinal Follow-up after Retropubic andTransobturator Midurethral SlingsKenton K, Stoddard AM, Zyczynski H, et alJ Urol. In press. http://dx.doi.org/10.1016/j.juro.2014.08.089Experts’ summary:The observational study by Kenton et al [1] includes a largepercentage of women enrolled in the TOMUS trial, a random-ized equivalence trial of retropubic and transobturator mid-urethral sling (MUS) approaches, published in 2010. In thisarticle, the authors present the 5-yr outcomes for 404 womenin terms of success, satisfaction, symptom-specific distress,quality of life, and adverse events after MUS. Treatmentsuccess was defined as no retreatment and no self-reportedsymptomsofstressurinaryincontinence.Ananswerof‘‘never’’or ‘‘rarely’’ to all stress-specific questions was considered neg-ative for symptoms. Treatment success declined over-time inboth group, and 5 yr after surgery it was 51.3% and 43.4% afterretropubic and transobturator MUS, respectively. In addition,the proportion of women who stated they were ‘‘very muchbetter’’ or ‘‘much better’’ according to a patient global impres-sion of improvement declined over-time in both groups(p < 0.0001). However, a greater proportion of women in thetransobturator group reported that they were ‘‘very muchbetter’’ or ‘‘much better’’ at 5 yr (88% vs 77%, p = 0.01). Theauthorsconcludedthatlong-termtreatmentsuccessandsatis-faction for both retropubic and transobturator MUS declineover time; nevertheless, women undergoing transobturatorMUSreportedagreaterimprovementinurinarysymptoms[1].Experts’ comments:In the present midurethral sling era, the medium- and long-term outcomes for MUS and comparisons between retropubicand transobturator MUS are the two most debated topics.Several randomized or prospective studies showed veryhigh and long-lasting objective cure rates using MUS[2–4]. A recently published randomized control trialcomparing the retropubic tension-free vaginal tape (TVT)procedure with transobturator TVT (TVT-O) showed thatobjective cure rates remained very high forboth approaches(84.7% and 86.2%, respectively) at 5 yr after surgery.Furthermore,subjectivetreatmentsatisfactionwasexcellent(94.2% in the TVT group and 91.7% in the TVT-O group). Nodifferences in terms of objective or subjective cure ratesbetweenretropubicandtransobturatorMUSwerefound[5].The great merit of the study by Kenton et al [1] is that itfocuses attention on these hot topics. However, data on theefficacyofMUStreatmentat5-yrfollow-uparesignificantlylowerincomparisontothosereportedinthevastmajorityoftheliteratureonthisissue.Theauthorsrepeatedlyunderlinethat in their study, pelvic examinations were performed atannual visits to assess for visual and palpable evidence ofmesh exposure and patient symptoms associated withphysical findings. This is a strength of the study, but it isunusual that no objective methods were used during theseannual examinations to assess the efficacy of MUS position-ing. In the study, success was defined as no retreatment andno self-reported symptoms of stress urinary incontinence.However, using this definition, the success rate of MUSappears to be unusually low (43–51%) at 5-yr follow-up; inaddition, the rate is not in agreement with data reported byother authors on this topic or with findings by the sameauthors in terms of patient satisfaction (79–85%).Therefore, we believe that this study offers interestingdataforphysiciansandpatients,butitisnotveryrealistictoattribute a success rate