What is the preferred surgical approach between a supra pubic (suprapubic) sling and a bladder sling for managing stress urinary incontinence?

Surgical Management of Stress Urinary Incontinence: Suprapubic vs. Bladder Sling

For most women with stress urinary incontinence, either retropubic midurethral sling (RMUS) or transobturator midurethral sling (TMUS) can be offered as they have similar efficacy rates, but with different risk profiles that should guide selection. 1

Understanding the Options

The terminology in the question requires clarification:

• "Suprapubic sling" typically refers to retropubic midurethral sling (RMUS)
• "Bladder sling" likely refers to transobturator midurethral sling (TMUS)

Both are synthetic mesh slings but differ in their anatomical placement:

Retropubic Midurethral Sling (RMUS)

• Passes through retropubic space behind pubic bone
• Approaches include bottom-to-top (preferred) or top-to-bottom techniques

Transobturator Midurethral Sling (TMUS)

• Passes through obturator foramen
• Can be placed using medial-to-lateral or lateral-to-medial approaches

Efficacy Comparison

Both procedures demonstrate similar effectiveness:

• Short-term subjective cure rates: Similar between RMUS and TMUS 1
• Medium-term (1-5 years) subjective cure: Similar between groups 2
• Long-term (>5 years) subjective cure: 43-92% for TMUS vs 51-88% for RMUS 1, 2

Complication Profiles

The key differences lie in their complication profiles:

RMUS Complications

• Higher rates of bladder perforation (4.5% vs 0.6% with TMUS) 1, 2
• More major vascular/visceral injuries 1
• Higher risk of voiding dysfunction 1
• More suprapubic pain (2.9% vs 0.8%) 1
• Lower risk of requiring repeat incontinence surgery long-term 1, 2

TMUS Complications

• Higher rates of groin pain (6.4% vs 1.3% with RMUS) 1
• Higher likelihood of requiring repeat incontinence surgery in long term 1, 2
• Similar rates of vaginal mesh erosion/exposure/extrusion compared to RMUS 1

Patient Selection Algorithm

Based on the AUA/SUFU guidelines, selection should be guided by:

1. For patients with normal urethral mobility:

   • Either RMUS or TMUS is appropriate 1
   • Consider TMUS if patient has risk factors for voiding dysfunction
   • Consider RMUS if long-term durability is a priority

2. For patients with fixed, immobile urethra (intrinsic sphincter deficiency):

   • Pubovaginal sling (PVS) is preferred 1
   • RMUS may be considered as an alternative 1
   • Avoid TMUS in this population 1

3. For patients with severe outlet dysfunction or recurrent/persistent SUI:

   • Consider autologous pubovaginal sling 1
   • In extreme cases, consider obstructing autologous sling or bladder neck closure 1

4. For patients with specific contraindications:

   • Avoid synthetic mesh slings in patients with:
     • Urethral injury during procedure 1
     • Concurrent urethral diverticulectomy 1
     • Urethrovaginal fistula repair 1
     • Urethral mesh excision 1

Special Considerations

• Technique selection for RMUS: Bottom-to-top route is more effective than top-to-bottom for subjective cure and has fewer complications 2
• Technique selection for TMUS: No significant difference between medial-to-lateral vs lateral-to-medial approaches for cure rates 2
• Single-incision slings (SIS): May be offered but patients should be informed about limited evidence regarding efficacy and safety 1
• Autologous vs. synthetic materials: Autologous fascial slings have fewer complications than synthetic materials but may require more extensive surgery 3

Common Pitfalls to Avoid

1. Ignoring urethral mobility assessment: This is crucial for proper sling selection
2. Using synthetic mesh when contraindicated: Avoid in cases of urethral injury, diverticulectomy, or fistula repair 1
3. Overlooking patient-specific risk factors: Consider activity level, comorbidities, and previous surgeries
4. Inadequate counseling about complications: Each approach has specific risks that should be discussed
5. Failure to consider long-term outcomes: RMUS may have better long-term durability despite similar short-term results 1

In summary, both RMUS and TMUS are effective treatments for stress urinary incontinence with similar cure rates but different complication profiles. The choice between them should be guided by patient characteristics, particularly urethral mobility, and surgeon experience, with careful consideration of the specific risks associated with each approach.