Association of sling location and bladder descent on ultrasound with cure, satisfaction and complications 10-20 years after midurethral sling surgery: multicenter cross-sectional study.

Abstract

The primary aim of this study was to investigate the association between sling location and cure 10-20 years after midurethral sling (MUS) surgery. The secondary aims were to explore the association of sling location with patient satisfaction and complications and the association of bladder descent with cure, satisfaction and complications, 10-20 years after MUS surgery. This was a multicenter cross-sectional study of 263 women who underwent MUS surgery at Ålesund Hospital, Oslo University Hospital or Trondheim University Hospital, Norway, from 2001-2002 or 2011-2012. Inclusion periods were extended to 2001-2003 at Oslo University Hospital and 2001-2006 at Trondheim University Hospital to reach the statistical power estimate. Participants were identified from the Norwegian Female Incontinence Registry. Subjective cure (stress urinary incontinence (SUI) index < 3 (SUI index score range, 0-12)), satisfaction with MUS surgery and complications after MUS surgery (urgency urinary incontinence (UUI) index ≥ 3 (UUI index score range, 0-8), persisting pain, subjective voiding difficulties, > 1 urinary tract infection (UTI) within the last year) were assessed using validated questionnaires. Objective cure was defined as < 3 g urinary leakage on a pad-weighing cough/jump stress test conducted with a minimum bladder volume of 200 mL. Post-void residual volume ≥ 200 mL, measured by catheterization, was defined as significant objective voiding difficulty. Transperineal ultrasound was used to assess sling location (sling-to-bladder-neck distance at rest and sling-to-symphysis distance during Valsalva maneuver). Bladder neck descent and bladder descent were also measured during Valsalva maneuver. The primary null hypothesis was that subjective and objective cures are not associated with sling location. The secondary null hypothesis was that there is no difference in cure between women with vs those without significant bladder descent. We found no association between sling location and subjective or objective cure, satisfaction or persisting pain after MUS surgery. Women with a UUI index ≥ 3 had a significantly shorter sling-to-symphysis distance compared to women with a UUI index < 3 (adjusted mean difference (aMD), -0.13 (95% CI, -0.15 to -0.001) cm; P = 0.048). Women who had experienced > 1 UTI within the last year had a significantly shorter sling-to-symphysis distance than women who had ≤ 1 UTI within the last year (aMD, -0.14 (95% CI, -0.24 to -0.01) cm; P = 0.03). Women with bladder descent > 50^th percentile had greater odds of having objective voiding difficulties compared to women with bladder descent ≤ 50^th percentile (adjusted odds ratio, 3.2 (95% CI, 1.6-9.0); P = 0.03). No associations were found between bladder descent or bladder neck descent and any of the other outcomes. We found no differences in sling location between women who were cured vs those who were not, those who were satisfied vs those who were dissatisfied with MUS surgery, and women who did vs those who did not experience complications after MUS surgery. This indicates that other factors, such as age-related changes, repeat SUI surgery or medication, can influence long-term results. However, women with a UUI index ≥ 3 and those who had > 1 UTI within the last year had a shorter sling-to-symphysis distance compared to women with a UUI index of < 3 and those who had ≤ 1 UTI within the last year, respectively, indicating that the tension of the sling may be increased in these women. Ultrasound-measured bladder descent > 50^th percentile was associated with higher odds of objective voiding difficulties at long-term follow-up, indicating that bladder descent, rather than tape location, has an impact on residual urine. © 2025 International Society of Ultrasound in Obstetrics and Gynecology.