Transobturator mid-urethral sling in females with stress urinary incontinence and detrusor underactivity: effect on voiding phase

  • Franca NataleEmail author
  • Ester Illiano
  • Alessandro Zucchi
  • Matteo Balzarro
  • Chiara La Penna
  • Elisabetta Costantini
Original Article


Introduction and hypothesis

To assess whether detrusor underactivity (DU) is a risk factor for voiding dysfunction (VD) after transobturator tape (TOT) and if a detrusor pressure at maximum flow (PdetQmax) value predicts postoperative VD in DU patients. Also, we examined uncomplicated patients for postoperative VD.


This is a prospective long-term study on SUI patients who underwent TOT. Exclusion criteria were preoperative POP stage ≥ 2, previous anti-incontinence surgery and comorbidities.

Patients were grouped by detrusor contractility using the projected isovolumetric pressure (PIP) index (PdetQmax + maximum flow rate) with values of 30–75 cmH2O indicating normal contractility.

Follow-up was at 1, 3, 6 and 12 months, and then annually. All patients underwent a stress test and responded to the Urogenital Distress Inventory questionnaire and to the King’s Health Questionnaire. The subjective cure was evaluated using the Patient Global Impression of Improvement.

We determined the diagnostic accuracy of PdetQmax levels using ROC curve analysis, with a cut-off point calculated for optimal sensitivity and specificity.


In 2007–2013, 118 patients underwent TOT. We included 50 in the undercontractility group (G1) and 50 in the normocontractility group (G2).

Continence rates were 82% in G1 and 84% in G2 (mean follow-up 76 months). VD increased from 18 to 36% (p < 0.05) in G1 and from 14 to 16% (p = 0.198) in G2. De novo VD was 28% in G1 and 2% in G2.

In the G1 group PdetQmax ≤ 12 cmH2O predicted postoperative VD with 71.4% specificity and 80.0% sensitivity.


DU adversely affects the voiding phase of micturition after TOT. In DU patients, PdetQmax ≤ 12 cmH2O predicts postoperative VD.


SUI surgery Detrusor underactivity Voiding dysfunction Urodynamics Uncomplicated SUI patients Long-term follow-up Trans-obturator mid-urethral sling Projected isovolumetric pressure Quality of life 



We thank David Nicholson for his invaluable help with and revision of the English in this paper.

Compliance with ethical standards

Conflicts of interest



  1. 1.
    Schimpf MO, Rahn DD, Wheeler TL, Patel M, White AB, Orejuela FJ, et al. Sling surgery for stress urinary incontinence in women: a systematic review and metanalysis. Am J Obstet Gynecol. 2014;211:71.e1–71.e27.CrossRefGoogle Scholar
  2. 2.
    Karram MM, Segal JL, Vassallo BJ, Kleeman SD. Complications and untoward effects of the tension-free vaginal tape procedure. Obstet Gynecol. 2003;101(5 Pt 1):929–32.Google Scholar
  3. 3.
    Kleeman S, Goldwasser S, Vassallo B, Karram M. Predicting postoperative voiding efficiency after operation for incontinence and prolapse. Am J Obstet Gynecol. 2002;187:49–52.CrossRefGoogle Scholar
  4. 4.
    Salin A, Conquy S, Elie C, Touboul C, Parra J, Zerbib M, et al. Identification of risk factors for voiding dysfunction following TVT placement. Eur Urol. 2007;51:782–7.CrossRefGoogle Scholar
  5. 5.
    Hong B, Park S, Kim HS, Choo MS. Factors predictive of urinary retention after a tension-free vaginal tape procedure for female stress urinary incontinence. J Urol. 2003;170:852–6.CrossRefGoogle Scholar
  6. 6.
    Moore C, Paraiso MF. Voiding dysfunction after the tension-free vaginal tape procedure. Curr Urol Rep. 2005;6:356–9.CrossRefGoogle Scholar
  7. 7.
    Abrams P, Cardozo L, Fall M, Griffiths D, Rosier P, Ulmsten U, et al. The standardisation of terminology of lower urinary tract function: report from the standardisation sub-committee of the International Continence Society. Am J Obstet Gynecol. 2002;187(1):116–26.CrossRefGoogle Scholar
  8. 8.
    Osman NI, Chapple CR, Abrams P, Dmochowski R, Haab F, Nitti V, et al. Detrusor underactivity and the underactive bladder: a new clinical entity? A review of current terminology, definitions, epidemiology, etiology, and diagnosis. Eur Urol. 2014;65:389–98.CrossRefGoogle Scholar
  9. 9.
    Medina CA, Costantini E, Petri E, Mourad S, Singla A, Rodríguez-Colorado S, et al. Evaluation and surgery for stress urinary incontinence: a FIGO working group report. Neurourol Urodyn. 2017;36:518–28.CrossRefGoogle Scholar
  10. 10.
    Griffiths D. Detrusor contractility–order out of chaos. Scand J Urol Nephrol Suppl. 2004;215:93–100.CrossRefGoogle Scholar
  11. 11.
    Bump RC, Mattiasson A, Bø K, Brubaker LP, DeLancey JO, Klarskov P, et al. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol. 1996;175:10–7.CrossRefGoogle Scholar
  12. 12.
    Swift SE, Yoon EA. Test-retest reliability of the cough stress test in the evaluation of urinary incontinence. Obstet Gynecol. 1999;94:99–102.Google Scholar
  13. 13.
    Artibani W, Pesce F, Prezioso D, Scarpa RM, Zattoni F, Tubaro A, et al. FLOW study group. Italian validation of the urogenital distress inventory and its application in LUTS patients. Eur Urol. 2006;50:1323–9.CrossRefGoogle Scholar
  14. 14.
    Ingelmann-Sundberg A, Ulmsten U. Surgical treatment of female urinary stress incontinence. Contrib Gynecol Obstet. 1983;10:51–69.CrossRefGoogle Scholar
  15. 15.
    Kelleher CJ, Cardozo LD, Khullar V, Salvatore S. A new questionnaire to assess the quality of life of urinary incontinent women. Br J Obstet Gynaecol. 1997;104:1374–9.CrossRefGoogle Scholar
  16. 16.
    Haylen BT, de Ridder D, Freeman RM, Swift SE, Berghmans B, et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Int Urogynecol J. 2010;21:5–26.CrossRefGoogle Scholar
  17. 17.
    Delorme E. Transobturator urethral suspension: mini-invasive procedure in the treatment of stress urinary incontinence in women. Prog Urol. 2001;11:1306–13.Google Scholar
  18. 18.
    Deval B, Jeffry L, Al Najjar F, Soriano D, Darai E. Determinants of patient dissatisfaction after a tension-free vaginal tape procedure for urinary incontinence. J Urol. 2002;67:2093–7.CrossRefGoogle Scholar
  19. 19.
    Bullock TL, Ghoniem G, Klutke CG, Staskin DR. Advances in female stress urinary incontinence: mid-urethral slings. BJU Int. 2006;98(Suppl 1):32–40.CrossRefGoogle Scholar
  20. 20.
    Kleeman S, Goldwasser S, Vassallo B, Karram M. Predicting post-operative voiding efficiency after operation for incontinence and prolapse. Am J Obstet Gynecol. 2002;187:49–52.CrossRefGoogle Scholar
  21. 21.
    Miller EA, Amundsen CL, Toh KL, Flynn BJ, Webster GD. Preoperative urodynamic evaluation may predict voiding dysfunction in women undergoing pubovaginal sling. J Urol. 2003;169:2234–7.CrossRefGoogle Scholar
  22. 22.
    Ahn C, Bae J, Lee KS, Lee HW. Analysis of voiding dysfunction after transobturator tape procedure for stress urinary incontinence. Korean J Urol. 2015;56:823–30.CrossRefGoogle Scholar
  23. 23.
    Cocci A, Cacciamani GE, Russo GI, Cerruto MA, Milanesi M, Medina LG, et al. Impact of preoperative patient characteristics and flow rate on failure, early complications, and voiding dysfunction after a transobturator tape procedure: a multicentre study. Int Neurourol J. 2017;21:282–8.CrossRefGoogle Scholar
  24. 24.
    Linder BJ, Trabuco EC, Gebhart JB, Klingele CJ, Occhino JA, Elliott DS, et al. Can urodynamic parameters predict sling revision for voiding dysfunction in women undergoing synthetic midurethral sling placement? Female Pelvic Med Reconstr Surg. 2017.
  25. 25.
    Resnick NM, Brandeis GH, Baumann MM, DuBeau CE, Yalla SV. Misdiagnosis of urinary incontinence in nursing home women: prevalence and a proposed solution. Neurourol Urodyn. 1996;15:599–613.CrossRefGoogle Scholar
  26. 26.
    Groutz A, Gordon D, Lessing JB, Wolman I, Jaffa A, David MP. Prevalence and characteristics of voiding difficulties in women: are subjective symptoms substantiated by objective urodynamic data? Urology. 1999;54:268–72.CrossRefGoogle Scholar
  27. 27.
    Valentini FA, Robain G, Marti BG. Urodynamics in women from menopause to oldest age: what motive? What diagnosis? Int Braz J Urol. 2011;37:100–7.CrossRefGoogle Scholar
  28. 28.
    Griffiths DJ. Editorial: bladder failure—a condition to reckon with. J Urol. 2003;169:1011–2.CrossRefGoogle Scholar
  29. 29.
    Griffiths DJ. The mechanics of the urethra and of micturition. Br J Urol. 1973;45:497–507.CrossRefGoogle Scholar
  30. 30.
    Schafer W. Analysis of bladder-outlet function with the linearized passive urethral resistance relation, linPURR, and a disease-specific approach for grading obstruction: from complex to simple. World J Urol. 1995;3:47–58.Google Scholar
  31. 31.
    Abrams P. Bladder outlet obstruction index, bladder contractility index and bladder voiding efficiency: three simple indices to define bladder voiding function. BJU Int. 1999;84:14–5.CrossRefGoogle Scholar

Copyright information

© The International Urogynecological Association 2019

Authors and Affiliations

  1. 1.Urogynecology UnitSan Carlo di Nancy HospitalRomeItaly
  2. 2.Andrology and Urogynecology Clinic, Santa Maria Terni HospitalUniversity of PerugiaPerugiaItaly
  3. 3.Department of Surgical and Biomedical Sciences, Urology and Andrology ClinicUniversity of PerugiaPerugiaItaly
  4. 4.Department of UrologyAzienda Ospedaliera Universitaria Integrata (A.O.U.I.)VeronaItaly
  5. 5.Section of Gynecology and Obstetrics, Department of Surgery“Tor Vergata” UniversityRomeItaly

Personalised recommendations