Stress urinary incontinence (SUI) is characterized by involuntary urine leakage triggered by physical activities that increase intra-abdominal pressure, such as coughing, sneezing, or lifting heavy objects. Factors contributing to SUI include childbirth, aging, hormonal changes during menopause, obesity, and a sedentary lifestyle. Vaginal deliveries, especially complicated ones, significantly raise the risk by damaging pelvic support structures (1). SUI affects 4% to 35% of women, depending on the population and diagnostic criteria, and its impact extends beyond physical discomfort, leading to emotional distress, social withdrawal, economic burden, and reduced quality of life. Despite its high prevalence, SUI often remains underdiagnosed due to stigma and embarrassment, delaying effective management (2).

A major breakthrough came with the development of sling procedures. Initially, autologous fascial slings using the patient's tissues offered durable outcomes but required extensive surgical exposure. Subsequently, synthetic midurethral slings (MUS) transformed the treatment landscape. Tension-Free Vaginal Tape (TVT), introduced as a synthetic sling placed via the retropubic route, offered high success rates with fewer complications and quicker recovery. However, concerns over bladder perforation led to the refinement of techniques, resulting in the development of the Trans-obturator Tape (TOT) procedure. By routing the sling through the obturator foramen, TOT reduced risks associated with retropubic passage, such as bladder injury and voiding dysfunction (5).

Objective

To compare the surgical outcomes of TOT and TVT regarding quality-of-life improvement, complication rates, and recurrence.

This prospective analytical study was conducted at S.N. Medical College and Hospital, Agra, from January 2023 to January 2025 after ethical approval. The study included women aged 35–75 years, diagnosed with SUI or mixed urinary incontinence with a predominant stress component, having no or mild cystocele (grade 1 or 2 POP-Q). Eligible patients underwent at least three months of pelvic floor muscle training prior to surgical consideration and were willing to complete bladder diaries and quality of life assessments.

Exclusion criteria included prior pelvic surgeries, significant comorbidities, predominant urge

 Incontinence, neuromuscular disorders, active urinary infections, pelvic organ prolapse needing surgery, pregnancy, and histories of urogenital cancers or pelvic radiation. Consecutive sampling was used for patient recruitment after informed consent.

Sample size calculation was based on prior prevalence data, using the formula

Where Z represents the standard normal deviate (1.96 for 95% confidence), p is the estimated prevalence, and e is the margin of error. The study was conducted over 24 months to ensure adequate follow-up and data collection.

Table 1- Postoperative complications of pain comparison with the TOT and TVT

Postoperative pain patterns differed between the TOT and TVT groups, though not significantly (p=0.09). Groin pain was more common in the TOT group (25%), while pelvic pain was slightly higher in TVT (15%). Notably, a higher percentage of TVT patients (20%) reported no pain compared to the TOT group (5%).

Table 2- Postoperative complications of Voiding Dysfunction comparison with the TOT and TVT

Voiding dysfunction occurred similarly between TOT and TVT groups, with no significant difference (p=0.19). In the TOT group, 7.5% experienced voiding dysfunction, while in the TVT group, 12.5% had dysfunction. Although slightly more dysfunction was observed with TOT, the difference was not statistically significant

This study found a mean patient age of 57.4 years and an average parity of 3.2, linking postmenopausal status and higher parity to stress urinary incontinence. These findings align with previous studies by Sensoy et 2013, Falah-Hassani et al 2021 and Kobashi et al 2017, which identified age and parity as key risk factors for SUI development (10, 11, 12)

This study found an average BMI of 27.3, indicating overweight status, a known risk factor for stress urinary incontinence (SUI), which align with Long et al., 2024 (13).

This study investigated various clinical, surgical, and postoperative outcomes in women undergoing surgical treatment for stress urinary incontinence (SUI). The mean age of patients was 57.4 years, reflecting a predominantly postmenopausal group, and the average parity was 3.2, supporting existing evidence that aging and higher parity significantly contribute to pelvic floor dysfunction and SUI. These findings align with earlier studies by Sensoy et al 2013. reinforcing the role of age and childbirth history as critical risk factors (14).

Patients had an average BMI of 27.3, indicating overweight status, another recognized risk factor for SUI, which highlight the stronger influence of central obesity measures such as waist circumference over BMI alone. The dose-response relationship between BMI and incontinence risk underlines the importance of addressing weight management in SUI care (15).

Preoperatively, patients showed a baseline ICIQ-LUTS QoL score of 15.5, suggesting a moderate to severe quality of life impact. Similar burdens were documented by Nyström et al., 2015, emphasizing how SUI affects daily functioning, emotional health, and social participation. Post-surgical follow-up showed a consistent improvement in QoL scores: from 11.6 at 6 months, 10.3 at 1 year, and 10 at 2 years, reflecting sustained benefit. These trends parallel findings from Zalewski et al. and Hoffman et al., confirming the lasting positive effect of both surgical and non-surgical interventions on QoL in SUI patients (16).

Bladder function also improved, with a mean postoperative residual urine volume of 23.6 ml compared to 50.4 ml preoperatively. This indicates better bladder emptying and reduced risk of complications. Decalf et al 2020, similarly reported favorable voiding outcomes postoperatively, supporting our observations (17).Surgical efficiency was demonstrated by an average operating time of 38.1 minutes. Patient satisfaction averaged 5.65/10, suggesting moderate satisfaction with room for enhancement. Erickson et al 2022 and Popiel et al 2023. similarly reported high patient satisfaction rates following minimally invasive sling procedures, further validating the effectiveness of these techniques (18, 19).  Quality of life improvements were sustained, with mean scores improving from 15.5 preoperatively to 9.075 at two years post-surgery, reflecting a significant and stable therapeutic gain. These findings align with Tennstedt et al 2008. Highlighting long-term improvements in continence, psychosocial well-being, and social confidence following surgical treatment for SUI (20).

Complication rates were initially notable, with 30% in the TOT group and 25% in the TVT group at six months. However, by two years, all patients were complication-free, showing that postoperative issues resolved over time. Similar trends were seen in studies by Abdelwahab et al 2010, emphasizing comparable safety and efficacy between TOT and TVT procedures (21).

Finally, this study observed a 30% recurrence rate at six months post-surgery but no recurrences at 1 or 2 years, indicating excellent long-term success. This pattern is supported by findings from De Miguel Manso et al., 2020, who also emphasized that most recurrences occur early but often stabilize with time and proper management (22).

Both Trans-obturator Tape (TOT) and Tension-Free Vaginal Tape (TVT) procedures were found to be highly effective in enhancing continence, improving quality of life, and reducing complication rates over time in women with stress urinary incontinence (SUI). TOT demonstrated a shorter surgical duration, offering potential advantages in terms of faster postoperative recovery and greater patient comfort. The notable decline in recurrence rates further emphasizes the durability and long-term efficacy of both procedures.

Given these outcomes, both TOT and TVT remain excellent and reliable treatment options for SUI. The selection of the appropriate surgical approach should be individualized, taking into account patient-specific factors such as pelvic anatomy, severity of incontinence, comorbidities, and patient preference. Future larger-scale studies with longer follow-up periods may help refine the decision-making process further and optimize treatment strategies for better patient-centered outcomes.

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