Why should we stop implanting transobturator sling?

Abstract

Since the first FDA warning on pelvic mesh in 2008, the debate on the use of synthetic polypropylene slings for the treatment of stress urinary incontinence (SUI) and pelvic organ prolapse (POP) has intensified. Despite the controversy, transvaginal tape (TVT) and transobturator tape (TOT) have revolutionized pelvic floor surgery. Systematic reviews and large trials confirm that synthetic slings, especially TVT, are safe and effective with low long-term complication and revision rates. Compared with older methods such as Burch colposuspension, slings offer similar efficacy but fewer voiding problems. While TOT is associated with a lower risk of bladder perforation and other intraoperative complications, it has a significantly higher incidence of chronic groin and pelvic pain. Emerging evidence links this pain to anatomical challenges, nerve entrapment and possible inflammatory responses, often making symptom resolution difficult even after mesh removal. In addition, the complete mesh removal is difficult in case of TOT, contributing to long-term patient morbidity. Given the higher re-operation rates, the prevalence of chronic pain, and the complex management associated with TOT, we argue for its discontinuation. TVT, despite its own risks, is more effective, reversible and manageable in the event of complications. Clinical focus should now shift to improving surgeon training, patient selection and postoperative care to optimise outcomes and minimise harm. LEVEL OF EVIDENCE: 3.