Achieving competence in the retropubic mid-urethral sling (MUS) surgery for stress urinary incontinence takes longer than previously acknowledged, researchers found.

Using bladder perforation rates as a proxy for inadequate skill, Paul Hilton, MD, and Karen Rose, MD, of Royal Victoria Infirmary in Newcastle, U.K., assessed surgical competence in retropubic MUS (tension-free vaginal tape) at a single institution from 1997 to 2013. Of 1,568 MUS surgeries performed, 20% were secondary procedures and 36% involved additional procedures performed at the same time.

Bladder perforation rates ranged from 0% to 31% for the 16 individual surgeons, according to results published online ahead of print in the International Urogynecology Journal. By professional level, the 6 residents and 7 senior residents averaged 10.3%, the 2 fellows 4.5%, and 1 consultant 1.3%. The rate of bladder perforation during secondary operations did not differ significantly from primary operations.

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Previous research has suggested that a 5% or lower bladder perforation rate is a marker of surgical competence. Trainees only attained this target after performing 20 to 80 surgeries – more than many expect. No trainee performing fewer surgeries achieved competency.

“Whilst seductively simple in concept, mid-urethral tape procedures are not without risk; their inherently ‘blind’ nature makes them difficult to teach,” the investigators explained. “The ‘learning curve’ to independent practice may be longer than previously considered.”

They Royal College of Obstetrics and Gynecology recommends trainees complete a minimum of 20 MUS surgeries before competency assessment. However, this study suggests the number required to obtain proficiency can range higher.

The investigators also examined operating time, post-operative voiding difficulties, tape extrusion, and patient satisfaction but could not determine trends due to inadequate numbers.


  1. Hilton, P and Rose, K. Int Urogynecol J; doi: 10.1007/s00192-015-2853-z.