Open retropubic colposuspension for urinary incontinence in women

[Alloplastic material in the treatment of urinary incontinence]

Surgery for urinary incontinence is indicated after failure of conservative treatment with pelvic floor therapy. Different sling systems are the established treatment option for urinary incontinence for female and male patients. Tension-free vaginal tapes represent the standard of care in the surgical treatment of female stress urinary incontinence. In male patients with mild or moderate stress urinary incontinence, fixed repositioning slings or adjustable compressive slings represent minimally invasive alternatives to the artificial urinary sphincter. The use of surgical mesh material has been widely discussed within the last years. The current US Food and Drug Administration warning was focused on the use of transvaginal mesh implants in female patients with pelvic organ prolapse. Within the current debate, surgery for stress urinary incontinence and surgery for pelvic organ prolapse have often not been differentiated. With this ongoing discussion about the use of foreign material in reconstructive surgery, laparoscopic colposuspension might be performed more often in the near future.

[Incontinence surgery-quality criteria and structured follow-up]

The following article summarizes the current evidence including postoperative success rates and complications for various surgical options in the treatment of urinary incontinence. Due to different inclusion criteria and inconsistent definitions of study endpoints, the analysis of available studies is difficult. Thus, comparative studies with new devices for established treatment options should be planned. Structured processes used in certified continence centers improve the quality of care. Furthermore by documenting relevant complications, comparisons of treatment results thus become possible and provide evidence for the use of different surgical options in the treatment of urinary incontinence.

Comparison of synthetic mesh erosion and chronic pain rates after surgery for pelvic organ prolapse and stress urinary incontinence: a systematic review

BACKGROUND

The aim of this study is to systematically compare rates of erosion and chronic pain after mesh insertion for pelvic organ prolapse (POP) and stress urinary incontinence (SUI) surgery.

METHODS

A systematic electronic search was performed on studies that evaluated the incidence of erosion and chronic pain after mesh insertion for POP or SUI. The primary outcome measurement was to compare mesh erosion rates for POP and SUI surgery. Secondary outcome measurements were incidence of de novo pain and a comparison of patient demographics for both surgeries.

RESULTS

Twenty-six studies on 292,606 patients (n = 9077 for POP surgery and n = 283,529 for SUI surgery) met the inclusion criteria. Median follow-up was 26.38 ± 22.17 months for POP surgery and 39.33 ± 27.68 months for SUI surgery. Overall, the POP group were older (p < 0.0001) and had a lower BMI (p < 0.0001). Mesh erosion rates were significantly greater in the POP group compared to the SUI group (4% versus 1.9%) (OR 2.13; 95% CI 1.91-2.37; p < 0.0001). The duration from surgery to onset of mesh erosion was 306.84 ± 183.98 days. There was no difference in erosion rates between abdominal and transvaginal mesh for POP. There was no difference in erosion rates between the transobturator and retropubic approach for SUI. The incidence of chronic pain was significantly greater in the POP group compared to the SUI group (6.7% versus 0.6%) (OR 11.02; 95% CI 8.15-14.9; p < 0.0001). The duration from surgery to onset of chronic pain was 325.88 ± 226.31 days.

CONCLUSIONS

The risk of mesh erosion and chronic pain is significantly higher after surgery for POP compared to SUI. These significant complications occur within the first year after surgery.

Regenerative potential of human dental pulp stem cells in the treatment of stress urinary incontinence: In vitro and in vivo study

OBJECTIVES

To evaluate the regenerative potential of human dental pulp stem cells (hDPSCs) in an animal model of stress urinary incontinence (SUI). SUI, an involuntary leakage of urine, is due to physical stress involving an increase in bladder pressure and a damage of external urethral sphincter affecting muscles and nerves. Conventional therapies can only relieve the symptoms. Human DPSCs are characterized by peculiar stemness and immunomodulatory properties and might provide an alternative tool for SUI therapy.

MATERIALS AND METHODS

In vitro phase: hDPSCs were induced towards the myogenic commitment following a 24 hours pre-conditioning with 5-aza-2'-deoxycytidine (5-Aza), then differentiation was evaluated. In vivo phase: pudendal nerve was transected in female rats to induce stress urinary incontinence; then, pre-differentiated hDPSCs were injected in the striated urethral sphincter. Four weeks later, urethral sphincter regeneration was assayed through histological, functional and immunohistochemical analyses.

RESULTS

Human DPSCs were able to commit towards myogenic lineage in vitro and, four weeks after cell injection, hDPSCs engrafted in the external urethral sphincter whose thickness was almost recovered, committed towards myogenic lineage in vivo, promoted vascularization and an appreciable recovery of the continence. Moreover, hDPSCs were detected within the nerve, suggesting their participation in repair of transected nerve.

CONCLUSIONS

These promising data and further investigations on immunomodulatory abilities of hDPSCs would allow to make them a potential tool for alternative therapies of SUI.

Anterior vaginal repair for urinary incontinence in women

BACKGROUND

Anterior vaginal repair (anterior colporrhaphy) is an operation traditionally used for moderate or severe stress urinary incontinence (SUI) in women. About a third of adult women experience urinary incontinence. SUI imposes significant health and economic burden to the society and the women affected.

OBJECTIVES

To determine the effects of anterior vaginal repair (anterior colporrhaphy) on urinary incontinence in comparison with other management options.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Trials Register (searched 1 September 2009) and the reference lists of relevant articles.

SELECTION CRITERIA

Randomised or quasi-randomised trials that included anterior vaginal repair for the treatment of urinary incontinence.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed trial quality. Three trial investigators were contacted for additional information.

MAIN RESULTS

Ten trials were identified which included 385 women having an anterior vaginal repair and 627 who received comparison interventions.A single small trial provided insufficient evidence to assess anterior vaginal repair in comparison with physical therapy. The performance of anterior repair in comparison with bladder neck needle suspension appeared similar (risk ratio (RR) for failure after one year 1.16, 95% confidence interval (CI) 0.86 to 1.56), but clinically important differences could not be confidently ruled out. No trials compared anterior repair with suburethral sling operations or laparoscopic colposuspensions, or compared alternative vaginal operations.Anterior vaginal repair was less effective than open abdominal retropubic suspension based on patient-reported cure rates in eight trials both in the medium term (failure rate within one to five years after anterior repair 97/259 (38%) versus 57/327 (17%); RR 2.29, 95% confidence Interval (CI) 1.70 to 3.08) and in the long term (after five years, (49/128 (38%) versus 31/145 (21%); RR 2.02, 95% CI 1.36 to 3.01). There was evidence from three of these trials that this was reflected in a need for more repeat operations for incontinence (25/107 (23%) versus 4/164 (2%); RR 8.87, 95% CI 3.28 to 23.94). These findings held, irrespective of the co-existence of prolapse (pelvic relaxation). Although fewer women had a prolapse after anterior repair (RR 0.24, 95% CI 0.12 to 0.47), later prolapse operation appeared to be equally common after vaginal (3%) or abdominal (4%) operation.In respect of the type of open abdominal retropubic suspension, most data related to comparisons of anterior vaginal repair with Burch colposuspension. The few data describing comparison of anterior repair with the Marshall-Marchetti-Krantz procedure were consistent with those for Burch colposuspension.

AUTHORS' CONCLUSIONS

There were not enough data to allow comparison of anterior vaginal repair with physical therapy or needle suspension for primary urinary stress incontinence in women. Open abdominal retropubic suspension appeared to be better than anterior vaginal repair judged on subjective cure rates in eight trials, even in women who had prolapse in addition to stress incontinence (six trials). The need for repeat incontinence surgery was also less after the abdominal operation. However, there was not enough information about postoperative complications and morbidity.A Brief Economic Commentary (BEC) identified one study suggesting that vaginoplasty may be more cost-effective compared with tension-free vaginal tape (TVT-O).

Laparoscopic colposuspension for urinary incontinence in women

BACKGROUND

Stress urinary incontinence (SUI) imposes significant health and economic burden on society and the women affected. Laparoscopic colposuspension was one of the first minimal access operations for the treatment of women with SUI, with the presumed advantages of avoiding major incisions, shorter hospital stays and quicker return to normal activities.

OBJECTIVES

To determine the effects of laparoscopic colposuspension for urinary incontinence in women.

SEARCH METHODS

We searched the Cochrane Incontinence Group Trials Register (searched 2 July 2009), and sought additional trials from other sources and by contacting study authors for unpublished data and trials.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials in women with symptomatic or urodynamic diagnosis of stress or mixed incontinence that included laparoscopic surgery as the intervention in at least one arm of the studies.

DATA COLLECTION AND ANALYSIS

The review authors evaluated trials for methodological quality and their appropriateness for inclusion in the review. Two review authors extracted data and another cross checked them. Where appropriate, we calculated a summary statistic.

MAIN RESULTS

We identified 22 eligible trials. Ten involved the comparison of laparoscopic with open colposuspension. Whilst the women's subjective impression of cure seemed similar for both procedures, in the short- and medium-term follow-up, there was some evidence of poorer results of laparoscopic colposuspension on objective outcomes. The results showed trends towards fewer perioperative complications, less postoperative pain and shorter hospital stay for laparoscopic compared with open colposuspension, however, laparoscopic colposuspension was more costly.Eight studies compared laparoscopic colposuspension with newer 'self-fixing' vaginal slings. There were no significant differences in the reported short- and long-term subjective cure rates of the two procedures but objective cure rates at 18 months favoured slings. We observed no significant differences for postoperative voiding dysfunction and perioperative complications. Laparoscopic colposuspension had a significantly longer operation time and hospital stay. We found significantly higher subjective and objective one-year cure rates for women randomised to two paravaginal sutures compared with one suture in a single trial. Three studies compared sutures with mesh and staples for laparoscopic colposuspension and showed a trend towards favouring the use of sutures.

AUTHORS' CONCLUSIONS

Currently available evidence suggests that laparoscopic colposuspension may be as good as open colposuspension at two years post surgery. However, the newer vaginal sling procedures appear to offer even greater benefits, better objective outcomes in the short term and similar subjective outcomes in the longer term. If laparoscopic colposuspension is performed, the use of two paravaginal sutures appears to be the most effective method. The place of laparoscopic colposuspension in clinical practice should become clearer when there are more data available describing long-term results. A brief economic commentary (BEC) identified three studies suggesting that tension-free vaginal tape (TVT) may be more cost-effective compared with laparoscopic colposuspension but laparoscopic colposuspension may be slightly more cost-effective when compared with open colposuspension after 24 months follow-up.

Traditional suburethral sling operations for urinary incontinence in women

BACKGROUND

Stress urinary incontinence constitutes a significant health and economic burden to society. Traditional suburethral slings are one of the surgical operations used to treat women with symptoms of stress urinary incontinence.

OBJECTIVES

To determine the effects of traditional suburethral slings on stress or mixed incontinence in comparison with other management options.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Register (searched 3 June 2010) and the reference lists of relevant articles.

SELECTION CRITERIA

Randomised or quasi-randomised trials that included traditional suburethral slings for the treatment of stress or mixed urinary incontinence.

DATA COLLECTION AND ANALYSIS

At least three reviewers independently extracted data from included trials onto a standard form and assessed trial methodological quality. The data abstracted were relevant to predetermined outcome measures. Where appropriate, we calculated a summary statistic: a relative risk for dichotomous data and a weighted mean difference for continuous data.

MAIN RESULTS

We included 26 trials involving 2284 women. The quality of evidence was moderate for most trials and there was generally short follow-up ranging from 6 to 24 months.One medium-sized trial compared traditional suburethral sling operations with oxybutynin in the treatment of women with mixed urinary incontinence. Surgery appeared to be more effective than drugs in treating participant-reported incontinence (n = 75, risk ratio (RR) 0.18, 95% confidence interval (CI) 0.08 to 0.43).One trial found that traditional slings were more effective than transurethral injectable treatment (RR for clinician-assessed incontinence within a year 0.21, 95% CI 0.09 to 0.21)Seven trials compared slings with open abdominal retropubic colposuspension. Participant-reported incontinence was lower with the slings after one year (RR 0.75, 95% CI 0.62 to 0.90), but not when assessed by clinicians. Colposuspension, however, was associated with fewer peri-operative complications, shorter duration of use of indwelling catheter and less long-term voiding dysfunction. One study showed there was a 20% lower risk of bladder perforation with the sling procedure but a 50% increase in urinary tract infection with the sling procedure compared with colposuspension. Fewer women developed prolapse after slings (compared with after colposuspension) in two small trials but this did not reach statistical significance.Twelve trials addressed the comparison between traditional sling operations and minimally invasive sling operations. These seemed to be equally effective in the short term (RR for incontinence within first year 0.97, 95% CI 0.78 to 1.20) but minimally invasive slings had a shorter operating time, fewer peri-operative complications (other than bladder perforation) and some evidence of less post-operative voiding dysfunction and detrusor symptoms.Six trials compared one type of traditional sling with another. Materials included porcine dermis, lyophilised dura mater, fascia lata, vaginal wall, autologous dermis and rectus fascia. Participant-reported improvement rates within the first year favoured the traditional autologous material rectus fascia over other biological materials (RR 0.45, 95% CI 0.21 to 0.98). There were more complications with the use of non-absorbable Gore-Tex in one trial.Data for comparison of bladder neck needle suspension with suburethral slings were inconclusive because they came from a single trial with a small specialised population.No trials compared traditional suburethral slings with anterior repair, laparoscopic retropubic colposuspension or artificial sphincters. Most trials did not distinguish between women having surgery for primary or recurrent incontinence when reporting participant characteristics.For most of the comparisons, clinically important differences could not be ruled out.

AUTHORS' CONCLUSIONS

Traditional slings seem to be as effective as minimally invasive slings, but had higher rates of adverse effects. This should be interpreted with some caution however, as the quality of evidence for the studies was variable, follow-up short and populations small, particularly for identifying complication rates. Tradional sling procedures appeared to confer a similar cure rate in comparison to open retropubic colposuspension, but the long-term adverse event profile is still unclear. A brief economic commentary (BEC) identified two studies suggesting that traditional slings may be more cost-effective compared with collagen injection but not cost-effective when compared with minimally invasive sling operations. Reliable evidence to clarify whether or not traditional suburethral slings may be better or worse than other surgical or conservative management options is lacking.

The Long-Term Outcome of the Turner-Warwick Vaginal Obturator Shelf Urethral Repositioning Colposuspension Procedure for Urodynamically Proven Stress Urinary Incontinence

OBJECTIVE

To analyze long-term continence, voiding dysfunction and secondary prolapse rates following Turner-Warwick Vaginal Obturator Shelf Urethral Repositioning colposuspension (VOSURP) for urodynamically proven stress urinary incontinence (USUI).

PATIENTS AND METHODS

Telephone and/or outpatient review of the outcomes of 50 consecutive patients undergoing VOSURP between 1997 and 2008 was conducted. Outcomes assessed included urinary continence (pad free/leak free), need to self-catheterise (ISC), secondary posterior pelvic organ prolapse (POP) development and need for further continence and POP-related surgical interventions. All patients with continued/recurrent urinary incontinence had repeat videourodynamics.

RESULTS

At a median follow-up of 108.5 months (17-153), complete urinary continence was reported in 41 (82%) of patients, post procedure new onset ISC in 2 (4%) and new onset posterior POP in 2 (4%). The cause of continued urinary incontinence was persistent USUI in 3 (6%), new onset idiopathic detrusor overactivity (IDO) in 4 (8%) and failure of resolution of pre-existing IDO in 2 (4%).

CONCLUSIONS

Long-term complete urinary continence and cure of USUI following VOSURP are excellent at 82 and 94%, respectively. Voiding dysfunction and secondary POP procedure rates are low. The VOSURP is an excellent alternative to classical Burch colposuspension for the treatment of primary and recurrent USUI.

The role of bladder neck suspension in the era of mid-urethral sling surgery

INTRODUCTION

Mid-urethral slings are currently considered to be the gold standard for the surgical treatment of stress urinary incontinence, replacing bladder neck suspension techniques which previously occupied this position. In recent years, however, there have been concerns with regard to the use of synthetic material in vaginal surgery.

METHODS

We performed a review of the literature to discuss the role of bladder neck suspension techniques in the current clinical setting.

CONCLUSIONS

Bladder neck suspension techniques consist of vaginal techniques, needle suspension techniques and retropubic techniques. The latter two techniques have been proven to offer durable outcomes for stress urinary incontinence. As compared to autologous slings, the long-term success rates may be considered inferior, but so is the rate of complication, resulting in higher patient satisfaction. Bladder neck suspension techniques may have a role in treating recurrent and/or persisting stress urinary incontinence after (failed) sling surgery and remain of particular interest in patients with stress urinary incontinence when performing concomitant surgery, for example for prolapse.

Pleated colposuspension: Our modification of Burch colposuspension

Introduction:

Burch colposuspension is a standard treatment for stress urinary incontinence. However, it is associated with recurrence and urinary retention. We describe a modification of this technique to overcome these problems and evaluate the results in comparison with the standard procedure.

Materials and Methods:

A total of 145 patients with isolated stress urinary incontinence (SUI), underwent either our modified pleated colposuspension (PC); n = 97) or standard Burch colposuspension (BC) (n = 48). Description of PC: Three No. 0 non-absorbable sutures were placed in the side-to-side manner at the mid-urethral level with 0.5-1.0 cm distance between them using double bites and were passed through the Cooper's ligament. The patients were followed-up every 6 months for SUI and genital prolapse evaluation. Successful surgery was defined as (1) No self-reported SUI symptoms, (2) Negative Marshall's coughing test (MT), (3) No retreatment for SUI, (4) Absence of urodynamic SUI. In addition, failure was defined as the occurrence of urinary retention, use of catheter on 6-week visit, maximum flow rate >15 ml/s, flow time <60 s, or residual urine <100 ml. Data was compared using Student's paired test and Mantel-Haenzel's χ² test. P > 0.05 was considered significant.

Results:

The mean follow-up after surgery for PC was 102.4 months and for BC was 103.6 months. At last follow-up, data suggesting failure (Stress score ≥7, urge score ≥7, Pad test with weight < 15 g/day and positive MT during lithotomic/upright position) were more frequent in BC group (P > 0.05; P > 0.0; P > 0.01; P > 0.05; P > 0.05, respectively). The incidence of recurrent SUI was 5.2% after PC and almost triple (14.6%) after BC. Residual urine <100 ml and weak stream were more frequent in the BC group (P > 0.05; P > 0.01, respectively). Detrusor over-activity on urodynamic studies, Flow time <60 s, urethral pressure profilometry positive for obstruction had a higher incidence in BC group (P > 0.01; P > 0.001; P > 0.01, respectively).

Conclusion:

Our modified pleated colposuspension showed improved outcomes when compared with standard Burch colposuspension.

Long-term outcomes after stress urinary incontinence surgery

OBJECTIVES

To compare the long-term risk of repeat stress urinary incontinence (SUI) surgery after different types of initial SUI surgery and to identify predictors of time to repeat SUI surgery in a large, population-based cohort.

METHODS

We used de-identified, adjudicated health care claims data from approximately 100 employer-based plans across the United States from 2000 to 2009. We identified the index SUI surgery in women aged 18 to 64 years. Kaplan-Meier survival curves were used to estimate cumulative incidence of repeat surgery through 9 years. Cox proportional hazards models were used to estimate the adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) for factors associated with recurrent SUI surgery.

RESULTS

Over 10 years, we identified 155,458 eligible women who underwent one or more SUI surgeries, with a total of 294,855 person-years of follow-up. Of these index surgeries, 127,848 (82.2%) were slings. The 9-year cumulative incidence of repeat surgery after any SUI surgery was 14.5% (95% CI 13.4-15.5). As expected, bulking agents had the highest cumulative incidence of repeat surgery (61.2%, 95% CI 56.3-66.0) followed by needle suspension (22.2%, 95% CI 16.5-27.9); the lowest 9-year incidences were for Burch (10.8%, 95% CI 9.3-12.3) and sling (13.0%, 95% CI 11.7-14.3). In a Cox proportional hazards model that adjusted for age, year of index surgery, and region of the United States, the rate of repeat surgery was 28% higher for slings compared with Burch (adjusted HR 1.28, 95% CI 1.19-1.37).

CONCLUSION

In this population-based analysis of women aged 18 to 64 years, Burch procedures had the lowest 9-year cumulative incidence of repeat SUI surgery.

Patient related factors associated with long-term urinary continence after Burch colposuspension and pubovaginal fascial sling surgeries

PURPOSE

We examined preoperative and postoperative patient related factors associated with continence status up to 7 years after surgery for stress urinary incontinence.

MATERIALS AND METHODS

Women randomized to Burch colposuspension or fascial sling surgery and assessed for the primary outcome of urinary continence 2 years after surgery were eligible to enroll in a prospective observational study. Survival analysis was used to investigate baseline and postoperative factors in the subsequent risk of stress urinary incontinence, defined as self-report of stress urinary incontinence symptoms, incontinence episodes on a 3-day diary or surgical re-treatment.

RESULTS

Of the women who participated in the randomized trial 74% (482 of 655) were enrolled in the followup study. Urinary continence rates decreased during a period of 2 to 7 years postoperatively from 42% to 13% in the Burch group and from 52% to 27% in the sling group, respectively. Among the baseline factors included in the first multivariable model age (p = 0.03), prior stress urinary incontinence surgery (p = 0.02), menopausal status (0.005), urge index (0.006), assigned surgery (p = 0.01) and recruiting site (p = 0.02) were independently associated with increased risk of incontinence. In the final multivariable model including baseline and postoperative factors, Burch surgery (p = 0.01), baseline variables of prior urinary incontinence surgery (p = 0.04), menopausal status (p = 0.03) and postoperative urge index (p <0.001) were each significantly associated with a greater risk of recurrent urinary incontinence.

CONCLUSIONS

Preoperative and postoperative urgency incontinence symptoms, Burch urethropexy, prior stress urinary incontinence surgery and menopausal status were negatively associated with long-term continence rates. More effective treatment of urgency urinary incontinence in patients who undergo stress urinary incontinence surgery may improve long-term overall continence status.

[Sacropolpopexy - pro robotic]

Abdominal sacrocolpopexy is a standard procedure for the correction of pelvic organ prolapse of all three compartments and can also be performed minimally invasively without compromising efficacy as by open techniques. In comparison to conventional laparoscopy robotic-assisted laparoscopic sacrocolpopexy benefits from several technical stand-alone features, such as three-dimensional view, increased degrees of freedom through angulated instruments, tremor filter and up and down scaling of instrument movements. These advantages facilitate preparation of the vesicovaginal and rectovaginal spaces as well as suturing and reperitonealization, which should lead to decreased operation time and anesthesia time in extreme Trendelenburg position. Surgeon also benefit from the much more ergonomic working conditions of the da Vinci® system: however, comparative studies are rare and conclusions are preliminary. The German reimbursement system (DRG) does not adequately cover da Vinci expenses which, despite the obvious advantages represents the most significant obstacle in the propagation of this technique.

Slings in surgery of genuine stress incontinence

PURPOSE

To summarize the available evidence concerning efficacy and safety of standard mid-urethral sling (SMUS) operations for the treatment of stress urinary incontinence (SUI).

METHODS AND RESULTS

A non-systematic literature review was carried out in order to collect the available evidence concerning efficacy and safety of SMUS operations for the treatment of SUI. According to the data of our prior meta-analysis, patients receiving SMUS had significantly higher overall and objective cure rates than those receiving Burch colposuspension, although they had a higher risk of bladder perforations. Patients undergoing SMUS and pubovaginal slings had similar cure rates, although the latter were slightly more likely to experience storage lower urinary tract symptoms and had a higher reoperation rate. Patients treated with retropubic SMUS had slightly higher objective cure rates than those treated with transobturator tape (TOT); however, subjective cure rates were similar, and patients treated with TOT had a much lower risk of some complications. Meta-analysis demonstrated similar outcomes for TOTs. With regard to the novel mini-sling, another meta-analysis from Abdel-fattah et al. demonstrated that repeat continence surgery and de novo urgency incontinence were significantly higher in the patients treated with mini-slings.

CONCLUSION

Patients treated with retropubic tape (RT) experienced slightly higher continence rates than those treated with Burch colposuspension, but they faced a much higher risk of intraoperative complications. RT and pubovaginal slings were similarly effective. The use of RT was followed by objective cure rates slightly higher than TOT and by higher risk of complications. The novel mini-slings do not seem to be more effective than the SMUS.

Trends in inpatient urinary incontinence surgery in the USA, 1998-2007

INTRODUCTION AND HYPOTHESIS

This study was conducted to assess national rates in stress urinary incontinence (SUI) surgery in the USA from 1998 to 2007.

METHODS

We utilized the 1998-2007 Nationwide Inpatient Sample and assessed women aged 20 years and older who underwent SUI surgery based on the International Classification of Diseases, 9th Revision (ICD-9) procedure and diagnosis codes.

RESULTS

The total number of SUI surgeries performed during this 10-year period was 759,821. The annual number of procedures increased from 37,953 in 1998 to 94,910 in 2007. The type of SUI surgery performed also changed (p < 0.001). In 1998, retropubic suspensions represented 52.3%, decreasing to 13.8% in 2007. "Other repair of SUI" (ICD-9 59.79) comprised 22.4% in 1998, increasing to 75.2% in 2007, likely representing midurethral slings.

CONCLUSIONS

The total number and incidence rates of SUI surgeries have increased from 1998 to 2007. The type of SUI surgery performed has also changed significantly, likely secondary to adoption of midurethral slings.

Traditional suburethral sling operations for urinary incontinence in women

BACKGROUND

Traditional suburethral slings are surgical operations used to treat women with symptoms of stress urinary incontinence.

OBJECTIVES

To determine the effects of traditional suburethral slings on stress or mixed incontinence in comparison with other management options.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group Specialised Register (searched 3 June 2010) and the reference lists of relevant articles.

SELECTION CRITERIA

Randomised or quasi-randomised trials that included traditional suburethral slings for the treatment of stress or mixed urinary incontinence.

DATA COLLECTION AND ANALYSIS

At least three reviewers independently extracted data from included trials onto a standard form and assessed trial methodological quality. The data abstracted were relevant to predetermined outcome measures. Where appropriate, a summary statistic was calculated: a relative risk for dichotomous data and a weighted mean difference for continuous data.

MAIN RESULTS

Twenty six trials involving 2284 women were included. The quality of evidence was moderate for most trials and there was generally short follow-up ranging from 6-24 months.One medium sized trial compared traditional suburethral sling operations with oxybutynin in the treatment of mixed urinary incontinence patients. Surgery appeared to be more effective than drugs in treating patient-reported incontinence (n = 75, Risk Ratio (RR) 0.18, 95% Confidence Interval (CI) 0.08 to 0.43).One trial found that traditional slings were more effective than transurethral injectable treatment (RR for clinician-assessed incontinence within a year 0.21; 95% CI 0.09 to 0.21), and also cheaper on average cost.Seven trials compared slings with open abdominal retropubic colposuspension. Patient-reported incontinence was lower with the slings after one year (RR 0.75; 95% CI 0.62 to 0.90), but not when assessed by clinicians. Colposuspension, however, was associated with fewer peri-operative complications, shorter duration of use of indwelling catheter and less long term voiding dysfunction. One study showed there was a 20% lower risk of bladder perforation with the sling procedure but a 50% increase in urinary tract infection with the sling procedure compared with colposuspension. Fewer women developed prolapse after slings (compared with after colposuspension) in two small trials but this did not reach statistical significance.Twelve trials addressed the comparison between traditional sling operations and minimally invasive sling operations.These seemed to be equally effective in the short term (RR for incontinence within first year 0.97; 95% CI 0.78 to 1.20) but minimally invasive slings had a shorter operating time, fewer peri-operative complications (other than bladder perforation) and some evidence of less post-operative voiding dysfunction and detrusor symptoms.Six trials compared one type of traditional sling with another. Materials included porcine dermis, lyophilised dura mater, fascia lata, vaginal wall, autologous dermis and rectus fascia. Patient-reported improvement rates within the first year favoured the traditional autologous material rectus fascia over other biological materials (RR 0.45; 95% CI 0.21 to 0.98). There were more complications with the use of non-absorbable Goretex in one trial.Data for comparison of bladder neck needle suspension with suburethral slings were inconclusive because they came from a single trial with a small specialised population.No trials compared traditional suburethral slings with anterior repair, laparoscopic retropubic colposuspension or artificial sphincters. Most trials did not distinguish between women having surgery for primary or recurrent incontinence when reporting patient characteristics.For most of the comparisons, clinically important differences could not be ruled out.

AUTHORS' CONCLUSIONS

Traditional slings seem to be as effective as minimally invasive slings, but had higher rates of adverse effects. This should be interpreted with some caution however, as the quality of evidence for the studies was variable, follow-up short and populations small, particularly for identifying complication rates. Tradional sling procedures appeared to confer a similar cure rate in comparison to open retropubic colposuspension, but the long term adverse event profile is still unclear. Reliable evidence to clarify whether or not traditional suburethral slings may be better or worse than other surgical or conservative management options is lacking.

Surgical management of pelvic organ prolapse in women

BACKGROUND

Pelvic organ prolapse may occur in up to 50% of parous women. A variety of urinary, bowel and sexual symptoms may be associated with the prolapse.

OBJECTIVES

To determine the effects of the many different surgeries used in the management of pelvic organ prolapse.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group Specialised Register (9 February 2009) and reference lists of relevant articles. We also contacted researchers in the field.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials that included surgical operations for pelvic organ prolapse.

DATA COLLECTION AND ANALYSIS

Trials were assessed and data extracted independently by two review authors. Six investigators were contacted for additional information with five responding.

MAIN RESULTS

Forty randomised controlled trials were identified evaluating 3773 women. Abdominal sacral colpopexy was better than vaginal sacrospinous colpopexy in terms of a lower rate of recurrent vault prolapse (RR 0.23, 95% CI 0.07 to 0.77) and less dyspareunia (RR 0.39, 95% CI 0.18 to 0.86). However there was no statistically significant difference in re-operation rates for prolapse (RR 0.46, 95% CI 0.19 to 1.11). The vaginal sacrospinous colpopexy was quicker and cheaper to perform and women had an earlier return to activities of daily living. The three trials contributing to this analysis were clinically heterogeneous.For anterior vaginal wall prolapse, standard anterior repair was associated with more recurrent cystoceles than when supplemented with a polyglactin mesh inlay (RR 1.39, 95% CI 1.02 to 1.90) or porcine dermis mesh inlay (RR 2.72, 95% CI 1.20 to 6.14); but data on morbidity and other clinical outcomes were lacking. Standard anterior repair was associated with more anterior compartment failures on examination than for polypropylene mesh repair as an overlay (RR 2.14, 95% CI 1.23 to 3.74) or armed transobturator mesh (RR 3.55, 95% CI 2.29 to 5.51). Data relating to polypropylene mesh overlay were extracted from conference abstracts without any peer reviewed manuscripts available and should be interpreted with caution. No differences in subjective outcomes, quality of life data, de novo dyspareunia, stress incontinence, re-operation rates for prolapse or incontinence were identified. Blood loss with transobturator meshes was significantly higher than for native tissue anterior repair. Mesh erosions were reported in 10% (30/293) of anterior repairs with polypropylene mesh.For posterior vaginal wall prolapse, the vaginal approach was associated with a lower rate of recurrent rectocele or enterocele, or both, than the transanal approach (RR 0.24, 95% CI 0.09 to 0.64); although there was a higher blood loss and post-operative narcotic use. No data exist on efficacy or otherwise of polypropylene mesh in the posterior vaginal compartment.Meta-analysis on the impact of continence surgery at the time of prolapse surgery was performed with data from seven studies. Continence surgery at the time of prolapse surgery in continent women did not significantly reduce the rate of post-operative stress urinary incontinence (RR 1.39, 95% CI 0.53 to 3.70; random-effects model).

AUTHORS' CONCLUSIONS

Abdominal sacral colpopexy was associated with a lower rate of recurrent vault prolapse and dyspareunia than with vaginal sacrospinous colpopexy. These benefits must be balanced against a longer operating time, longer time to return to activities of daily living and increased cost of the abdominal approach. The use of mesh or graft inlays at the time of anterior vaginal wall repair reduces the risk of recurrent anterior wall prolapse, on examination. Posterior vaginal wall repair may be better than transanal repair in the management of rectoceles in terms of recurrence of prolapse. The value of the addition of a continence procedure to a prolapse repair operation in women who are dry before operation remains to be assessed. Adequately powered randomised controlled clinical trials are urgently needed on a wide variety of issues and particularly need to include women's perceptions of prolapse symptoms.

Minimally invasive synthetic suburethral sling operations for stress urinary incontinence in women

BACKGROUND

Stress urinary incontinence (SUI) is a common condition affecting up to 30% of women. Minimally invasive synthetic suburethral sling operations are among the latest forms of procedures introduced to treat SUI.

OBJECTIVES

To assess the effects of minimally invasive synthetic suburethral sling operations for treatment of SUI, urodynamic stress incontinence (USI) or mixed urinary incontinence (MUI) in women.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group Specialised Register (searched 20 March 2008), MEDLINE (January 1950 to April 2008), EMBASE (January 1988 to April 2008), CINAHL (January 1982 to April 2008), AMED (January 1985 to April 2008), the UK National Research Register, ClinicalTrials.gov, and reference lists of relevant articles.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials amongst women with SUI, USI or symptoms of stress or mixed urinary incontinence, in which at least one trial arm involved a minimally invasive synthetic suburethral sling operations.

DATA COLLECTION AND ANALYSIS

Two review authors assessed the methodological quality of potentially eligible studies and independently extracted data from the included trials.

MAIN RESULTS

Sixty two trials involving 7101 women were included. The quality of evidence was moderate for most trials. Minimally invasive synthetic suburethral sling operations appeared to be as effective as traditional suburethral slings ( trials, n = 599, Risk Ratio (RR) 1.03, 95% Confidence Interval (CI) 0.94 to 1.13) but with shorter operating time and less post-operative voiding dysfunction and de novo urgency symptoms.Minimally invasive synthetic suburethral sling operations appeared to be as effective as open retropubic colposuspension (subjective cure rate at 12 months RR 0.96, 95% CI 0.90 to 1.03; at 5 years RR 0.91, 95% CI 0.74 to 1.12) with fewer perioperative complications, less postoperative voiding dysfunction, shorter operative time and hospital stay but significantly more bladder perforations (6% versus 1%, RR 4.24, 95% CI 1.71 to 10.52).There was conflicting evidence about the effectiveness of minimally invasive synthetic suburethral sling operations compared to laparoscopic colposuspension in the short term (objective cure, RR 1.15, 95% CI 1.06 to 1.24; subjective cure RR 1.11, 95% CI 0.99 to 1.24). Minimally invasive synthetic suburethral sling operations had significantly less de novo urgency and urgency incontinence, shorter operating time, hospital stay and time to return to daily activities.A retropubic bottom-to-top route was more effective than top-to-bottom route (RR 1.10, 95% CI 1.01 to 1.20; RR 1.06, 95% CI 1.01 to 1.11) and incurred significantly less voiding dysfunction, bladder perforations and tape erosions.Monofilament tapes had significantly higher objective cure rates (RR 1.15, 95% CI 1.02 to 1.30) compared to multifilament tapes and fewer tape erosions (1.3% versus 6% RR 0.25, 95% CI 0.06 to 1.00).The obturator route was less favourable than the retropubic route in objective cure (84% versus 88%; RR 0.96, 95% CI 0.93 to 0.99; 17 trials, n = 2434), although there was no difference in subjective cure rates. However, there was less voiding dysfunction, blood loss, bladder perforation (0.3% versus 5.5%, RR 0.14, 95% CI 0.07 to 0.26) and shorter operating time with the obturator route.

AUTHORS' CONCLUSIONS

The current evidence base suggests that minimally invasive synthetic suburethral sling operations are as effective as traditional suburethral slings, open retropubic colposuspension and laparoscopic colposuspension in the short term but with less postoperative complications. Women were less likely to be continent after operations performed via the obturator (rather than retropubic) route, but they had fewer complications. Most of the trials had short term follow up and the quality of the evidence was variable.

Oestrogen therapy for urinary incontinence in post-menopausal women

BACKGROUND

It is possible that oestrogen deficiency may be an aetiological factor in the development of urinary incontinence in women.

OBJECTIVES

To assess the effects of local and systemic oestrogens used for the treatment of urinary incontinence.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group Specialised Register of trials (2 April 2009) and the reference lists of relevant articles.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials that included oestrogens in at least one arm, in women with symptomatic or urodynamic diagnoses of stress, urgency or mixed urinary incontinence or other urinary symptoms post-menopause.

DATA COLLECTION AND ANALYSIS

Trials were evaluated for methodological quality and appropriateness for inclusion by the review authors. Data were extracted by at least two authors and cross checked. Subgroup analyses were performed grouping participants under local or systemic administration. Where appropriate, meta-analysis was undertaken.

MAIN RESULTS

Thirty- three trials were identified which included 19,313 (1,262 involved in trials of local administration) incontinent women of whom 9417 received oestrogen therapy. Sample sizes ranged from 16 to 16,117. The trials used varying combinations of type of oestrogen, dose, duration of treatment and length of follow up. Outcome data were not reported consistently and were available for only a minority of outcomes.Systemic administration (of oral oestrogens) resulted in worse incontinence than on placebo (RR 1.32, 95% CI 1.17 to 1.48). This result is heavily weighted by a subgroup of women from the Hendrix trial, which had large numbers of participants and a longer follow up of one year; all the women had had a hysterectomy and the treatment used was conjugated equine oestrogen. The result for women with an intact uterus where oestrogen and progestogen combined were used also showed a statistically significant worsening of incontinence (RR 1.11, 95% CI 1.04 to 1.18).There was some evidence that oestrogens used locally (for example vaginal creams or tablets) may improve incontinence (RR 0.74, 95% CI 0.64 to 0.86). Overall, there were around one to two fewer voids in 24 hours and nocturnal voids amongst women treated with local oestrogen, and there was less frequency and urgency. No serious adverse events were reported although some women experienced vaginal spotting, breast tenderness or nausea.Women who were continent and received systemic oestrogen replacement, with or without progestogens, for reasons other than urinary incontinence were more likely to report the development of new urinary incontinence in one large study.The data were too few to address questions about oestrogens compared with or in combination with other treatments, different types of oestrogen or different modes of delivery.

AUTHORS' CONCLUSIONS

Local oestrogen treatment for incontinence may improve or cure it, but there was little evidence from the trials on the period after oestrogen treatment had finished and none about long-term effects. However, systemic hormone replacement therapy, using conjugated equine oestrogen, may make incontinence worse. There were too few data to reliably address other aspects of oestrogen therapy, such as oestrogen type and dose, and no direct evidence on route of administration. The risk of endometrial and breast cancer after long-term use suggests that oestrogen treatment should be for limited periods, especially in those women with an intact uterus.

Laparoscopic colposuspension for urinary incontinence in women

BACKGROUND

Laparoscopic colposuspension was one of the first minimal access operations for the treatment of women with stress urinary incontinence, with the presumed advantages over traditional Burch colposuspension of avoiding major incisions, shorter hospital stay, and quicker return to normal activities. A variety of approaches and methods are used.

OBJECTIVES

To determine the effects of laparoscopic colposuspension for urinary incontinence.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group Specialised Trials Register (searched 21 September 2005). Additional trials were sought from other sources such as reference lists, reviews and researchers and authors were contacted for unpublished data and trials.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials in women with symptomatic or urodynamic diagnosis of stress or mixed incontinence that included laparoscopic surgery in at least one arm of the study.

DATA COLLECTION AND ANALYSIS

Trials were evaluated for methodological quality and appropriateness for inclusion by the reviewers. Data were extracted by two of the reviewers and cross checked by another. Trial data were analysed by intervention. Where appropriate, a summary statistic was calculated.

MAIN RESULTS

Twenty-one eligible trials were identified. Nine involved the comparison of laparoscopic with open colposuspension. Whilst the women's subjective impression of cure seemed similar for both procedures in the short and medium term follow-up, there was some evidence of poorer results of laparoscopic colposuspension, within 18 months, on objective outcomes. Two poor quality trials reported conflicting long term results (after five years) for this comparison. No significant differences were observed for post-operative urgency, voiding dysfunction or de novo detrusor overactivity. Trends were shown towards a lower perioperative complication rate, longer operating time, less intraoperative blood loss, less postoperative pain, shorter hospital stay, quicker return to normal activities, and shorter duration of catheterisation for laparoscopic compared with open colposuspension. Benefits did not come without a price, as laparoscopic colposuspension in the short term is more costly.Eight studies compared laparoscopic colposuspension with newer 'self-fixing' vaginal slings. Overall there were no significant differences in the reported subjective cure rates of the two procedures, however vaginal sling procedures did have significantly higher objective cure rates at 18 months. No significant differences were observed for post-operative voiding dysfunction, de novo detrusor activity and perioperative complications. Laparoscopic colposuspension has a significantly longer operation time, longer hospital stay and slower return to normal activities when compared to the sling procedures. Significantly higher subjective and objective (dry on 'ultrashort' pad test) one year cure rates were found for women randomised to two paravaginal sutures compared with one suture in a single trial (89% versus 65% and 83% versus 58% respectively). Two small studies compared sutures with mesh and staples for laparoscopic colposuspension and the comparisons, although showing a trend towards favouring the sutures, were not significant. One study compared transperitoneal with extraperitoneal access for laparoscopic colposuspension but it was also small and of poor quality.

AUTHORS' CONCLUSIONS

The long-term performance of laparoscopic colposuspension remains uncertain. Currently available evidence suggests that it may be as good as open colposuspension at two years post surgery. Like other laparoscopically performed operations, patients having laparoscopic colposuspension recovered quicker, but the operation itself took longer to perform. However, the newer vaginal sling procedures appear to offer even greater benefits of minimal access surgery and better objective outcomes in the short-term. If laparoscopic colposuspension is performed, two paravaginal sutures appear to be more effective than one. The place of laparoscopic colposuspension in clinical practice should become clearer when ongoing trials are reported and when there are more data available describing long-term cure results.

Bladder neck needle suspension for urinary incontinence in women

BACKGROUND

Bladder neck needle suspension is an operation traditionally used for moderate or severe stress urinary incontinence in women. About a third of adult women experience some urinary incontinence, and about a third of them have moderate or severe symptoms.

OBJECTIVES

To determine the effects of needle suspension on stress or mixed urinary incontinence in comparison with other management options.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group trials register (searched 18 September 2003). The reference lists of relevant articles were also searched.

SELECTION CRITERIA

Randomised or quasi-randomised trials that included needle suspension for the treatment of urinary incontinence.

DATA COLLECTION AND ANALYSIS

Trials were assessed and data extracted independently by at least two reviewers. Two trial investigators provided additional information.

MAIN RESULTS

Nine trials were identified which included 347 women having six different types of needle suspension procedures and 437 who received comparison interventions. Needle suspensions were more likely to fail than open abdominal retropubic suspension (higher subjective failure rate after the first year (91/313, 29% failed versus 47/297, 16% failed after open abdominal retropubic suspension: the relative risk (RR) was 2.00 (95% confidence interval (CI) 1.47 to 2.72) although the difference in peri-operative complications was not significant (17/75, 23% versus 12/77, 16%; RR 1.44, 95% CI 0.73 to 2.83): there were no significant differences for other outcome measures. This effect was seen in both women with primary incontinence and women with recurrent incontinence after failed primary operations. Needle suspensions may be as effective as anterior vaginal repair (46/128, 36% failed after needles versus 50/129, 39% after anterior repair; RR 0.93, 95% CI 0.68 to 1.26) but there was little information about morbidity. Data for comparison with suburethral slings were inconclusive because they came from a small and atypical population. No trials compared needle suspensions with conservative management, peri-urethral injections, sham or laparoscopic surgery.

REVIEWERS' CONCLUSIONS

Bladder neck needle suspension surgery is probably not as good as open abdominal retropubic suspension for the treatment of primary and secondary urodynamic stress incontinence because the cure rates were lower in the trials reviewed. However, the reliability of the evidence was limited by poor quality and small trials. There was not enough information to comment on comparisons with suburethral sling operations. Although cure rates were similar after needle suspension compared with after anterior vaginal repair, the data were insufficient to be reliable and inadequate to compare morbidity.

Anterior vaginal repair for urinary incontinence in women

BACKGROUND

Anterior vaginal repair (anterior colporrhaphy) is an operation traditionally used for moderate or severe stress urinary incontinence in women. About a third of adult women experience urinary incontinence.

OBJECTIVES

To determine the effects of anterior vaginal repair (anterior colporrhaphy) on stress or mixed urinary incontinence in comparison with other management options.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group's trials register, and the reference lists of relevant articles. Date of most recent search: September 2000.

SELECTION CRITERIA

Randomised or quasi-randomised trials that included anterior vaginal repair for the treatment of urinary incontinence.

DATA COLLECTION AND ANALYSIS

Both reviewers independently extracted data and assessed trial quality. Two trial investigators were contacted for additional information.

MAIN RESULTS

Nine trials were identified which included 333 women having an anterior vaginal repair and 599 who received comparison interventions. A single small trial provided insufficient evidence to assess anterior vaginal repair in comparison with physical therapy. The performance of anterior repair in comparison with needle suspension appeared similar but clinically important differences could not be confidently ruled out. No trials compared anterior repair with suburethral sling operations or laparoscopic retropubic suspensions, or compared alternative vaginal operations. Anterior vaginal repair was less effective than open abdominal retropubic suspension based on patient-reported cure rates in eight trials both in the short-term (failure rate within first year after anterior repair 82/279, 29% vs 50/346, 14%; RR 1.89, 95% CI 1.39 to 2.59) and long-term (after first year, 132/322, 41% vs 68/395, 17%; RR 2.50, 95% CI 1.92 to 3.26). There was evidence from three of these trials that this was reflected in more repeat operations for incontinence (25/107, 23% vs 4/164, 2%; RR 8.87, 95% CI 3.28 to 23.94). These findings held irrespective of the co-existence of prolapse (pelvic relaxation). Later prolapse operation appeared to be equally common after vaginal (3%) or abdominal (4%) operation. In respect of the type of open abdominal retropubic suspension, most data related to comparisons of anterior vaginal repair with Burch colposuspension. The few data describing comparison of anterior repair with the Marshall-Marchetti-Krantz procedure were consistent with those for Burch colposuspension.

REVIEWER'S CONCLUSIONS

There were not enough data to allow comparison of anterior vaginal repair with physical therapy or needle suspension for primary urinary stress incontinence in women. Open abdominal retropubic suspension appeared to be better than anterior vaginal repair judged on subjective cure rates in six trials, even in women who had prolapse in addition to stress incontinence (four trials). The need for repeat incontinence surgery was also less after the abdominal operation. However, there was not enough information about post-operative complications and morbidity.