A multi-centre, randomised clinical control trial comparing the retropubic (RP) approach versus the transobturator approach (TO) for tension-free, suburethral sling treatment of urodynamic stress incontinence: the TORP study

Long-term outcomes of surgical interventions for stress urinary incontinence: a systematic review and network meta-analysis

BACKGROUND

Stress urinary incontinence is common among women, and surgical interventions have significantly improved patients' symptoms. The long-term effectiveness of these surgeries is increasingly drawing attention, yet it remains sparsely documented in the literature.

OBJECTIVE

To compare the long-term effectiveness and safety of retropubic tension-free vaginal tape (TVT-RP), tension-free vaginal tape-obturator (TVT-O), transobturator tape (TOT), single-incision sling (SIS), Burch colposuspension, and pubovaginal sling (PVS).

METHODS

A comprehensive and systematic literature review was conducted in PubMed, EMBASE, MEDLINE, Cochrane Library, Medicine, and clinicaltrials.gov from inception to May 2023. Selected trials were evaluated for potential bias using the Cochrane tool. Treatment modalities were compared using network meta-analysis to assess objective success rate, subjective success rate, and complications as outcomes.

RESULTS

A total of 37 studies involving 5720 patients were included. No significant statistical differences were found among the interventions regarding objective success rate. PVS had the highest surface under the cumulative ranking curve SUCRA value (93.1). For subjective success rate, TVT-RP, TVT-O, and PVS demonstrated superiority over SIS, with PVS having the highest SUCRA value (80.1). SIS had lower overall complication and pain rates compared to other methods, with statistical significance. There were no differences in reoperation rate, exposure rate, and urinary tract infection occurrence among the surgical approaches.

CONCLUSIONS

In terms of long-term effectiveness and safety, TVT-RP and TVT-O appear to be the preferred options for patients opting for synthetic slings, while for patients seeking nonsynthetic slings, PVS may represent the optimal choice.

[Complications of mid-urethral sling - A review from the Committee for Female Urology and Pelviperineology for the French Association of Urology]

INTRODUCTION

Placement of a mid-urethral sling is the gold standard in the surgical management of stress urinary incontinence in women in France. The cure rate of this material is no longer to be demonstrated, but the per- and post-operative complications are currently the subject of a growing controversy not only in Europe but also across the Channel and across the Atlantic, having led to the modification of operative indications. In France, recommendations are also evolving with a stricter framework for indications for surgery by multidisciplinary consultation meeting and an obligation for postoperative follow-up in the short and long term.

OBJECTIVES

In this context, CUROPF realized a review of the literature bringing together the available scientific evidence concerning the occurrence of per- and post-operative complications relating to the installation of mid urethral sling. The bibliographic search was carried out using the Medline database and 123 articles were selected.

RESULTS

Analysis of the data highlights various complications, depending on the implanted material, the patient and the indication for surgery. The retro-pubic mid urethral sling provides more bladder erosion during surgery (up to 14%), more suprapubic pain (up to 4%) and more acute urinary retention (up to 19,7%) and postoperative dysuria (up to 26%). The trans obturator mid-urethral sling is responsible for more vaginal erosion during the operation (up to 10,9%), more lower limb pain of neurological origin (up to 26,7%). The risk of developing over active bladder is similar in both procedures (up to 33%). But these risks of complications must be balanced by the strong impact of urinary incontinence surgery on the overall quality of life of these women.

CONCLUSION

Thus, surgical failure and long term complications exist but should not limit the surgical management of stress urinary incontinence with mid urethral tape. Women should be treated with individualized decision-making process and long-term follow -up is necessary.

Surgical treatments for women with stress urinary incontinence: the ESTER systematic review and economic evaluation

BACKGROUND

Urinary incontinence in women is a distressing condition that restricts quality of life and results in a large economic burden to both the NHS and women themselves.

OBJECTIVE

To evaluate the clinical effectiveness, safety and cost-effectiveness of surgical treatment for stress urinary incontinence (SUI) in women and explore women's preferences.

DESIGN

An evidence synthesis, a discrete choice experiment (DCE) and an economic decision model, with a value-of-information (VOI) analysis. Nine surgical interventions were compared. Previous Cochrane reviews for each were identified and updated to include additional studies. Systematic review methods were applied. The outcomes of interest were 'cure' and 'improvement'. Both a pairwise and a network meta-analysis (NMA) were conducted for all available surgical comparisons. A DCE was undertaken to assess the preferences of women for treatment outcomes. An economic model assessed the cost-effectiveness of alternative surgeries and a VOI analysis was undertaken.

RESULTS

Data from 175 studies were included in the effectiveness review. The majority of included studies were rated as being at high or unclear risk of bias across all risk-of-bias domains. The NMA, which included 120 studies that reported data on 'cure' or 'improvement', showed that retropubic mid-urethral sling (MUS), transobturator MUS, traditional sling and open colposuspension were more effective than other surgical procedures for both primary outcomes. The results for other interventions were variable. In general, rate of tape and mesh exposure was higher after transobturator MUS than after retropubic MUS or single-incision sling, whereas the rate of tape or mesh erosion/extrusion was similar between transobturator MUS and retropubic MUS. The results of the DCE, in which 789 women completed an anonymous online questionnaire, indicate that women tend to prefer surgical treatments associated with no pain or mild chronic pain and shorter length of hospital stay as well as those treatments that have a smaller risk for urinary symptoms to reoccur after surgery. The cost-effectiveness results suggest that, over a lifetime, retropubic MUS is, on average, the least costly and most effective surgery. However, the high level of uncertainty makes robust estimates difficult to ascertain. The VOI analysis highlighted that further research around the incidence rates of complications would be of most value.

LIMITATIONS

Overall, the quality of the clinical evidence was low, with limited data available for the assessment of complications. Furthermore, there is a lack of robust evidence and significant uncertainty around some parameters in the economic modelling.

CONCLUSIONS

To our knowledge, this is the most comprehensive assessment of published evidence for the treatment of SUI. There is some evidence that retropubic MUS, transobturator MUS and traditional sling are effective in the short to medium term and that retropubic MUS is cost-effective in the medium to long term. The VOI analysis highlights the value of further research to reduce the uncertainty around the incidence rates of complications. There is a need to obtain robust clinical data in future work, particularly around long-term complication rates.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42016049339.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

What can we learn from the vaginal mesh story?

The use of vaginal mesh in prolapse surgery has created enormous controversy and unprecedented media interest; it has become the most emotive topic in urogynecology today. The US Food and Drug Administration 510(k) system allowed the proliferation of mesh products which were rapidly adopted by surgeons internationally. The importance of a firm understanding of the biomechanical properties of tissue and implants, surgical skill, patient selection, communication skills, informed consent, and high-quality research are all important lessons we can learn from the mesh story. These lessons need to be applied to all novel treatments in the field of urogynecology and beyond.

Update on complications of synthetic suburethral slings

Synthetic suburethral slings have become the most widely used technique for the surgical treatment of stress urinary incontinence. Despite its high success rates, significant complications have been reported including bleeding, urethral or bladder injury, urethral or bladder mesh erosion, intestinal perforation, vaginal extrusion of mesh, urinary tract infection, pain, urinary urgency and bladder outlet obstruction. Recent warnings from important regulatory agencies worldwide concerning safety issues of the use of mesh for urogynecological reconstruction have had a strong impact on patients as well as surgeons and manufacturers. In this paper, we reviewed the literature regarding surgical morbidity associated with synthetic suburethral slings.

Mid-urethral sling operations for stress urinary incontinence in women

BACKGROUND

Urinary incontinence is a very common and debilitating problem affecting about 50% of women at some point in their lives. Stress urinary incontinence (SUI) is a predominant cause in 30% to 80% of these women imposing significant health and economic burden on society and the women affected. Mid-urethral sling (MUS) operations are a recognised minimally invasive surgical treatment for SUI. MUS involves the passage of a small strip of tape through either the retropubic or obturator space, with entry or exit points at the lower abdomen or groin, respectively. This review does not include single-incision slings.

OBJECTIVES

To assess the clinical effects of mid-urethral sling (MUS) operations for the treatment of SUI, urodynamic stress incontinence (USI) or mixed urinary incontinence (MUI) in women.

SEARCH METHODS

We searched: Cochrane Incontinence Specialised Register (including: CENTRAL, MEDLINE, MEDLINE In-Process, ClinicalTrials.gov) (searched 26 June 2014); Embase Classic (January 1947 to Week 25 2014); WHO ICTRP (searched 30 June 2014); reference lists.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials amongst women with SUI, USI or MUI, in which both trial arms involve a MUS operation.

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

We included 81 trials that evaluated 12,113 women. We assessed the quality of evidence for outcomes using the GRADE assessment tool; the quality of most outcomes was moderate, mainly due to risk of bias or imprecision.Fifty-five trials with data contributed by 8652 women compared the use of the transobturator route (TOR) and retropubic route (RPR). There is moderate quality evidence that in the short term (up to one year) the rate of subjective cure of TOR and RPR are similar (RR 0.98, 95% CI 0.96 to 1.00; 36 trials, 5514 women; moderate quality evidence) ranging from 62% to 98% in the TOR group, and from 71% to 97% in the RPR group. Short-term objective cure was similar in the TOR and RPR groups (RR 0.98, 95% CI 0.96 to 1.00; 40 trials, 6145 women). Fewer trials reported medium-term (one to five years) and longer-term (over five years) data, but subjective cure was similar between the groups (RR 0.97, 95% CI 0.87 to 1.09; 5 trials, 683 women; low quality evidence; and RR 0.95, 95% CI 0.80 to 1.12; 4 trials, 714 women; moderate quality evidence, respectively). In the long term, subjective cure rates ranged from 43% to 92% in the TOR group, and from 51% to 88% in the RPR group.MUS procedures performed using the RPR had higher morbidity when compared to TOR, though the overall rate of adverse events remained low. The rate of bladder perforation was lower after TOR (0.6% versus 4.5%; RR 0.13, 95% CI 0.08 to 0.20; 40 trials, 6372 women; moderate quality evidence). Major vascular/visceral injury, mean operating time, operative blood loss and length of hospital stay were lower with TOR.Postoperative voiding dysfunction was less frequent following TOR (RR 0.53, 95% CI 0.43 to 0.65; 37 trials, 6200 women; moderate quality evidence). Overall rates of groin pain were higher in the TOR group (6.4% versus 1.3%; RR 4.12, 95% CI 2.71 to 6.27; 18 trials, 3221 women; moderate quality evidence) whereas suprapubic pain was lower in the TOR group (0.8% versus 2.9%; RR 0.29, 95% CI 0.11 to 0.78); both being of short duration. The overall rate of vaginal tape erosion/exposure/extrusion was low in both groups: 24/1000 instances with TOR compared with 21/1000 for RPR (RR 1.13, 95% CI 0.78 to 1.65; 31 trials, 4743 women; moderate quality evidence). There were only limited data to inform the need for repeat incontinence surgery in the long term, but it was more likely in the TOR group than in the RPR group (RR 8.79, 95% CI 3.36 to 23.00; 4 trials, 695 women; low quality evidence).A retropubic bottom-to-top route was more effective than top-to-bottom route for subjective cure (RR 1.10, 95% CI 1.01 to 1.19; 3 trials, 477 women; moderate quality evidence). It incurred significantly less voiding dysfunction, and led to fewer bladder perforations and vaginal tape erosions.Short-and medium-term subjective cure rates between transobturator tapes passed using a medial-to-lateral as opposed to a lateral-to-medial approach were similar (RR 1.00, 95% CI 0.96 to 1.06; 6 trials, 759 women; moderate quality evidence, and RR 1.06, 95% CI 0.91 to 1.23; 2 trials, 235 women; moderate quality evidence). There was moderate quality evidence that voiding dysfunction was more frequent in the medial-to-lateral group (RR 1.74, 95% CI 1.06 to 2.88; 8 trials, 1121 women; moderate quality evidence), but vaginal perforation was less frequent in the medial-to-lateral route (RR 0.25, 95% CI 0.12 to 0.53; 3 trials, 541 women). Due to the very low quality of the evidence, it is unclear whether the lower rates of vaginal epithelial perforation affected vaginal tape erosion (RR 0.42, 95% CI 0.16 to 1.09; 7 trials, 1087 women; very low quality evidence).

AUTHORS' CONCLUSIONS

Mid-urethral sling operations have been the most extensively researched surgical treatment for stress urinary incontinence (SUI) in women and have a good safety profile. Irrespective of the routes traversed, they are highly effective in the short and medium term, and accruing evidence demonstrates their effectiveness in the long term. This review illustrates their positive impact on improving the quality of life of women with SUI. However, a brief economic commentary (BEC) identified three studies suggesting that transobturator may be more cost-effective compared with retropubic. Fewer adverse events occur with employment of a transobturator approach with the exception of groin pain. When comparing transobturator techniques of a medial-to-lateral versus a lateral-to-medial insertion, there is no evidence to support the use of one approach over the other. However, a bottom-to-top route was more effective than top-to-bottom route for retropubic tapes.A salient point illustrated throughout this review is the need for reporting of longer-term outcome data from the numerous existing trials. This would substantially increase the evidence base and provide clarification regarding uncertainties about long-term effectiveness and adverse event profile.

Comparison between the retropubic and transobturator approaches in the treatment of female stress urinary incontinence: a systematic review and meta-analysis of effectiveness and complications

Objective

This study aimed to compare the effectiveness and complications between the retropubic and transobturator approaches for the treatment of female stress urinary incontinence (SUI) by conducting a systematic review.

Materials and Methods

We selected all randomized controlled trials (RCTs) that compared retropubic and transobturator sling placements for treatment of SUI. We estimated pooled odds ratios and 95% confidence intervals for intraoperative and postoperative outcomes and complications.

Results

Six hundred twelve studies that compared retropubic and transobturator approaches to midurethral sling placement were identified, of which 16 were included in our research. Our study was based on results from 2646 women. We performed a subgroup analysis to compare outcomes and complications between the two approaches. The evidence to support the superior approach that leads to better objective/subjective cure rate was insufficient. The transobturator approach was associated with lower risks of bladder perforation (odds ratio (OR) 0.17, 95% confidence interval (CI) 0.09-0.32), retropubic/vaginal hematoma (OR 0.32, 95% CI 0.16-0.63), and long-term voiding dysfunction (OR 0.32, 95% CI 0.17-0.61). However, the risk of thigh/groin pain seemed higher in the transobturator group (OR 2.53, 95% CI 1.72-3.72). We found no statistically significant differences in the risks of other complications between the two approaches.

Conclusions

This meta-analysis shows analogical objective and subjective cure rates between the retropubic and transobturator approaches to midurethral sling placement. The transobturator approach was associated with lower risks of several complications. However, good-quality studies with long-term follow-ups are warranted for further research.

Randomized trial of a single incision versus an outside-in transobturator midurethral sling in women with stress urinary incontinence: 12 month results

OBJECTIVE

The objective of the study was to evaluate objective and subjective outcomes of MiniArc and Monarc (American Medical Systems, Minnetonka, MN) midurethral sling (MUS) in women with stress incontinence at 12 months.

STUDY DESIGN

A total of 225 women were randomized to receive MiniArc or Monarc. Women with intrinsic sphincter deficiency, previous MUS, or untreated detrusor overactivity were excluded. Objective cure was defined as negative cough stress test with a comfortably full bladder. Subjective cure was defined as no report of leakage with coughing or exercise on questionnaire. Validated questionnaires, together with urodynamic and clinical cough stress test, were used to evaluate the objective and subjective outcomes following surgery. Participants and clinicians were not masked to treatment allocation. Outcomes were compared with exact binomial tests (eg, Fisher exact test for dichotomous data) for categorical data and Student t tests or exact versions of Wilcoxon tests for numerical data as appropriate.

RESULTS

There was no statistically significant difference in the subjective (92.2% vs 94.2%; P = .78; difference, 2.0%; 95% confidence interval, -2.7% to +6.7%) or objective (94.4% vs 96.7%; P = .50; difference, 2.3%; 95% confidence interval, -1.5% to +6.1%) cure rates between MiniArc and Monarc at 12 m, respectively, with a significant improvement in overactive bladder outcomes and incontinence impact from baseline in both arms.

CONCLUSION

MiniArc outcomes are not inferior to Monarc MUS outcomes at 12 months' follow-up in women without intrinsic sphincter deficiency.

Mid-urethral sling operations for stress urinary incontinence in women

BACKGROUND

Urinary incontinence is a very common and debilitating problem affecting about 50% of women at some point in their lives. Stress urinary incontinence (SUI) is a contributory or predominant cause in 30% to 80% of these women. Mid-urethral sling (MUS) operations are a recognised minimally invasive surgical treatment for SUI. MUS involves the passage of a small strip of tape through either the retropubic or obturator space, with entry or exit points at the lower abdomen or groin, respectively. This review does not include single incision slings.

OBJECTIVES

To assess the clinical effects of mid-urethral sling (MUS) operations for the treatment of stress urinary incontinence (SUI), urodynamic stress incontinence (USI) or mixed urinary incontinence (MUI) in women.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Register, which contains trials identified from CENTRAL, MEDLINE, MEDLINE in process, ClinicalTrials.gov and handsearching of journals and conference proceedings (searched 26 June 2014), Embase and Embase Classic (January 1947 to Week 25 2014), WHO ICTRP (searched on 30 June 2014) and the reference lists of relevant articles.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials amongst women with SUI, USI or MUI, in which both trial arms involve a MUS operation.

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

We included 81 trials that evaluated 12,113 women. We assessed the quality of evidence for outcomes using the GRADE assessment tool; the quality of most outcomes was moderate, mainly due to risk of bias or imprecision.Fifty-five trials with data contributed by 8652 women compared the use of the transobturator route (TOR) and retropubic route (RPR). There is moderate quality evidence that in the short term (up to one year) the rate of subjective cure of TOR and RPR are similar (RR 0.98, 95% CI 0.96 to 1.00; 36 trials, 5514 women; moderate quality evidence) ranging from 62% to 98% in the TOR group, and from 71% to 97% in the RPR group. Short-term objective cure was similar in the TOR and RPR groups (RR 0.98, 95% CI 0.96 to 1.00; 40 trials, 6145 women). Fewer trials reported medium-term (one to five years) and longer-term (over five years) data, but subjective cure was similar between the groups (RR 0.97, 95% CI 0.87 to 1.09; 5 trials, 683 women; low quality evidence; and RR 0.95, 95% CI 0.80 to 1.12; 4 trials, 714 women; moderate quality evidence, respectively). In the long term, subjective cure rates ranged from 43% to 92% in the TOR group, and from 51% to 88% in the RPR group.MUS procedures performed using the RPR had higher morbidity when compared to TOR, though the overall rate of adverse events remained low. The rate of bladder perforation was lower after TOR (0.6% versus 4.5%; RR 0.13, 95% CI 0.08 to 0.20; 40 trials, 6372 women; moderate quality evidence). Major vascular/visceral injury, mean operating time, operative blood loss and length of hospital stay were lower with TOR.Postoperative voiding dysfunction was less frequent following TOR (RR 0.53, 95% CI 0.43 to 0.65; 37 trials, 6200 women; moderate quality evidence). Overall rates of groin pain were higher in the TOR group (6.4% versus 1.3%; RR 4.12, 95% CI 2.71 to 6.27; 18 trials, 3221 women; moderate quality evidence) whereas suprapubic pain was lower in the TOR group (0.8% versus 2.9%; RR 0.29, 95% CI 0.11 to 0.78); both being of short duration. The overall rate of vaginal tape erosion/exposure/extrusion was low in both groups: 24/1000 instances with TOR compared with 21/1000 for RPR (RR 1.13, 95% CI 0.78 to 1.65; 31 trials, 4743 women; moderate quality evidence). There were only limited data to inform the need for repeat incontinence surgery in the long term, but it was more likely in the TOR group than in the RPR group (RR 8.79, 95% CI 3.36 to 23.00; 4 trials, 695 women; low quality evidence).A retropubic bottom-to-top route was more effective than top-to-bottom route for subjective cure (RR 1.10, 95% CI 1.01 to 1.19; 3 trials, 477 women; moderate quality evidence). It incurred significantly less voiding dysfunction, and led to fewer bladder perforations and vaginal tape erosions.Short-and medium-term subjective cure rates between transobturator tapes passed using a medial-to-lateral as opposed to a lateral-to-medial approach were similar (RR 1.00, 95% CI 0.96 to 1.06; 6 trials, 759 women; moderate quality evidence, and RR 1.06, 95% CI 0.91 to 1.23; 2 trials, 235 women; moderate quality evidence). There was moderate quality evidence that voiding dysfunction was more frequent in the medial-to-lateral group (RR 1.74, 95% CI 1.06 to 2.88; 8 trials, 1121 women; moderate quality evidence), but vaginal perforation was less frequent in the medial-to-lateral route (RR 0.25, 95% CI 0.12 to 0.53; 3 trials, 541 women). Due to the very low quality of the evidence, it is unclear whether the lower rates of vaginal epithelial perforation affected vaginal tape erosion (RR 0.42, 95% CI 0.16 to 1.09; 7 trials, 1087 women; very low quality evidence).

AUTHORS' CONCLUSIONS

Mid-urethral sling operations have been the most extensively researched surgical treatment for stress urinary incontinence (SUI) in women and have a good safety profile. Irrespective of the routes traversed, they are highly effective in the short and medium term, and accruing evidence demonstrates their effectiveness in the long term. This review illustrates their positive impact on improving the quality of life of women with SUI. With the exception of groin pain, fewer adverse events occur with employment of a transobturator approach. When comparing transobturator techniques of a medial-to-lateral versus a lateral-to-medial insertion, there is no evidence to support the use of one approach over the other. However, a bottom-to-top route was more effective than top-to-bottom route for retropubic tapes.A salient point illustrated throughout this review is the need for reporting of longer-term outcome data from the numerous existing trials. This would substantially increase the evidence base and provide clarification regarding uncertainties about long-term effectiveness and adverse event profile.

TVT-Exact and midurethral sling (SLING-IUFT) operative procedures: a randomized study

OBJECTIVES

The aim of the study is to compare results, effectiveness and complications of TVT exact and midurethral sling (SLING-IUFT) operations in the treatment of female stress urinary incontinence (SUI).

METHODS

A single center nonblind, randomized study of women with SUI who were randomized to TVT-Exact and SLING-IUFT was performed by one surgeon from April 2009 to April 2011. SUI was diagnosed on coughing and Valsalva test and urodynamics (cystometry and uroflowmetry) were assessed before operation and 1 year after surgery. This was a prospective randomized study. The follow up period was 12 months. 76 patients were operated using the TVT-Exact operation and 78 patients - using the SLING-IUFT operation. There was no statistically significant differences between groups for BMI, parity, menopausal status and prolapsed stage (no patients had cystocele greater than stage II).

RESULTS

Mean operative time was significantly shorter in the SLING-IUFT group (19 ± 5.6 min.) compared with the TVT-Exact group (27 ± 7.1 min.). There were statistically significant differences in the effectiveness of both procedures: TVT-Exact - at 94.5% and SLING-IUFT - at 61.2% after one year. Hospital stay was statistically significantly shorter in the SLING-IUFT group (1. 2 ± 0.5 days) compared with the TVT-Exact group (3.5 ± 1.5 days). Statistically significantly fewer complications occurred in the SLING-IUFT group.

CONCLUSION

the TVT-Exact and SLING-IUFT operations are both effective for surgical treatment of female stress urinary incontinence. The SLING-IUFT involved a shorter operation time and lower complications rate., the TVT-Exact procedure had statistically significantly more complications than the SLING-IUFT operation, but a higher effectiveness.

The surgical management of recurrent stress urinary incontinence: a systematic review

BACKGROUND

Despite a wide spectrum of interventions, surgical treatments of recurrent stress urinary incontinence (SUI) are associated with high failure rates.

OBJECTIVES

To systematically review current evidence on the effectiveness of surgical interventions for recurrent SUI.

DATA SOURCES

An electronic database search was undertaken (1980-2014). Keywords were: "stress urinary incontinence," "failure," "recurrence," "treatment." References of identified studies and abstracts from conferences were considered.

STUDY SELECTION

We restricted the search to female patients and currently used surgical procedures, including studies with five or more cases. After the initial yield, studies were selected following title screening, abstract and full text scrutiny.

RESULTS

The pooled objective cure rates of colposuspension for recurrent SUI are 76% (95% CI ±5.04), whereas rates for midurethral sling procedures are 68.5% (95% CI ±3.11). Repeat midurethral sling procedures have pooled success rates of 66.2% (95% CI ±4) but those of the transobturator approach appear lower than retropubic procedures. Pubovaginal slings for recurrent SUI have pooled success of 79.3% (95% CI ±6.54). Success rates for adjustable continence therapy and adjustable slings for recurrent SUI are 53.8% (95% CI ±5.28), whereas for midurethral sling fixation procedures the pooled success is 61% (95% CI ±10.56). Urethral bulking injections have success rates of 38% (95% CI ±10.7). Laparoscopic two-team sling procedures, salvage spiral slings, and artificial urinary sphincter have shown promising results, but there are limited data on recurrent cases.

CONCLUSION

There is a wide spectrum of surgical interventions reported for secondary or tertiary treatment of SUI. A common characteristic for all recurrent procedures is a lower success rate compared with those reported following primary procedures.

Sling surgery for stress urinary incontinence in women: a systematic review and metaanalysis

OBJECTIVE

Understanding the long-term comparative effectiveness of competing surgical repairs is essential as failures after primary interventions for stress urinary incontinence (SUI) may result in a third of women requiring repeat surgery.

STUDY DESIGN

We conducted a systematic review including English-language randomized controlled trials from 1990 through April 2013 with a minimum 12 months of follow-up comparing a sling procedure for SUI to another sling or Burch urethropexy. When at least 3 randomized controlled trials compared the same surgeries for the same outcome, we performed random effects model metaanalyses to estimate pooled odds ratios (ORs).

RESULTS

For midurethral slings (MUS) vs Burch, metaanalysis of objective cure showed no significant difference (OR, 1.18; 95% confidence interval [CI], 0.73-1.89). Therefore, we suggest either intervention; the decision should balance potential adverse events (AEs) and concomitant surgeries. For women considering pubovaginal sling vs Burch, the evidence favored slings for both subjective and objective cure. We recommend pubovaginal sling to maximize cure outcomes. For pubovaginal slings vs MUS, metaanalysis of subjective cure favored MUS (OR, 0.40; 95% CI, 0.18-0.85). Therefore, we recommend MUS. For obturator slings vs retropubic MUS, metaanalyses for both objective (OR, 1.16; 95% CI, 0.93-1.45) and subjective cure (OR, 1.17; 95% CI, 0.91-1.51) favored retropubic slings but were not significant. Metaanalysis of satisfaction outcomes favored obturator slings but was not significant (OR, 0.77; 95% CI, 0.52-1.13). AEs were variable between slings; metaanalysis showed overactive bladder symptoms were more common following retropubic slings (OR, 1.413; 95% CI, 1.01-1.98, P = .046). We recommend either retropubic or obturator slings for cure outcomes; the decision should balance AEs. For minislings vs full-length MUS, metaanalyses of objective (OR, 4.16; 95% CI, 2.15-8.05) and subjective (OR, 2.65; 95% CI, 1.36-5.17) cure both significantly favored full-length slings. Therefore, we recommend a full-length MUS.

CONCLUSION

Surgical procedures for SUI differ for success rates and complications, and both should be incorporated into surgical decision-making. Low- to high-quality evidence permitted mostly level-1 recommendations when guidelines were possible.

A 5-year follow-up study comparing Burch colposuspension and transobturator tape for the surgical treatment of stress urinary incontinence

OBJECTIVE

To compare the effectiveness of transobturator tape (TOT) and Burch colposuspension in the treatment of stress urinary incontinence (SUI).

METHODS

The present retrospective study included 770 patients who underwent SUI surgery with Burch colposuspension (n=498) or TOT (n=272). Clinical follow-up occurred at 2 weeks, 3, 6, and 12 months, and annually thereafter. Objective and subjective cure rates and intra- and postoperative complications were assessed.

RESULTS

Among patients who had SUI surgery without another concomitant procedure, the Burch group had a significantly longer mean operation time (41.48 ± 10.61 minutes versus 23.77 ± 10.49 minutes; P<0.001) and a significantly longer length of hospital stay (3.11 ± 0.49 days versus 1.98 ± 0.40 days; P<0.001), compared with the TOT group. The rates of unintended functional outcomes were lower among women undergoing TOT than among those undergoing the Burch procedure (long-term voiding dysfunction 0.7% versus 4.2%, P=0.007; urinary retention 10.7% versus 26.9%, P<0.001). The 5-year cure rates were similar in the 2 groups (objective cure rate, 73.9% versus 77.5%, P=0.574; subjective cure rate, 76.8% versus 81.7%, P=0.416).

CONCLUSION

In terms of efficacy, TOT appears equal to Burch colposuspension; however, TOT has fewer unintended functional outcomes than Burch colposuspension.

Surgical treatment of recurrent stress urinary incontinence in women: a systematic review and meta-analysis of randomised controlled trials

CONTEXT

Recurrent stress urinary incontinence (R-SUI) represents a management dilemma; however, only a limited number of randomised controlled trials (RCTs) have assessed the various surgical procedures used for its treatment.

OBJECTIVE

To assess the effectiveness and complications of various surgical procedures for the treatment of female R-SUI.

EVIDENCE ACQUISITION

A prospective peer-reviewed protocol was prepared a priori. A systematic literature review of all published RCTs comparing surgical procedures for treatment of R-SUI was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis statement. Data were analysed using RevMan 5.

EVIDENCE SYNTHESIS

We conducted a literature search from 1945 to February 2013. Data were available for a total of 350 women in 10 RCTs with a mean follow-up of 18.1 mo. Meta-analysis was possible for the comparison of retropubic tension-free vaginal tape (RP-TVT) versus transobturator tension-free vaginal tape (TO-TVT) in five RCTs (n = 135). There was no statistically significant difference between RP-TVT and TO-TVT in the patient-reported improvement (odds ratio [OR]: 0.84, 95% confidence interval [CI], 0.41-1.69) or objective cure/improvement (OR: 1.75; 95% CI, 0.86-3.54). One RCT showed a trend towards a higher rate of patient-reported and objective cure/improvement with the inside-out TO-TVT compared with the outside-in; however, it was not statistically significant (OR: 3.00; 95% CI, 0.85-10.57, and OR: 3.32; 95% CI, 0.96-11.41, respectively). There was no significant difference between Burch colposuspension and RP-TVT (one RCT) in patient-reported improvement (OR: 0.33; 95% CI, 0.01-8.57) or objective cure/improvement (OR: 0.52; 95% CI, 0.13-2.05).

CONCLUSIONS

This meta-analysis shows no evidence of a significant difference in patient-reported and objective cure/improvement rates between RP-TVT and TO-TVT in the surgical treatment of women with R-SUI. However, due to the relatively low number of patients, the analysis might be underpowered. This review highlights the poor level of evidence in this field and the need for well-designed clinical trials to address this important clinical dilemma.

Female incontinence: long-term results of slings

PURPOSE OF REVIEW

Several different sling procedures are currently in use and most of them are newly developed. Despite the fact that they are widely in use, knowledge about their long-term efficacy, morbidity, and functional sequeal is scarce. The aim of the present review is to provide an update of several different procedures.

RECENT FINDINGS

The tension-free vaginal tape is the best studied and documented procedure with excellent long-term outcome data and low rates of complications. Tension-free vaginal tape appears to be followed by significantly higher objective cure rates than transobturator tape. Concerning comparison of different types of transobturator tape, no significant differences were found so far. Minislings still need to be evaluated concerning long-term safety and efficacy.

SUMMARY

Tension-free vaginal tape and transobturator tape are equally effective; for assessment of new approaches, surgical long-term data are mandatory.

Transobturator tapes are preferable over transvaginal tapes for the management of female stress urinary incontinence: For

Tension-free midurethral slings have proven to have low morbidity and high success rates in the management of female stress urinary incontinence. Among midurethal slings, the transobtuator tapes has comparable success and satisfaction rates as the transvaginal tapes but with reduced risk of intra-operative bladder injury, shorter operating time and quicker return to activities. Thus, the transobturator tapes may be recommended as the primary choice for the treatment of female stress urinary incontinence.

Complications of mid-urethral slings for treatment of stress urinary incontinence

OBJECTIVE

To compare the incidence of complications associated with the use of retropubic tension-free vaginal tape (TVT) and transobturator tension-free vaginal tape (TVT-O) for the management of stress urinary incontinence (SUI).

METHODS

In a cross-sectional study, 1081 patients were treated for SUI via mid-urethral slings, and the outcomes of those treated via TVT and those treated via TVT-O were compared. Patients who suffered from recurrent or mixed urinary incontinence were excluded.

RESULTS

Group 1 included patients treated via TVT (n=207) and group 2 included those treated with TVT-O (n=570). There was a higher incidence of bladder perforation (5.4% versus 0.6%; P=0.001) and hematoma formation (9.1% versus 1.5%; P=0.001) in group 1 than in group 2. Compared with group 1, there was higher incidence of vaginal wall perforation in group 2 (0.0% versus 3.8%, P=0.044). The rate of intraoperative complications was not related to patient age, body mass index, or parity. Of the patients who did not leak urine during a cough test 1 month after surgery, 90.9% still had a negative cough test at the long-term follow-up.

CONCLUSION

TVT-O was superior to TVT with regard to the incidence of bladder perforation and hematoma formation, but it resulted in more vaginal wall injuries.

Retropubic and transobturator slings: still useful or should all patients be treated with mini-slings?

Traditional retropubic and transobturator midurethral slings are reliable, safe, and effective treatments for stress urinary incontinence. Unfortunately, they also are associated with rare but severe complications, such as bladder or bowel perforation, vascular injury, nerve damage, and/or groin muscle pain that can occur with the blind passage of trocars. To maintain efficacy and patient satisfaction while avoiding such complications, minimally invasive mini-slings have been developed. These smaller mini-slings can be placed through a single vaginal incision at the level of the midurethra without trocars. Mini-slings often are performed as an outpatient surgery, with minimal morbidity, pain, and quick patient recovery. With continued refinement and surgeon experience, mini-slings potentially may be performed safely in the office setting under local anesthesia while maintaining the efficacy of traditional slings.

[Evaluation of urodynamic parameters following the placement of tension-free tape]

OBJECTIVE

To analyse the urodynamic changes subsequent to the placement of TVT tension-free tape (retropubic tension-free vaginal tape) or TVT-O (obturator tension-free vaginal tape).

MATERIALS AND METHODS

We carried out a retrospective cohort study that included women with urodynamic diagnosis of stress incontinence, in whom we placed type TVT or TVT-O tension-free tape, and on whom we performed a urodynamic study one year later. We calculated the size of the sample based on the area of continence and it consisted of 15 women per group. We included 40 women. 22 had TVT placed and 18 had TVT-O. We carried out the trial between February 1999 and March 2009. We analysed the means of the pre and postoperative urodynamic parameters using the Student's t-test for dependent variables.

RESULTS

We noted an average decrease in the maximum flow of 9 ml/s following the placement of the TVT-O (p=0.05). For the TVT group, we noted an increase in the flow and micturition times of 5.3 and 6 seconds, as well as in the detrusor pressure at the maximum flow of 6.2 cm H(2)O and of the maximum detrusor pressure when voiding, of 8 cm H(2)O (p=0.37, 0.47, 0.21 and 0.12, respectively).

CONCLUSIONS

In women with urodynamic stress incontinence, the maximum flow decreased a year after the TVT-O was placed.

Analysis of 1,000 cases of synthetic midurethral slings used for treatment of female urinary incontinence - a single-center experience

Introduction

This study summarized our experience in the treatment of 1,081 women with stress urinary incontinence (SUI) using mid-urethral slings.

Material and methods

The study included 1,081 operated patients. Pure SUI was diagnosed in 77.80% (841) of the patients; another 18.68% (202) had mixed symptoms. The remaining 3.52% (38) suffered from recurrent SUI. Group 1 included the SUI patients treated with TVT. Group 2 – SUI managed with TVT-O. In Group 3, mixed urinary incontinent (MUI) patients were treated with TVT-O.

Results

Retropubic TVT was used in 273 patients (25.25%) and TVT-O in 740 (68.45%). Other slings were used in 68 patients (6.3%). Mean follow-up for the groups was 50.1, 31.1, and 32.6 months respectively. For objective evaluation of cure rate we used the cough stress test. Subjective efficacy was studied via a visual analog scale. The complication rate in each group of the patients was used as a secondary end point. A negative cough test was found in 85.58% of patients in Group 1. For the TVT-O group, the objective cure rate was 84.36%. Intra-operative complications for TVT and TVT-O were not related to age, BMI, or parity. Bladder perforation and pelvic hematoma developed more frequently in the TVT group. There is a higher risk of vaginal perforation for TVT-O. The objective and subjective cure rates for MUI patients were 86.15% and 87.69% respectively.

Conclusions

TVT and TVT-O are equally effective and safe methods of treatment for women suffering from SUI and MUI.

The influence of preoperative bladder outlet obstruction on continence and satisfaction in patients with stress urinary incontinence after midurethral sling

PURPOSE

We studied the influence of preoperative bladder outlet obstruction (BOO) on postoperative continence rates and patient satisfaction after the midurethral sling procedure.

METHODS

A total of 159 women who underwent the midurethral sling procedure were evaluated. Using the Blaivas-Groutz nomogram, we assigned the patients were assigned to Group I (n=37, no obstruction), Group II (n=89, mild obstruction), or Group III (n=33, moderate to severe obstruction). Continence rates, patient satisfaction, urinary sensation scale and uroflowmetry were evaluated postoperatively.

RESULTS

There were no significant differences in continence rates, satisfaction, or postoperative maximal flow rate between the 3 groups. Postoperative urgency was improved after surgery in Groups I and II (P<0.05) but not in Group III.

CONCLUSIONS

BOO does not seem to be a risk factor for failure after the midurethral sling procedure. However, BOO may be considered as a potential factor for persistent storage symptoms after the midurethral sling.

[Sub-urethral sling in the treatment of female urinary incontinence: which? how?]

Review of the literature that formed the basis for drafting the guideline on the sub-uretral sling in the first-line surgical treatment of female stress urinary incontinence. Medline database query since the introduction of TVT on the questions of various chapters and sub-chapters of the present article. The use of tapes made of polypropylene monofilament exclusively, knitted, is recommended to the exclusion of any other material. Regarding the choice of procedure, the objective cure rate of transobturator and retro-pubic routes cannot be evaluated clearly because of vague evaluation criteria from one study to another. Without adequate clinical trials proving their efficacy and safety, the mini-bands can so far be recommended to treat female stress urinary incontinence. Moderate overweight does not affect the results of laying tape. In patients with severe obesity, surgery to correct obesity is even better than surgery for incontinence. Age is not a contra-indication. If the patient is young and nulliparous, it is reasonable to advise her to postpone surgery after her last pregnancy. In case of multiparous patient, the risk of vaginal delivery does not seem sufficient to suggest a cesarean section. To conclude, sub-urethral slings are the first-line surgical treatment of female stress urinary incontinence.

Updated systematic review and meta-analysis of the comparative data on colposuspensions, pubovaginal slings, and midurethral tapes in the surgical treatment of female stress urinary incontinence

CONTEXT

Burch colposuspension, pubovaginal sling, and midurethral retropubic tape (RT) and transobturator tape (TOT) have been the most popular surgical treatments for female stress urinary incontinence (SUI). Several randomized controlled trials (RCTs) have been published comparing the different techniques, with conflicting results.

OBJECTIVE

Our aim was to evaluate the efficacy, complication, and reoperation rates of midurethral tapes compared with other surgical treatments for female SUI.

EVIDENCE ACQUISITION

A systematic review of the literature was performed using the Medline, Embase, Scopus, Web of Science databases, and Cochrane Database of Systematic Reviews.

EVIDENCE SYNTHESIS

Thirty-nine RCTs were identified. Patients receiving midurethral tapes had significantly higher overall (odds ratio [OR]: 0.61; confidence interval [CI]: 0.46-0.82; p=0.00009) and objective (OR: 0.38; CI: 0.25-0.57; p<0.0001) cure rates than those receiving Burch colposuspension, although they had a higher risk of bladder perforations (OR: 4.94; CI: 2.09-11.68; p=0.00003). Patients undergoing midurethral tapes and pubovaginal slings had similar cure rates, although the latter were slightly more likely to experience storage lower urinary tract symptoms (LUTS) (OR: 0.31; CI: 0.10-0.94; p=0.04) and had a higher reoperation rate (OR: 0.31; CI: 0.12-0.82; p=0.02). Patients treated with RT had slightly higher objective cure rates (OR: 0.8;CI: 0.65-0.99; p=0.04) than those treated with TOT; however, subjective cure rates were similar, and patients treated with TOT had a much lower risk of bladder and vaginal perforations (OR: 2.5; CI: 1.75-3.57; p<0.00001), hematoma (OR: 2.62; CI: 1.35-5.08; p=0.005), and storage LUTS (OR: 1.35; CI: 1.05-1.72; p=0.02). Meta-analysis demonstrated similar outcomes for TVT-O (University of Liège, Liège, Wallonia, Belgium) and Monarc (AMS, Minnetonka, MN, USA).

CONCLUSIONS

Patients treated with 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, although patients with pubovaginal slings were more likely to experience storage LUTS. The use of RT was followed by objective cure rates slightly higher than TOT, but subjective cure rates were similar. TOT had a lower risk of bladder and vaginal perforations and storage LUTS than RT. The strength of these findings is limited by the heterogeneity of the outcome measures and the short length of follow-up.

Single incision mini-sling versus a transobutaror sling: a comparative study on MiniArc and Monarc slings

INTRODUCTION AND HYPOTHESIS

A retrospective, dual-center, cohort study on the single incision MiniArc sling and the transobturator Monarc sling in the treatment of stress urinary incontinence is presented. We hypothesized that both systems would perform equally well.

METHODS

One hundred thirty-one (MiniArc n = 75, Monarc n = 56) consecutive patients were evaluated. Evaluation was performed by cough stress test (CST), daily pad use, IIQ-7, UDI-6, and a 0-5 visual analog scale for quality of life. The 1-year data are presented.

RESULTS

Six weeks after surgery, 91% of the patients in both populations had a negative CST. At 1 year, 85% of the MiniArc group and 89% of the Monarc group (p = 0.60) maintained a negative CST. QoL, symptom scores, and number of pads improved significantly and were comparable in both groups. Complication rates were similar.

CONCLUSIONS

These results suggest that MiniArc sling and Monarc sling are equally effective in the treatment of stress incontinence at 1 year follow-up.

A randomised trial of a retropubic tension-free vaginal tape versus a mini-sling for stress incontinence

OBJECTIVE

To compare a mini-sling with a retropubic tension-free vaginal tape (TVT) in the treatment of stress urinary incontinence (SUI) and urodynamic stress incontinence (USI).

DESIGN

Randomised trial.

SETTING

Urogynaecology unit in large UK district general hospital.

POPULATION

Women with USI resistant to conservative management and requiring a suburethral sling.

METHODS

A total of 71 women with SUI and confirmed USI were randomised to undergo treatment with either a retropubic TVT or mini-sling. Follow-up was at 6 weeks, with a history, examination and quality of life questionnaire, and at 6 months with further subjective evaluation and twin-channel subtraction cystometry and pressure-flow studies.

MAIN OUTCOME MEASURES

The presence of SUI at 6 weeks and 6 months after treatment.

RESULTS

The mini-sling was associated with a significantly higher rate of persistent SUI at 6 weeks (OR 9.49, 95% CI 2.8-32.6) and 6 months (OR 8.14, 95% CI 2.7-24.7), and of USI at 6 months (OR 7.58, 95% CI 2.7-24.7). The rate of complication was similar in the two groups.

CONCLUSIONS

The mini-sling is associated with a higher failure rate than a retropubic TVT. Longer term and multicentre outcome data are necessary to explore these findings further. Until this is available, the mini-sling should be used with caution.

Effectiveness of midurethral slings in intrinsic sphincteric-related stress urinary incontinence

PURPOSE OF REVIEW

Previous literature has shown that urodynamic evidence of intrinsic sphincter deficiency (ISD) decreases the surgical success of traditional antistress incontinence surgeries. The aim of this review is to assess recent evidence on the effectiveness of the increasingly popular midurethral slings (MUS) in women with ISD and stress urinary incontinence.

RECENT FINDINGS

Using the ISD definition of maximum urethral closure pressure of 20 cm H2O or less and/or abdominal/valsalva leak point pressure of 60 cm H2O or less, current literature would suggest that the effectiveness of retropubic MUS is reduced but remained acceptable in women with stress urinary incontinence and ISD. There are conflicting data on whether coexisting poor urethral mobility could further compromise surgical success. Of note, there is now emerging evidence to suggest that transobturator tapes are associated with much higher failure rates in this setting and retropubic MUS should be used instead. Currently, there is too little data on the new single-incision mini-slings for any recommendation of use in women with stress incontinence with good or poor intrinsic urethral function.

SUMMARY

MUS is an effective treatment for stress urinary incontinence. However, when urodynamic evidence of ISD is present, the retropubic approach may be preferable to the transobturator approach.

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.

Comparison of tension-free vaginal tape and transobturator tape procedure for the treatment of stress urinary incontinence

PURPOSE OF REVIEW

The aim of this review was to assess the recent evidence on the effectiveness and complications of tension-free vaginal tape (TVT) and transobturator tape (TOT) procedures for female stress urinary incontinence between January 2008 and March 2009.

RECENT FINDINGS

A meta-analysis of recent studies revealed that the short-term objective cure rate was borderline worse in the TOT group compared with TVT [odds ratio (OR) 0.62; 95% confidence interval (CI) 0.37-1.00; P = 0.05]. Bladder perforation (OR 12.23; 95% CI 2.86-52.34) was significantly more common, whereas groin/thigh pain was significantly less in the TVT group (OR 0.32; 95% CI 0.11-0.92; P = 0.022). Postoperative urinary retention was slightly more in women undergoing TVT than those undergoing TOT (OR 1.6; 95% CI 0.90-3.12; P = 0.06). The rates of vaginal erosion (OR 0.34; 95% CI 0.09-1.33), de-novo urgency (OR 1.21; 95% CI 0.52-2.79) and urinary tract infection (OR 0.88; 95% CI 0.56-1.38) were comparable in both procedures. In addition, TVT appeared to be more obstructive than TOT, as evidenced by ultrasonographic and urodynamic findings. Changes in sexual function need further investigation because this issue has not been well studied for either sling procedure.

SUMMARY

TOT has the advantages over TVT with shorter operative time and a relatively lower complication rate. For women with intrinsic sphincter deficiency, however, TVT appears to be a better option because it is more obstructive.