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

Impact of Single-Incision Sling Placement on Female Sexual Function in Women with Stress Urinary Incontinence

INTRODUCTION AND HYPOTHESIS

Stress urinary incontinence (SUI) is a common condition among women of childbearing age, often requiring surgical intervention. The midurethral sling (MUS), including first-generation tension-free vaginal tapes (TVT) and second-generation transobturator tapes (TOT, TVT-O), has long been the standard treatment. However, both approaches have associated risks, prompting the development of single-incision slings (SIS) as a third option. SIS have proven their efficacy in SUI treatment, but the impact of these slings on female sexual function specifically remains underexplored.

METHODS

A literature search was conducted using PubMed using the keywords "stress urinary incontinence," "midurethral slings," "single-incision slings," "female sexual function," and "dyspareunia."

RESULTS

The reviewed studies demonstrated that SIS generally maintain or improve sexual function postoperatively, but with varying impact on specific aspects of sexual function. While coital urinary incontinence often improved or resolved, new or worsened dyspareunia was reported in a significant number of patients.

CONCLUSION

SIS placement for SUI generally preserves or enhances sexual function, though individual aspects, such as dyspareunia, may worsen for some patients. Given that an important goal of SUI treatment is to improve quality of life, it is crucial to identify preoperative factors that will identify patients at risk of developing dyspareunia after surgery or are more likely to experience an improvement in sexual function. Further research is needed to better understand these predictors and optimize surgical outcomes for women undergoing SUI treatment with SIS.

Instruments Used for the Assessment of SUI Severity in Urogynecologic Surgical Trials: A Scoping Review

INTRODUCTION AND HYPOTHESIS

Various instruments are used to evaluate the severity of stress urinary incontinence (SUI) in clinical trials for SUI surgery. We conducted a scoping review with the primary aim of investigating the use of such instruments.

METHODS

A comprehensive search in PubMed/MEDLINE, Cochrane Library, ClinicalTrials.gov, and WHO ICTRP was carried out. Inclusion criteria were studies including patients undergoing surgical intervention for SUI with assessment of SUI severity performed pre- and post-operatively. Exclusion criteria were nonprospective studies, nonrandomized studies, studies not in the English language, and the absence of reporting the methods of SUI severity evaluation in the study.

RESULTS

In total, 8,886 articles were identified, yielding 100 papers for data extraction. The most frequent interventions were mid-urethral slings (85 studies), Burch colposuspension (10 studies), and the use of bulking agents (3 studies). The most frequently used instruments for objective evaluation of SUI were urodynamics (90 studies), nonvalidated cough stress test (83 studies), and 1-h pad test (28 studies). The most frequently used instruments for subjective evaluation were bladder diary (37 studies), Incontinence Impact Questionnaire-7 (26 studies), and Urinary Distress Inventory-6 (23 studies). There were three studies reporting results according to the severity of pre- and post-operative SUI.

CONCLUSIONS

There is significant heterogeneity regarding the instruments used to evaluate the severity of SUI in surgical trials for female incontinence. There is a paucity of data regarding results according to the pre-operative severity of SUI. Hence, commonly agreed standardized methods for the assessment of SUI severity are needed to improve comparability between clinical trials for SUI surgery.

Single-incision sling operations for urinary incontinence in women

BACKGROUND

Stress urinary incontinence imposes a significant health and economic burden on individuals and society. Single-incision slings are a minimally-invasive treatment option for stress urinary incontinence. They involve passing a short synthetic device through the anterior vaginal wall to support the mid-urethra. The use of polypropylene mesh in urogynaecology, including mid-urethral slings, is restricted in many countries. This is a review update (previous search date 2012).

OBJECTIVES

To assess the effects of single-incision sling operations for treating urinary incontinence in women, and to summarise the principal findings of relevant economic evaluations.

SEARCH METHODS

We searched the Cochrane Incontinence Specialised Register, which contains trials identified from: CENTRAL, MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, and two trials registers. We handsearched journals, conference proceedings, and reference lists of relevant articles to 20 September 2022.

SELECTION CRITERIA

We included randomised or quasi-randomised controlled trials in women with stress (or stress-predominant mixed) urinary incontinence in which at least one, but not all, trial arms included a single-incision sling.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures. The primary outcome was subjective cure or improvement of urinary incontinence.

MAIN RESULTS

We included 62 studies with a total of 8051 women in this review. We did not identify any studies comparing single-incision slings to no treatment, conservative treatment, colposuspension, or laparoscopic procedures. We assessed most studies as being at low or unclear risk of bias, with five studies at high risk of bias for outcome assessment. Sixteen trials used TVT-Secur, a single-incision sling withdrawn from the market in 2013. The primary analysis in this review excludes trials using TVT-Secur. We report separate analyses for these trials, which did not substantially alter the effect estimates. We identified two cost-effectiveness analyses and one cost-minimisation analysis. Single-incision sling versus autologous fascial sling One study (70 women) compared single-incision slings to autologous fascial slings. It is uncertain if single-incision slings have any effect on risk of dyspareunia (painful sex) or mesh exposure, extrusion or erosion compared with autologous fascial slings. Subjective cure or improvement of urinary incontinence at 12 months, patient-reported pain at 24 months or longer, number of women with urinary retention, quality of life at 12 months and the number of women requiring repeat continence surgery or sling revision were not reported for this comparison. Single-incision sling versus retropubic sling Ten studies compared single-incision slings to retropubic slings. There may be little to no difference between single-incision slings and retropubic slings in subjective cure or improvement of incontinence at 12 months (risk ratio (RR) 0.99, 95% confidence interval (CI) 0.91 to 1.07; 2 trials, 297 women; low-certainty evidence). It is uncertain whether single-incision slings increase the risk of mesh exposure, extrusion or erosion compared with retropubic minimally-invasive slings; the wide confidence interval is consistent with both benefit and harm (RR 1.55, 95% CI 0.24 to 9.82; 3 trials, 267 women; low-certainty evidence). It is uncertain whether single-incision slings lead to fewer women having postoperative urinary retention compared with retropubic slings; the wide confidence interval is consistent with possible benefit and harm (RR 0.47, 95% CI 0.12 to 1.84; 2 trials, 209 women; low-certainty evidence). The effect of single-incision slings on the risk of repeat continence surgery or mesh revision compared with retropubic slings is uncertain (RR 4.19, 95% CI 0.31 to 57.28; 2 trials, 182 women; very low-certainty evidence). One study reported quality of life, but not in a suitable format for analysis. Patient-reported pain at more than 24 months and the number of women with dyspareunia were not reported for this comparison. We downgraded the evidence due to concerns about risks of bias, imprecision and inconsistency. Single-incision sling versus transobturator sling Fifty-one studies compared single-incision slings to transobturator slings. The evidence ranged from high to low certainty. There is no evidence of a difference in subjective cure or improvement of incontinence at 12 months when comparing single-incision slings with transobturator slings (RR 1.00, 95% CI 0.97 to 1.03; 17 trials, 2359 women; high-certainty evidence). Single-incision slings probably have a reduced risk of patient-reported pain at 24 months post-surgery compared with transobturator slings (RR 0.12, 95% CI 0.02 to 0.68; 2 trials, 250 women; moderate-certainty evidence). The effect of single-incision slings on the risk of dyspareunia is uncertain compared with transobturator slings, as the wide confidence interval is consistent with possible benefit and possible harm (RR 0.78, 95% CI 0.41 to 1.48; 8 trials, 810 women; moderate-certainty evidence). There are a similar number of mesh exposures, extrusions or erosions with single-incision slings compared with transobturator slings (RR 0.61, 95% CI 0.39 to 0.96; 16 trials, 2378 women; high-certainty evidence). Single-incision slings probably result in similar or reduced cases of postoperative urinary retention compared with transobturator slings (RR 0.68, 95% CI 0.47 to 0.97; 23 trials, 2891 women; moderate-certainty evidence). Women with single-incision slings may have lower quality of life at 12 months compared to transobturator slings (standardised mean difference (SMD) 0.24, 95% CI 0.09 to 0.39; 8 trials, 698 women; low-certainty evidence). It is unclear whether single-incision slings lead to slightly more women requiring repeat continence surgery or mesh revision compared with transobturator slings (95% CI consistent with possible benefit and harm; RR 1.42, 95% CI 0.94 to 2.16; 13 trials, 1460 women; low-certainty evidence). We downgraded the evidence due to indirectness, imprecision and risks of bias.

AUTHORS' CONCLUSIONS

Single-incision sling operations have been extensively researched in randomised controlled trials. They may be as effective as retropubic slings and are as effective as transobturator slings for subjective cure or improvement of stress urinary incontinence at 12 months. It is uncertain if single-incision slings lead to better or worse rates of subjective cure or improvement compared with autologous fascial slings. There are still uncertainties regarding adverse events and longer-term outcomes. Therefore, longer-term data are needed to clarify the safety and long-term effectiveness of single-incision slings compared to other mid-urethral slings.

Single Incision Mini-Sling Versus Mid-Urethral Sling (Transobturator/Retropubic) in Females With Stress Urinary Incontinence: A Systematic Review and Meta-Analysis

Stress urine incontinence (SUI) is most common in middle-aged women and the second most common in those over 75. SUI causes significant discomfort and suffering for patients and has a considerable financial impact on the healthcare system. Conservative approaches are recommended as the first step in treatment. However, surgery is often necessary to improve a patient's quality of life due to the high failure rate of conservative treatments. A thorough literature review of studies published before March 2023 was conducted on the safety and effectiveness of single-incision mini slings (SIMS) and standard mid-urethral slings (MUS). PubMed, Embase, Cochrane Library, and Elsevier's ScienceDirect were used to retrieve the studies. Two reviewers independently searched and evaluated the data based on inclusion and exclusion criteria. Review Manager 5.4 software was used for meta-analysis. Included were seventeen studies involving 3,503 female SUI patients without intrinsic sphincter deficiency (ISD) or mixed urinary incontinence. According to the results of our meta-analysis, the clinical efficacy of SIMS is comparable to that of MUS in terms of objective cure rate (RR: 0.99; 95% CI: 0.95 to 1.03, p: 0.66, I2: 29%). In contrast, it increases the post-procedure International Consultation on Incontinence Questionnaire (ICIQ) score (WMD: 0.08; 95% CI: -0.08 to 0.08). CI: -0.02 to 0.18, p: 0.11, I2: 55%) and improves the PGI-I score to a greater extent (RR: 1.04; 95% CI: 0.96 to 1.08, p: 0.36, I2: 76%). In contrast, there is no difference between the two groups regarding patient satisfaction (RR: 0.96; 95% CI: 0.92 to 1.01, p: 0.16, I2: 0%) and Sandvik score reduction (RR: 0.98; 95% CI: 0.94 to 1.02, p: 0.35, I2: 0%). In conclusion, single-incision mid-urethral slings (SIMS) are as effective as mid-urethral slings (MUS) for treating pure stress urinary incontinence (SUI) without intrinsic sphincter deficiency (ISD), with a shorter operation time. However, the SIMS procedure has a higher incidence of dyspareunia. At the same time, bladder perforation, mesh-related complications, pelvic/groin pain, urinary tract infection (UTI), worsening urgency, dysuria, and pain score are less likely to occur with SIMS. Only the decrease in pelvic/groin pain was statistically significant.

Is There Outcome Reporting Heterogeneity in Trials That Aim to Assess the Effectiveness of Surgical Treatments for Stress Urinary Incontinence in Women?

CONTEXT

Inconsistent reporting of effectiveness outcomes in surgical trials of stress urinary incontinence (SUI) has hindered direct comparisons of various surgical treatments for SUI.

OBJECTIVE

To systematically review the verbatim outcome names, outcome definitions, and tools used to measure the outcomes in surgical trials of SUI in women.

EVIDENCE ACQUISITION

Trials of women with SUI who have undergone surgical interventions were included. We conducted a systematic review (SR) on outcomes reported in randomized controlled trials of surgical management published in 2014-2019, covering the following databases: MEDLINE, EMBASE, CENTRAL, and CDSR. Verbatim outcome names extracted from the included studies were categorized and then grouped into domains using the Williamson-Clarke (W/C) outcome taxonomy. A matrix was also created to visualize and quantify the dimensions of outcome reporting heterogeneity in SUI trials.

EVIDENCE SYNTHESIS

A total of 844 verbatim outcome names were extracted, of which, 514 varied terms were reduced to 71 standardized outcome names. They were further categorized into 11 domains from the W/C taxonomy. There were 7.24 different terms on average to describe each outcome, and the four outcomes with the most heterogeneity evident in terms used to describe them were "urinary retention", "reoperation", "subjective cure rate" and "quality of life". Each of them had ≥20 different terms. Only 28% of the outcome definitions were reported and a variety of measuring tools was noted, particularly in subjective outcomes. High heterogeneity was found in the outcome names, outcome definitions, choice and number of measuring instruments of the outcomes, and choice and number of outcomes reported across studies.

CONCLUSIONS

This SR provides objective evidence of heterogeneity in outcome reporting in SUI surgical trials. Our categorization of outcomes highlights the difficulties in summarizing the current evidence base. A core outcome set, developed using the methods advocated by the Core Outcome Measures in Effectiveness Trials (COMET) and COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) initiatives, is required.

PATIENT SUMMARY

In this research, we have highlighted the diversity in outcomes reporting in stress urinary incontinence (SUI) surgical trials and have categorized the outcomes. We support the development of a core outcome set for SUI, which will promote future clinical researchers to measure the same outcome in the same way in all trials. This will, in turn, help researchers summarize the evidence more effectively and aid decision making for patients and doctors.

Focusing on long-term complications of mid-urethral slings among women with stress urinary incontinence as a patient safety improvement measure: A protocol for systematic review and meta-analysis

BACKGROUND

There are 3 different types of mid-urethral sling, retropubic, transobturator and single incision performed for women with stress urinary incontinence. Prior studies comparing these three surgeries merely focused on the successful rate or efficacy. But nevertheless, what is more clinically important dwells upon investigating postoperative complications as a safety improvement measure.

METHODS

A systematic review via PubMed, Ovid, and the Cochrane Database of Systematic Review and studies were applied based on the contents with clearly identified complications. Selected articles were reviewed in scrutiny by 2 individuals to ascertain whether they fulfilled the inclusion criteria: complications measures were clearly defined; data were extracted on study design, perioperative complications, postoperative lower urinary tract symptoms, postoperative pain, dyspareunia, and other specified late complications.

RESULTS

A total of 55 studies were included in the systemic review. Perioperative complications encompassed bladder perforation, vaginal injury, hemorrhage, hematoma, urinary tract infection. There were postoperative lower urinary tract symptoms including urine retention and de novo urgency. Furthermore, postoperative pain, tape erosion/ extrusion, further stress urinary incontinence surgery, and rarely, deep vein thrombosis and injury of inferior epigastric vessels were also reported.

CONCLUSIONS

Complications of mid-urethral sling are higher than previously thought and it is important to follow up on their long-term outcomes; future research should not neglect to address this issue as a means to improve patient safety.

Prospective study of a single-incision sling versus a transobturator sling in women with stress urinary incontinence: 3-year results

BACKGROUND

Long-term safety and efficacy data on use of single-incision slings in stress urinary incontinence are limited.

OBJECTIVE

To determine whether the single-incision sling Solyx (Boston Scientific, Marlborough, MA) is noninferior to the transobturator sling Obtryx II (Boston Scientific) in efficacy and safety for treatment of stress urinary incontinence. This 522 post-market surveillance study has been designed in response to a Food and Drug Administration request to evaluate improvement in stress urinary incontinence at 36 months following single-incision sling compared with baseline, as well as provide an assessment of mesh-related complications and subject-reported outcomes, relative to the transobturator sling control.

STUDY DESIGN

This prospective, nonrandomized, parallel cohort, multicenter postapproval study enrolled subjects to receive single-incision sling or transobturator sling. Study sites were assigned to a cohort group based on documented competency with the cohort device. Patient follow-up was 36 months to compare efficacy and adverse events for noninferiority. Inclusion criteria included stress predominant urinary incontinence, a positive cough stress test, and post-void residual ≤150 cc. Participants were ineligible if they had undergone previous stress urinary incontinence surgery or had a previous mesh complication. Primary endpoint was treatment success defined by composite negative cough stress test and subjective improvement in stress urinary incontinence using Patient Global Impression of Improvement at 36 months. Secondary endpoints included adverse events and indications for retreatment. Noninferiority margins of 15% and 10% were prespecified for the primary efficacy and safety endpoints. Data analysis was performed using intent-to-treat and per-protocol methods. Due to the observational nature of the study, a propensity score methodology was applied to account for differences in patient and surgeon characteristics between treatment groups. The study design and variables to be included in the propensity score model were reviewed and approved by Food and Drug Administration reviewers before outcome analyses were performed.

RESULTS

No evidence of imbalance in baseline characteristics was observed between groups after propensity score stratification in the 281 subjects. EBL (72.3±92 vs 73.1±63.9 mL, P=.786), time to spontaneous void (1.1±2 vs 0.8±2.8 days, P=.998), and time to discharge (0.7±0.7 vs 0.6±0.6 days, P=.524) were similar between groups. At 36 months, treatment success was 90.4% in the single-incision sling group and 88.9% in the transobturator sling group (P=.93). At 36 months, mesh-related complications were similar between groups (mesh exposure: 2.8% vs 5.0%, P=.38). Serious adverse events including pain during intercourse (0.7% vs 0%, P=1.00), pelvic pain (0.7% vs 0%, P=1.00), and urinary retention (2.8% vs 4.3%, P=.54) were similar between groups.

CONCLUSION

Single-incision sling was not inferior to transobturator sling for long-term treatment success of stress urinary incontinence. The rates of serious adverse events were acceptably low and similar between groups.

Ambulatory MiniArc Precise Sling under Local Anesthesia for Stress Urinary Incontinence: Feasibility and Outcome

Aims:

The aim of the study is to assess the feasibility of ambulatory stress urinary incontinence (SUI) surgery using the MiniArc Precise single-incision urethral sling without increasing the number of complications.

Settings and Design:

This was a retrospective observational study of prospectively collected data carried out in a Tertiary Referral Hospital in Barcelona, Spain.

Materials and Methods:

Forty patients diagnosed with SUI or stress predominant mixed urinary incontinence (MUI) treated surgically between November 2011 and November 2013. The MiniArc Precise^® sling was inserted under local anesthesia in the ambulatory setting.

Statistical Analysis Used:

Descriptive statistics included frequencies and percentages for categorical variables and mean and range for quantitative variables. The statistical package used was SPSS version 17.0.

Results:

Urodynamic studies showed SUI in 78% of cases and stress predominant MUI in 17%. Clinical findings included SUI in 56% of cases and MUI in 44%, with positive stress tests in all participants. The mean intraoperative pain (1–10 Visual Analog Scale) was 2. All patients were satisfied with the use of local anesthesia in the outpatient setting. Perioperative complications did not occur. One case of urinary retention and two cases of urinary tract infection (UTI) developed within this 1^st month after operation and were successfully managed conservatively. Midterm complications included eight cases of UTI and four de novo urge incontinence.

Conclusions:

Placement of the MiniArc Precise sling under local anesthesia is a feasible and safe technique, which when carried out by an experienced surgeon allows to be done as an outpatient basis without increasing the rate of postprocedural complications.

A systematic review and meta-analysis of single-incision mini-slings (MiniArc) versus transobturator mid-urethral slings in surgical management of female stress urinary incontinence

BACKGROUND

To assess the current evidence of effectiveness and safety of single-incision mini-slings (MiniArc) versus transobturator midurethral slings in the management of female stress urinary incontinence (SUI).

METHODS

A systematic search was performed from the electronic databases including PubMed, EMBASE, and Cochrane Library by November 2017. Using RevMan5.3 statistical software, the primary outcomes including subject and objective cure rates at 6 to 24 months follow-up were evaluated. Meanwhile, analysis was also performed for comparing the secondary outcomes such as peri- and postoperative complications, operative data, and quality of life.

RESULTS

Six randomized controlled trials (RCTs) and 6 retrospective cohort studies involving 1794 patients with SUI were analyzed based on the inclusion criteria. On the basis of our analysis, MiniArc was proven to have a noninferior clinical efficacy compared with transobturator midurethral slings with respect to the objective cure rate (risk ratio [RR] = 0.98, 95% confidence interval [CI] 0.94-1.03, P = .43) and subjective cure rate (RR = 0.97, 95% CI 0.91-1. 04, P = .38). In addition, pooled analysis showed that MiniArc had significantly lower postoperative pain scores (mean difference [MD] = -1.70, 95% CI -3.17 to -0.23, P = .02) and less postoperative groin pain (RR = 0.42, 95% CI 0.18-0.98, P = .04). Moreover, the MiniArc group also had a significantly shorter operation time (MD = -6.12, 95% CI -8.61 to -3.64, P < .001), less blood loss (MD = -16.67, 95% CI -26.29 to -7.05, P < .001), shorter in-patient stay (MD = 1.30, 95% CI -1.74 to -0.86, P < .001), and less urinary retention risk (RR = 1.15, 95% CI 0.46-2.87, P = .77). However, overall evidence was insufficient to suggest a statistically significant difference in the adverse event profile for MiniArc compared with transobturator slings.

CONCLUSIONS

This meta-analysis indicates that MiniArc is an effective method treating SUI. When compared with transobturator slings, it not only has a similar high cure rates, but also is associated with shorter operation time, less blood loss, more favorable recovery time, lower postoperative pain scores, less postoperative groin pain, less urinary retention, and absence of a visible wound. However, the findings of this study should be further confirmed by well-designed prospective RCTs with a larger patient series.

Outpatient mid-urethral tissue fixation system sling for urodynamic stress urinary incontinence: 3-year surgical and quality of life results

Introduction

To evaluate the clinical effectiveness and quality of life (QOL) of outpatient mid-urethral tissue fixation system sling (TFS) procedures for urodynamic stress urinary incontinence (SUI) at 3-year follow-up.

Methods

We analyzed 50 mid-urethral TFS sling operations between 2007 and 2012 at Yokohama Motomachi Women’s Clinic LUNA. The primary outcome was success defined as a negative 24-h pad test, negative cough and Valsalva stress test, and no re-treatment for SUI. Secondary outcome was improvement in quality of life, which was assessed using the Incontinence Questionnaire-Short Form (ICIQ-SF) and the Incontinence Impact Questionnaire Short Form (IIQ-7). The 3-year postoperative scores were compared with baseline scores using the Wilcoxon signed rank test. A 5% two-sided significance level was used for all statistical testing.

Results

All operations were carried out on an outpatient basis with no intraoperative complications. The primary cure rate result at 3-year follow-up was 90%. Median total ICIQ-SF score changed from 12 (6–20) to 0 (0–14) and median total IIQ-7 score changed from 156 (0–300) to 0 (0.00–16.7) at 3-year follow-up.

Conclusions

Results show that the TFS mid-urethral sling operation is a simple, safe, effective procedure that may be done without difficulty at a freestanding clinic on an outpatient basis and favorably improves subjective QOL of the patient.

Stress Urinary Incontinence: Comparative Efficacy Trials

Women seeking relief from symptoms of stress urinary incontinence (SUI) may choose from a broad array of treatment options. Therapies range from lifestyle/behavioral modification to surgical interventions, and differ in terms of both effectiveness and risk. Individualized treatment plans can be developed to address a patient's expectations and goals for treatment, as well as her tolerance for potential adverse events. This article reviews the highest-quality clinical trials comparing contemporary treatment options for women with SUI. Clinicians and patients can use this compendium to inform their treatment selection.

Supplementary searches of PubMed to improve currency of MEDLINE and MEDLINE In-Process searches via Ovid

OBJECTIVE

The research investigated whether conducting a supplementary search of PubMed in addition to the main MEDLINE (Ovid) search for a systematic review is worthwhile and to ascertain whether this PubMed search can be conducted quickly and if it retrieves unique, recently published, and ahead-of-print studies that are subsequently considered for inclusion in the final systematic review.

METHODS

Searches of PubMed were conducted after MEDLINE (Ovid) and MEDLINE In-Process (Ovid) searches had been completed for seven recent reviews. The searches were limited to records not in MEDLINE or MEDLINE In-Process (Ovid).

RESULTS

Additional unique records were identified for all of the investigated reviews. Search strategies were adapted quickly to run in PubMed, and reviewer screening of the results was not time consuming. For each of the investigated reviews, studies were ordered for full screening; in six cases, studies retrieved from the supplementary PubMed searches were included in the final systematic review.

CONCLUSION

Supplementary searching of PubMed for studies unavailable elsewhere is worthwhile and improves the currency of the systematic reviews.

Single incision slings: Are they ready for real life?

AIM: To review of the efficacy and safety outcomes of different single incision slings (SIS) systems, also in comparison with traditional slings.

METHODS: A literature search was conducted in PubMed/MEDLINE database. The research was restricted to randomized and/or prospective trials and retrospective studies, published after 2006, with at least 20 patients with non-neurogenic stress urinary incontinence (SUI). The studies had to assess efficacy and/or safety of the SIS with a minimum follow-up of 12 mo. All the paper assessing the performance of tension free vaginal tape secur were excluded from this review. The final selection included 19 papers fulfilling the aforementioned criteria. Two authors independently reviewed the selected papers.

RESULTS: Four different SIS systems were analysed: Ajust^®, Ophira^®, Altis^® and MiniArc^®. The average objective cure rate was 88%. Overall no statistically significant differences were found between SIS and traditional mid-urethral slings (MUS) in terms of objective cure (all P > 0.005). Only one paper showed a statistically lower success rate in MiniArc^®vs Advantage^® slings (40% vs 90%) and higher rates of failure in the SIS group. Since there was a great variability in terms of tests performed, it was not possible to compare subjective cure between studies. The vast part of the studies showed no major complications after SIS surgery. We also observed very low reported pain rates in SIS patients. The RCTs on Ajust^® and MiniArc^®, showed better outcomes in terms of post-operative pain compared to MUS. None of the patients reported long- term pain complains.

CONCLUSION: SIS showed similar efficacy to that of traditional slings but lower short-term pain, complication and failure rates.

Midurethral sling: is there an optimal choice?

PURPOSE OF REVIEW

Midurethral slings (MUS) are the most common procedure performed for female stress urinary incontinence (SUI). Several variations have been introduced and evidence supporting the optimal approach for outcomes is necessary.

RECENT FINDINGS

The bottom-up approach to the retropubic MUS may have higher subjective cure rates and lower rates of bladder puncture, voiding dysfunction, and vaginal extrusion compared to the top-bottom approach. Short-term and medium-term cure after retropubic and transobturator approaches are similar, whereas the retropubic approach may have better outcomes in the long term. The transobturator approach, however, appears to be associated with less bladder puncture, vascular injury, and postoperative voiding dysfunction, albeit at the expense of greater groin pain. De-novo storage symptoms and impact on sexual function are similar. The single incision mini sling (SIMS) may offer similar cure rates as the transobturator approach, with lower rates of early postoperative pain. SIMS offers inferior cure rates compared with the retropubic MUS.

SUMMARY

The bottom-up retropubic MUS may currently be the 'optimal' MUS procedure; however, the transobturator MUS should also be considered. Long-term results are currently emerging and detailed informed consent is required regardless of the approach.

Single incision slings: Past, present, and future

Pubovaginal slings have become the gold standard to treat stress urinary incontinence. Traditionally, the sling referred to a suspensory that was placed under the urethra and brought through the retropubic space and anchored on either side of the midline. Since this original concept, there have been many materials used for the sling, and there have been many different anchoring approaches. Most agree that one of the best materials is polypropylene mesh. However, the means of anchoring the device and where best to have this anchorage placed is debatable. The options for anchoring simply include using darts vs not to hold the sling in place. The location of this anchorage, on the other hand, is much more controversial. The main locations are retropubic, transobturator, and via a single incision. The obturator and retropubic slings have become the standard of care over time. The single incision sling, on the other hand, is starting to be more acceptable which has resulted in it being used more frequently. The single incision relies on mainly anchoring the sling through the obturator internus muscle with possible inclusion of the obturator membrane. The purpose of this review article is to present the data that exists for the use of the single incision sling.