Minimally invasive synthetic suburethral sling operations for stress urinary incontinence in women: a Cochrane review Clinical

Clinical questions How do the effects of minimally invasive synthetic suburethral sling operations differ from other surgical procedures for the treatment of stress or mixed urinary incontinence in women? Which is the “best” minimally invasive synthetic suburethral sling operation? SourceSource: Ogah J, Cody JD, Rogerson L. Minimally invasive synthetic suburethral sling operations for stress urinary incontinence in women. Cochrane Database of Systematic Reviews 2009, Issue 4. Art. No.: CD DOI: / CD pub2.

Context Stress urinary incontinence is the commonest form of incontinence in women and reduces their quality of life. One in three women will be affected by stress urinary incontinence during their adult life. If other treatments are unsuccessful, women might be offered surgery to try to cure the problem. Over the years, the operations have become less invasive but there are many different types of procedure.

Methods A Cochrane intervention review Relevant trials were identified from the Specialised Register of the Cochrane Incontinence Group. Searches were also done for published reports in MEDLINE, EMBASE, CINAHL and AMED; and for ongoing or recently closed trials in the UK National Research Register, and the ClinicalTrials.gov. Meta-analyses were done using risk ratio (RR) for dichotomous outcomes (such as cure) and using mean differences for continuous variables (such as operation time). There were no pre-planned subgroup analyses.

PICO(S) to assess eligible studies Participants: adult women with mixed incontinence, or with stress urinary incontinence due to hyper-mobility, intrinsic sphincter deficiency, or both (diagnosed clinically or with urodynamics). Intervention and Comparison: at least one group in the trial were allocated to minimally invasive synthetic suburethral sling operations, and this was compared with other surgical techniques and non-surgical interventions Outcomes: these include women’s reporting of cure and improvement in the short (less than 12 months) and longer term (more than 12 months), clinician’s reporting of cure, quantification of symptoms, quality of life, and adverse effects. Studies: Randomised or quasi-randomised trials.

Description of eligible studies Sixty two trials involving 7101 women were included, with a variety of treatment comparisons. Minimally invasive suburethral sling versus traditional suburethral slings (9 trials), open retropubic colposuspension (8 trials) or laparascopic colposuspension (8 trials). Retropubic vagina to abdomen versus retropubic abdomen to vagina (5 trials). Obturator medial to lateral approach versus obturator layteral to medial approach (4 trials). Monofilament versus multifilament tape material (3 trials). Transobturator route versus retropubic route (24 trials). The quality of evidence was moderate for most trials.

Results Minimally invasive surgery vs open surgery Minimally invasive synthetic suburethral sling operations appeared to be as effective as traditional suburethral slings (women’s reporting of cure: RR 1.03, 95% 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 (women’s reporting of cure at 1 year: 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, and 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 is conflicting evidence about the effectiveness of minimally invasive synthetic suburethral sling operations compared to laparoscopic colposuspension in the short term (women’s reporting of cure: RR 1.11, 95% CI 0.99 to 1.24; clinician’s reporting of cure: RR 1.15, 95% CI 1.06 to 1.24). But, the minimally invasive procedures had significantly less de novo urgency and urgency incontinence, operating time, hospital stay and time to return to daily activities. A retropubic vagina-to-abdomen route was more effective than abdomen-to-vagina route (women’s reporting of cure: RR % CI 1.01 to 1.20; clinician’s reporting of cure: RR 1.06, 95% CI 1.01 to 1.11) and incurred significantly less voiding dysfunction, bladder perforations and tape erosions. Results Minimally invasive surgery techniques

Monofilament tapes had higher cure rates (women’s reporting of cure: RR 1.08, 95% CI 0.98 to 1.19; clinician’s reporting of cure: 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 significantly less favourable than the retropubic route in clinician’s reporting of cure rates (84% versus 88%; RR 0.96, 95% CI 0.93 to 0.99) but there was no significant difference for women’s reporting of cure (RR 1.00, 95% CI 0.96 to 1.05) (see next slides). 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. Results Minimally invasive surgery techniques

Transobturator (TOR) versus retropubic (RPR) route Women’s reporting of cure within 12 months

Cochrane Journal Club Transobturator (TOR) versus retropubic (RPR) route Clinician’s reporting of cure within 12 months

Conclusions Current evidence 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 fewer postoperative complications. Women were less likely to become continent after operations performed via the obturator (rather than retropubic) route, but they had fewer complications. Most trials had short term follow up and the quality of the evidence was variable.

Useful links Cochrane Journal Club discussion points Minimally invasive synthetic suburethral sling operations for stress urinary incontinence in women (the Cochrane Review) Minimally invasive synthetic suburethral sling operations for stress urinary incontinence in women (the Cochrane Review) Bezerra CCB, Bruschini H, Cody JD. Traditional suburethral sling operations for urinary incontinence in women. Cochrane Database of Systematic Reviews 2005, Issue 3. Art. No.: CD DOI: / CD pub2 Bezerra CCB, Bruschini H, Cody JD. Traditional suburethral sling operations for urinary incontinence in women