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

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

• Clinical

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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?

Source 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. CD006375. DOI
10.1002/14651858.CD006375.pub2.
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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.

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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.

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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 womens reporting of cure
  and improvement in the short (less than 12
  months) and longer term (more than 12 months),
  clinicians reporting of cure, quantification of
  symptoms, quality of life, and adverse effects.
• Studies Randomised or quasi-randomised trials.

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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.

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ResultsMinimally invasive surgery vs open surgery

• Minimally invasive synthetic suburethral sling
  operations appeared to be as effective as
  traditional suburethral slings (womens 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 (womens 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).

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ResultsMinimally invasive surgery techniques

• There is conflicting evidence about the
  effectiveness of minimally invasive synthetic
  suburethral sling operations compared to
  laparoscopic colposuspension in the short term
  (womens reporting of cure RR 1.11, 95 CI 0.99
  to 1.24 clinicians 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 (womens
  reporting of cure RR 1.10 95 CI 1.01 to 1.20
  clinicians reporting of cure RR 1.06, 95 CI
  1.01 to 1.11) and incurred significantly less
  voiding dysfunction, bladder perforations and
  tape erosions.

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ResultsMinimally invasive surgery techniques

• Monofilament tapes had higher cure rates (womens
  reporting of cure RR 1.08, 95 CI 0.98 to 1.19
  clinicians 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
  clinicians reporting of cure rates (84 versus
  88 RR 0.96, 95 CI 0.93 to 0.99) but there was
  no significant difference for womens 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.

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Transobturator (TOR) versus retropubic (RPR)
route Womens reporting of cure within 12 months
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Transobturator (TOR) versus retropubic (RPR)
route Clinicians reporting of cure within 12
months
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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.

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Useful links

• Cochrane Journal Club discussion points
• 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.
  CD001754. DOI 10.1002/14651858.CD001754.pub2

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