Midurethral Sling Helpful for Stress Urinary Incontinence

Laurie Barclay, MD

July 02, 2015

Midurethral sling operations for stress urinary incontinence in women have a good safety profile and are highly effective in the short and medium term, based on a systematic review published online July 1 in the Cochrane Database of Systematic Reviews.

However, the sling implant is made of an artificial, nonabsorbable plastic mesh tape, which may explain reports of postoperative pain and injury. Although evidence is also building for long-term efficacy, differences in complications and the long-term need for repeat surgery should be weighed when considering sling surgery.

An additional consideration is use of the retropubic route, in which the tape passes behind the pubic bone and exits via the abdomen, or the transobturator route, in which the tape passes side-to-side and exits via the groin.

"This is a very significant review informing women about the minimally invasive surgical options available for the treatment of this very debilitating condition," lead author Abigail A. Ford, MD, from the Bradford Royal Infirmary, United Kingdom, said in a news release. "It helps to give women more information to make an informed choice."

However, Dr Ford cautions women to try less invasive alternatives such as pelvic floor (Kegel) exercises before contemplating any type of surgery. "As all surgery carries some risk, women must weigh up carefully how much they are troubled by their urine leakage against taking a small chance that things may go wrong as a result of surgery," she said.

Risk for bladder damage during surgery was lower with transobturator insertion (0.6% vs 4.5% in the retropubic group), as were rates of major vascular or visceral injury, mean operating time, operative blood loss, and length of hospital stay. The transobturator group also fared better in terms of postoperative voiding dysfunction (4% vs 7% in the retropubic group).

The downside of the transobturator procedure was greater likelihood of groin pain in the short term (6.4% vs 1.3%), as well as some low-quality evidence from four trials suggesting an increased need for repeat surgery compared with retropubic insertion.

For transobturator techniques, there was no evidence favoring the use of a medial-to-lateral vs a lateral-to-medial insertion, but for retropubic tapes, a bottom-to-top route was more effective than a top-to-bottom route.

At 1- to 5-year follow-up, the overall rate of erosion of the tape into the vagina was about 2% after either type of surgery, and both groups also had low rates of pain during sexual intercourse.

Of 81 trials included in the systematic review, enrolling a total of 12,113 women, 55 trials (8652 participants) directly compared retropubic and transobturator slings. There was moderate-quality evidence that either route effectively resolved symptoms in approximately 80% of women at around 12 months.

However, few studies reported 5-year data, and among these, subjective cure rates in either group were approximately 70%, ranging from 43% to 92% in the transobturator group, and from 51% to 88% in the retropubic group.

"We need to know more about what happens to women in the long term," senior author Joseph Ogah, MBBS, MRCOG, from University Hospitals of Morecambe Bay National Health Service Foundation Trust, Cumbria, United Kingdom, said in the news release. "Rather than starting any new trials in this area we need to obtain long-term follow up from the existing trials.

"Although this review compares the two most common operations in current practice in the developed world, we need more robust evidence about how well they compare with the older types of surgery that they have superseded."

The investigators identified randomized or quasirandomized controlled trials in which both trial groups involved a midurethral sling operation by searching the Cochrane Incontinence Group Specialised Register. Two review authors independently examined the methodological quality of potentially eligible studies and extracted data from the included trials.

The National Institute for Health Research funded this review. Dr Ford received funding from Johnson & Johnson for part sponsorship to attend the 2014 International Urogynaecology Association conference. One coauthor received funding from Astellas for attendance at the European Urogynaecological Association meeting in Berlin. Dr Ogah received funding for conference registration fees and speaker honoraria by Astellas UK and was sponsored to attend workshops by Johnson & Johnson and Speciality European Pharma. The remaining coauthor has disclosed no relevant financial relationships.

Cochrane Database Syst Rev. Published online July 1, 2015. Abstract

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