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

Minimally invasive mid-urethral sling operations are as effective as traditional suburethral slings, open retropubic colposuspension and laparoscopic colposuspension for stress urinary incontinence in women in the short term but with less postoperative complications.

A Cochrane review assessing mid-urethral sling operations included 81 studies with a total of 12 113 subjects. Transobturator route was compared with retropubic route in 55 trials (n=8 652). Rate of subjective cure of transobturator and retropubic route were similar in the short term and long term (moderate quality evidence) . Also short-term objective cure was similar between the groups (RR 0.98, 95% CI 0.96 to 1.00; 40 trials, n=6 145). Overall rate of adverse events remained low. Major vascular/visceral injury, mean operating time, operative blood loss and length of hospital stay were lower with transobturator route. Overall rates of groin pain were higher in the transobturator route group whereas suprapubic pain was lower in the transobturator route group ; both being of short duration. The overall rate of vaginal tape erosion/exposure/extrusion was low in both groups.

A retropubic bottom-to-top route was more effective than top-to-bottom route (RR 1.10, 95% CI 1.01 to 1.20; 3 trials, n=492 for patient-reported cure; RR 1.06, 95% CI 1.01 to 1.11; 4 trials n=636 for clinician-defined cure) and incurred significantly less voiding dysfunction, bladder perforations and 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, n=759; moderate quality evidence, and RR 1.06, 95% CI 0.91 to 1.23; 2 trials, n=235; moderate quality evidence). Voiding dysfunction was more frequent in the medial-to-lateral group (RR 1.74, 95% CI 1.06 to 2.88; 8 trials, n=1121; 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, n=541).

Another Cochrane review included 26 studies with a total of 2284 subjects. The quality of evidence was moderate for most trials. 7 trials compared slings with open abdominal retropubic colposuspension. Patient-reported incontinence was lower with the slings after one year (RR 0.75; 95% CI 0.62 to 0.90; 5 trials, n= 715), but not when assessed by clinicians (RR 0.95, 95% CI 0.64 to 1.41; 3 trials, n=620). 12 trials addressed the comparison between traditional sling operations and minimally invasive sling operations. These seemed to be equally effective in the short term (RR for incontinence within first year; womens opinion: 0.97, 95% CI 0.78 to 1.20: 8 trials, n= 693; clinicians observations: 1.29, 95% CI 0.45 to 3.71; 2 trials, n= 105) but minimally invasive slings had a shorter operating time, fewer peri-operative complications (other than bladder perforation) and some evidence of less post-operative voiding dysfunction and detrusor symptoms.

A randomized controlled multicenter study involved 267 participants comparing two mid-urethra tape procedures, the tension-free vaginal tape (TVT) with the tension-free vaginal tape-obturator (TVT-O). At 36 months of follow-up, 96% of the patients were evaluated with cough stress test. Objective cure rate was 94.6% in the TVT group and 89.5% in the TVT-O group (RR 1.06; 95 % CI 0.99 to1.14). With 2 days pad test (under 8g) the cure rate was 92.7 % in TVT group and 94.1 % in TVT-O-group. Subjective cure rates were significant with no difference between the groups (five different condition-specific quality of life questionnaires: UISS, VAS, IIQ-7, UDI-6, EQ-5D).

Ədəbiyyat

1. . Ford AA, Rogerson L, Cody JD et al. Mid-urethral sling operations for stress urinary incontinence in women. Cochrane Database Syst Rev 2015;(7):CD006375.
2. Rehman H, Bezerra CC, Bruschini H et al. Traditional suburethral sling operations for urinary incontinence in women. Cochrane Database Syst Rev 2011;(1):CD001754.
3. Palva K, Rinne K, Aukee P et al. A randomized trial comparing tension-free vaginal tape with tension-free vaginal tape-obturator: 36-month results. Int Urogynecol J 2010;21(9):1049-55.