Referral for surgery is recommended for women with urinary incontinence as second-line treatment after conservative treatments like pelvic floor muscle training.
The recommendation is strong because of patient important outcomes like quality of life. Surgery is only recommended as second-line treatment compared to pelvic floor muscle training because of uncertainty in the balance of benefits and harms.
A Cochrane review [Abstract] 1 assessing mid-urethral sling operations included 81 studies with a total of 12 113 subjects. Transobturator route (TOT, TVT-O) was compared with retropubic route (TVT) 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) T1. 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 T1; 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).
| Outcome | Relative effect (95% CI) | Assumed risk - Retropubic route | Corresponding risk - Intervention = Transobturator route (95% CI) | Participants (studies) |
|---|---|---|---|---|
| Subjective cure (Short term < 1 year) | RR 0.98(0.96 to 1.00) | 844/1000 | 827/1000(810 to 844) | 5 514(36) |
| Subjective cure (long term > 5 years) | RR 0.95(0.87 to 1.04) | 707/1000 | 671/1000(615 to 735)) | 714(4) |
| Bladder or urethral perforation | RR 0.13(0.08 to 0.20) | 49/1000 | 6 /1000 (4 to 10) | 6 372(40) |
| Voiding dysfunction (short and medium term, up to 5 years | RR 0.53(0.43 to 0.65) | 72/1000 | 38/1000(31 to 47) | 6 217(37) |
| Groin pain | RR 4.62(3.09 to 6.92) | 14/1000 | 66 /1000(44 to 99) | 3 226(18) |
| Subrapubic pain | RR 0.29(0.11 to 0.78) | 29/1000 | 8 /1000(3 to 23) | 1 105(4) |
Another Cochrane review [Abstract] 2 included 34 studies with a total of 3 244 subjects. The quality of evidence was moderate for most trials. 8 trials compared slings with open abdominal retropubic colposuspension. More women were continent with suburethral sling compared with colposuspension in the medium term (one to five years) (69% vs 59%; OR 1.70, 95% CI 1.22 to 2.37; moderate-quality evidence). High-quality evidence shows that women were less likely to need repeat continence surgery after a traditional sling operation than after colposuspension (RR 0.15, 95% CI 0.05 to 0.42). Traditional suburethral slings were no better than mid-urethral slings, in terms of number of women continent in the medium term (one to five years) (67% vs 74%; OR 0.67, 95% CI 0.44 to 1.02; n = 458; moderate-quality evidence).
Primary/Secondary Keywords