Laparoscopic colposuspension for urinary incontinence in women

Abstract

Background: Laparoscopic colposuspension was one of the first minimal access operations for the treatment of women with stress urinary incontinence, with the presumed advantages over traditional Burch colposuspension of avoiding major incisions, shorter hospital stay, and quicker return to normal activities. A variety of approaches and methods are used.

Objectives: To determine the effects of laparoscopic colposuspension for urinary incontinence.

Search strategy: We searched the Cochrane Incontinence Group Specialised Trials Register (searched 21 September 2005). Additional trials were sought from other sources such as reference lists, reviews and researchers and authors were contacted for unpublished data and trials.

Selection criteria: Randomised or quasi-randomised controlled trials in women with symptomatic or urodynamic diagnosis of stress or mixed incontinence that included laparoscopic surgery in at least one arm of the study.

Data collection and analysis: Trials were evaluated for methodological quality and appropriateness for inclusion by the reviewers. Data were extracted by two of the reviewers and cross checked by another. Trial data were analysed by intervention. Where appropriate, a summary statistic was calculated.

Main results: Twenty-one eligible trials were identified. Nine involved the comparison of laparoscopic with open colposuspension. Whilst the women's subjective impression of cure seemed similar for both procedures in the short and medium term follow-up, there was some evidence of poorer results of laparoscopic colposuspension, within 18 months, on objective outcomes. Two poor quality trials reported conflicting long term results (after five years) for this comparison. No significant differences were observed for post-operative urgency, voiding dysfunction or de novo detrusor overactivity. Trends were shown towards a lower perioperative complication rate, longer operating time, less intraoperative blood loss, less postoperative pain, shorter hospital stay, quicker return to normal activities, and shorter duration of catheterisation for laparoscopic compared with open colposuspension. Benefits did not come without a price, as laparoscopic colposuspension in the short term is more costly.Eight studies compared laparoscopic colposuspension with newer 'self-fixing' vaginal slings. Overall there were no significant differences in the reported subjective cure rates of the two procedures, however vaginal sling procedures did have significantly higher objective cure rates at 18 months. No significant differences were observed for post-operative voiding dysfunction, de novo detrusor activity and perioperative complications. Laparoscopic colposuspension has a significantly longer operation time, longer hospital stay and slower return to normal activities when compared to the sling procedures. Significantly higher subjective and objective (dry on 'ultrashort' pad test) one year cure rates were found for women randomised to two paravaginal sutures compared with one suture in a single trial (89% versus 65% and 83% versus 58% respectively). Two small studies compared sutures with mesh and staples for laparoscopic colposuspension and the comparisons, although showing a trend towards favouring the sutures, were not significant. One study compared transperitoneal with extraperitoneal access for laparoscopic colposuspension but it was also small and of poor quality.

Authors' conclusions: The long-term performance of laparoscopic colposuspension remains uncertain. Currently available evidence suggests that it may be as good as open colposuspension at two years post surgery. Like other laparoscopically performed operations, patients having laparoscopic colposuspension recovered quicker, but the operation itself took longer to perform. However, the newer vaginal sling procedures appear to offer even greater benefits of minimal access surgery and better objective outcomes in the short-term. If laparoscopic colposuspension is performed, two paravaginal sutures appear to be more effective than one. The place of laparoscopic colposuspension in clinical practice should become clearer when ongoing trials are reported and when there are more data available describing long-term cure results.