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Meta-Analysis
. 2017 Jul 26;7(7):CD001754.
doi: 10.1002/14651858.CD001754.pub4.

Traditional suburethral sling operations for urinary incontinence in women

Haroon Rehman  1 , Carlos A Bezerra, Homero Bruschini, June D Cody, Patricia Aluko
Affiliations
Meta-Analysis

Traditional suburethral sling operations for urinary incontinence in women

Haroon Rehman et al. Cochrane Database Syst Rev. .

Update in

Abstract

Background: Stress urinary incontinence constitutes a significant health and economic burden to society. Traditional suburethral slings are one of the surgical operations used to treat women with symptoms of stress urinary incontinence.

Objectives: To determine the effects of traditional suburethral slings on stress or mixed incontinence in comparison with other management options.

Search methods: We searched the Cochrane Incontinence Group Specialised Register (searched 3 June 2010) and the reference lists of relevant articles.

Selection criteria: Randomised or quasi-randomised trials that included traditional suburethral slings for the treatment of stress or mixed urinary incontinence.

Data collection and analysis: At least three reviewers independently extracted data from included trials onto a standard form and assessed trial methodological quality. The data abstracted were relevant to predetermined outcome measures. Where appropriate, we calculated a summary statistic: a relative risk for dichotomous data and a weighted mean difference for continuous data.

Main results: We included 26 trials involving 2284 women. The quality of evidence was moderate for most trials and there was generally short follow-up ranging from 6 to 24 months.One medium-sized trial compared traditional suburethral sling operations with oxybutynin in the treatment of women with mixed urinary incontinence. Surgery appeared to be more effective than drugs in treating participant-reported incontinence (n = 75, risk ratio (RR) 0.18, 95% confidence interval (CI) 0.08 to 0.43).One trial found that traditional slings were more effective than transurethral injectable treatment (RR for clinician-assessed incontinence within a year 0.21, 95% CI 0.09 to 0.21)Seven trials compared slings with open abdominal retropubic colposuspension. Participant-reported incontinence was lower with the slings after one year (RR 0.75, 95% CI 0.62 to 0.90), but not when assessed by clinicians. Colposuspension, however, was associated with fewer peri-operative complications, shorter duration of use of indwelling catheter and less long-term voiding dysfunction. One study showed there was a 20% lower risk of bladder perforation with the sling procedure but a 50% increase in urinary tract infection with the sling procedure compared with colposuspension. Fewer women developed prolapse after slings (compared with after colposuspension) in two small trials but this did not reach statistical significance.Twelve 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 0.97, 95% CI 0.78 to 1.20) 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.Six trials compared one type of traditional sling with another. Materials included porcine dermis, lyophilised dura mater, fascia lata, vaginal wall, autologous dermis and rectus fascia. Participant-reported improvement rates within the first year favoured the traditional autologous material rectus fascia over other biological materials (RR 0.45, 95% CI 0.21 to 0.98). There were more complications with the use of non-absorbable Gore-Tex in one trial.Data for comparison of bladder neck needle suspension with suburethral slings were inconclusive because they came from a single trial with a small specialised population.No trials compared traditional suburethral slings with anterior repair, laparoscopic retropubic colposuspension or artificial sphincters. Most trials did not distinguish between women having surgery for primary or recurrent incontinence when reporting participant characteristics.For most of the comparisons, clinically important differences could not be ruled out.

Authors' conclusions: Traditional slings seem to be as effective as minimally invasive slings, but had higher rates of adverse effects. This should be interpreted with some caution however, as the quality of evidence for the studies was variable, follow-up short and populations small, particularly for identifying complication rates. Tradional sling procedures appeared to confer a similar cure rate in comparison to open retropubic colposuspension, but the long-term adverse event profile is still unclear. A brief economic commentary (BEC) identified two studies suggesting that traditional slings may be more cost-effective compared with collagen injection but not cost-effective when compared with minimally invasive sling operations. Reliable evidence to clarify whether or not traditional suburethral slings may be better or worse than other surgical or conservative management options is lacking.

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Conflict of interest statement

Haroon Rehman: no interests to declare Carlos CB Bezerra: no interests to declare Homero Bruschini: no interests to declare June D Cody: no interests to declare

Patricia Aluko: July 2017 ‐ this project, to add brief economic commentaries to Cochrane Incontinence's reviews on surgery for urinary incontinence in women was supported by the National Institute for Health Research (NIHR), via the Cochrane Review Incentive Scheme 2016, to Cochrane Incontinence. The views and opinions expressed herein are those of the authors and do not necessarily reflect those of the Systematic Reviews Programme, NIHR, NHS or the Department of Health.

Figures

Figure 1
Figure 1
Figure 2
Figure 2
Analysis 3.1
Analysis 3.1
Comparison 3 Sling versus drugs, Outcome 1 Number with incontinence (worse, unchanged or improved) within the first year (women's observations).
Analysis 3.2
Analysis 3.2
Comparison 3 Sling versus drugs, Outcome 2 Urge symptoms or urge incontinence.
Analysis 4.1
Analysis 4.1
Comparison 4 Sling versus injectable, Outcome 1 Number with incontinence (worse, unchanged or improved) within the first year (women's observations).
Analysis 4.2
Analysis 4.2
Comparison 4 Sling versus injectable, Outcome 2 Number with incontinence (worse, unchanged or improved) after first year (women's observations).
Analysis 4.3
Analysis 4.3
Comparison 4 Sling versus injectable, Outcome 3 Number with incontinence (clinician's observations) within first year.
Analysis 4.4
Analysis 4.4
Comparison 4 Sling versus injectable, Outcome 4 Voiding dysfunction.
Analysis 4.5
Analysis 4.5
Comparison 4 Sling versus injectable, Outcome 5 De novo detrusor overactivity (urodynamic diagnosis).
Analysis 4.6
Analysis 4.6
Comparison 4 Sling versus injectable, Outcome 6 Urinary tract infection.
Analysis 5.1
Analysis 5.1
Comparison 5 Sling versus open abdominal retropubic suspension, Outcome 1 Number with incontinence (worse, unchanged or improved) within the first year (women's observations).
Analysis 5.3
Analysis 5.3
Comparison 5 Sling versus open abdominal retropubic suspension, Outcome 3 Number with incontinence (worse, unchanged or improved) after first year (women's observations).
Analysis 5.9
Analysis 5.9
Comparison 5 Sling versus open abdominal retropubic suspension, Outcome 9 Number with incontinence (clinician's observations) after first year.
Analysis 5.10
Analysis 5.10
Comparison 5 Sling versus open abdominal retropubic suspension, Outcome 10 Operative time (minutes).
Analysis 5.11
Analysis 5.11
Comparison 5 Sling versus open abdominal retropubic suspension, Outcome 11 Time to catheter removal (days).
Analysis 5.12
Analysis 5.12
Comparison 5 Sling versus open abdominal retropubic suspension, Outcome 12 Length of inpatient stay (days).
Analysis 5.14
Analysis 5.14
Comparison 5 Sling versus open abdominal retropubic suspension, Outcome 14 Peri‐operative surgical complications.
Analysis 5.15
Analysis 5.15
Comparison 5 Sling versus open abdominal retropubic suspension, Outcome 15 Bladder perforation.
Analysis 5.16
Analysis 5.16
Comparison 5 Sling versus open abdominal retropubic suspension, Outcome 16 Urinary tract infection.
Analysis 5.17
Analysis 5.17
Comparison 5 Sling versus open abdominal retropubic suspension, Outcome 17 Urge symptoms or urge incontinence.
Analysis 5.18
Analysis 5.18
Comparison 5 Sling versus open abdominal retropubic suspension, Outcome 18 Detrusor overactivity (urodynamic diagnosis).
Analysis 5.19
Analysis 5.19
Comparison 5 Sling versus open abdominal retropubic suspension, Outcome 19 Voiding dysfunction after three months.
Analysis 5.20
Analysis 5.20
Comparison 5 Sling versus open abdominal retropubic suspension, Outcome 20 Prolapse.
Analysis 6.1
Analysis 6.1
Comparison 6 Sling versus bladder neck (needle) suspension, Outcome 1 Number with incontinence (worse, unchanged or improved) within the first year (women's observations).
Analysis 6.2
Analysis 6.2
Comparison 6 Sling versus bladder neck (needle) suspension, Outcome 2 Number with incontinence (worse, unchanged or improved) after the first year (women's observations).
Analysis 6.3
Analysis 6.3
Comparison 6 Sling versus bladder neck (needle) suspension, Outcome 3 Length of inpatient stay.
Analysis 6.4
Analysis 6.4
Comparison 6 Sling versus bladder neck (needle) suspension, Outcome 4 Peri‐operative surgical complications.
Analysis 6.5
Analysis 6.5
Comparison 6 Sling versus bladder neck (needle) suspension, Outcome 5 Urge symptoms or urge incontinence.
Analysis 6.6
Analysis 6.6
Comparison 6 Sling versus bladder neck (needle) suspension, Outcome 6 Voiding dysfunction after three months.
Analysis 6.7
Analysis 6.7
Comparison 6 Sling versus bladder neck (needle) suspension, Outcome 7 Detrusor overactivity (urodynamic diagnosis).
Analysis 9.1
Analysis 9.1
Comparison 9 Traditional sling versus minimally invasive sling operation, Outcome 1 Number with incontinence (worse, unchanged or improved) within the first year (women's observations).
Analysis 9.2
Analysis 9.2
Comparison 9 Traditional sling versus minimally invasive sling operation, Outcome 2 Number not improved (worse or unchanged) within the first year (women's observations).
Analysis 9.3
Analysis 9.3
Comparison 9 Traditional sling versus minimally invasive sling operation, Outcome 3 Number with incontinence (worse, unchanged or improved) after first year (women's observations).
Analysis 9.4
Analysis 9.4
Comparison 9 Traditional sling versus minimally invasive sling operation, Outcome 4 Number not improved (worse or unchanged) after the first year (women's observations).
Analysis 9.5
Analysis 9.5
Comparison 9 Traditional sling versus minimally invasive sling operation, Outcome 5 Pad test: mean weight of urine.
Analysis 9.6
Analysis 9.6
Comparison 9 Traditional sling versus minimally invasive sling operation, Outcome 6 Number with incontinence (clinician's observations) within first year.
Analysis 9.7
Analysis 9.7
Comparison 9 Traditional sling versus minimally invasive sling operation, Outcome 7 Number with incontinence (clinician's observations) after first year.
Analysis 9.8
Analysis 9.8
Comparison 9 Traditional sling versus minimally invasive sling operation, Outcome 8 Operative time (mins).
Analysis 9.9
Analysis 9.9
Comparison 9 Traditional sling versus minimally invasive sling operation, Outcome 9 Length of hospital stay (days).
Analysis 9.10
Analysis 9.10
Comparison 9 Traditional sling versus minimally invasive sling operation, Outcome 10 Time to catheter removal (days).
Analysis 9.11
Analysis 9.11
Comparison 9 Traditional sling versus minimally invasive sling operation, Outcome 11 Peri operative surgical complications.
Analysis 9.12
Analysis 9.12
Comparison 9 Traditional sling versus minimally invasive sling operation, Outcome 12 Bladder perforations.
Analysis 9.13
Analysis 9.13
Comparison 9 Traditional sling versus minimally invasive sling operation, Outcome 13 Urethral injury.
Analysis 9.14
Analysis 9.14
Comparison 9 Traditional sling versus minimally invasive sling operation, Outcome 14 De novo detrusor urgency or urge symptoms.
Analysis 9.15
Analysis 9.15
Comparison 9 Traditional sling versus minimally invasive sling operation, Outcome 15 De novo detrusor overactivity (urodynamic diagnosis).
Analysis 9.16
Analysis 9.16
Comparison 9 Traditional sling versus minimally invasive sling operation, Outcome 16 Voiding dysfunction.
Analysis 9.17
Analysis 9.17
Comparison 9 Traditional sling versus minimally invasive sling operation, Outcome 17 Release of sling required.
Analysis 9.18
Analysis 9.18
Comparison 9 Traditional sling versus minimally invasive sling operation, Outcome 18 Retention up to 6 weeks.
Analysis 9.19
Analysis 9.19
Comparison 9 Traditional sling versus minimally invasive sling operation, Outcome 19 Vaginal erosion.
Analysis 9.20
Analysis 9.20
Comparison 9 Traditional sling versus minimally invasive sling operation, Outcome 20 Wound pain (6 months).
Analysis 10.1
Analysis 10.1
Comparison 10 One type of traditional sling versus another, Outcome 1 Number with incontinence (worse, unchanged or improved) within the first year (women's observations).
Analysis 10.2
Analysis 10.2
Comparison 10 One type of traditional sling versus another, Outcome 2 Number not improved (worse or unchanged) within the first year (women's observations).
Analysis 10.3
Analysis 10.3
Comparison 10 One type of traditional sling versus another, Outcome 3 Number with incontinence (worse, unchanged or improved) after first year (women's observations).
Analysis 10.4
Analysis 10.4
Comparison 10 One type of traditional sling versus another, Outcome 4 Number not improved (worse or unchanged) after the first year (women's observations).
Analysis 10.5
Analysis 10.5
Comparison 10 One type of traditional sling versus another, Outcome 5 Number with incontinence (worse, unchanged or improved) after five years (women's observations).
Analysis 10.6
Analysis 10.6
Comparison 10 One type of traditional sling versus another, Outcome 6 Pad test: mean weight of urine.
Analysis 10.7
Analysis 10.7
Comparison 10 One type of traditional sling versus another, Outcome 7 Operative time (mins).
Analysis 10.8
Analysis 10.8
Comparison 10 One type of traditional sling versus another, Outcome 8 Peri operative surgical complications.
Analysis 10.9
Analysis 10.9
Comparison 10 One type of traditional sling versus another, Outcome 9 Bladder perforation.
Analysis 10.10
Analysis 10.10
Comparison 10 One type of traditional sling versus another, Outcome 10 Urinary tract infection.
Analysis 10.11
Analysis 10.11
Comparison 10 One type of traditional sling versus another, Outcome 11 De novo detrusor urgency or urge symptoms or detrusor overactivity.
Analysis 10.12
Analysis 10.12
Comparison 10 One type of traditional sling versus another, Outcome 12 Voiding dysfunction.
Analysis 10.13
Analysis 10.13
Comparison 10 One type of traditional sling versus another, Outcome 13 De novo detrusor overactivity (urodynamic diagnosis).
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Update of

References

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