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Urogynaecology
Surgical Treatment of Female Stress Urinary Incontinence
Giacomo Novara
Assistant Professor, Urology Cinic, Department of Oncological and Surgical Sciences, University of Padua
Abstract
Stress urinary incontinence (SUI) is a a major healthcare problem affecting millions of women throughout the world. Several surgical treatments
have been proposed, but since the first reports from the Ulmsten group Tension-free Vaginal Tape (TVT) has become the most popular
procedure, due to both the high success rate and minimal invasiveness. Following the success of TVT, a second generation of tension-free mid-
urethral slings has been introduced to the market, including other devices that can be placed retropubically or in the transobturator way. Several
randomised controlled trials have been performed to compare TVT with other traditional surgical treatments for SUI and other retropubical and
transobturator tapes; these were evaluated in this meta-analysis. The meta-analysis showed that TVT outperformed Burch colposuspension and
the efficacy of TVT and pubovaginal sling was similar. TVT was more efficacious than the intra-vaginal sling (IVS) and SPARC, whereas retropubic
and trans-obturator tapes showed overlapping cure rates. With regard to complications, tension-free slings had a lower risk of re-operation
compared with Burch colposuspension, whereas pubovaginal sling and tension-free mid-urethral slings had similar complication rates. With
regard to different tension-free tapes, voiding lower urinary tract symptoms (LUTS) and reoperations were more common after SPARC, whereas
bladder perforations, pelvic haematoma and storage LUTS were less common after transobturator tapes. The poor quality of most of the studies,
in terms of both methodological and clinical parameters, limits the strengths of the recommendations derived by the meta-analysis.
Keywords
Stress urinary incontinence, Tension-free Vaginal Tape (TVT), TVT-O, Burch colposuspension, erosion
Disclosure: The author has no conflicts of interest to declare.
Received: 25 November 2008 Accepted: 13 February 2009
Correspondence: Giacomo Novara, Department of Oncological and Surgical Sciences, Urology Clinic, University of Padua, Monoblocco Ospedaliero, IV Floor, Via Giustiniani 2,
35128 Padua, Italy. E:
giacomonovara@unipd.it
Pelvic floor dysfunction is a major healthcare problem affecting supportive layer of endopelvic fascia and anterior vaginal wall
millions of women throughout the world. One in every nine attached to the arcus tendineus fascia pelvis and levator ani
American women will undergo surgery for a pelvic floor disorder in muscle, Delancey theorised that the transmission of intra-
her lifetime, with 30% of those women requiring additional surgical abdominal pressure to the bladder neck and proximal urethra
procedures for recurrence of the same condition.
1
Specifically, resulted in urethral compression against the rigid support of the
estimations from the US suggest that 135,000 women undergo pubocervical fascia and anterior vaginal wall, preventing
surgery for urinary incontinence and 200,000 for prolapse incontinence.
7
In the same period, Petros and Ulmsten introduced
annually.
2–4
Moreover, it is thought that the demand for pelvic floor the ‘integral’ theory of stress and urge urinary incontinence, where
disorder surgery will increase by 45% in the next 30 years due to the the main role was no longer attributed to the position of the
demographic distribution of the population in the developed world bladder neck but rather to the efficacy of the support of both
and the increasing prevalence of pelvic floor dysfunction with age.
5
pubourethral ligament and anterior vaginal wall to the mid-urethra.
The laxity of the vaginal wall was supposed to cause stress urinary
To date, the pathophysiological bases of stress urinary incontinence incontinence because of a dissipation of urethral closure pressures
have not been completely understood and several hypotheses have due to the lack of compression of the urethra by the anterior
been suggested, along with several surgical treatments. The theory pubococcygeus muscle and anterior vaginal wall, as well as the
of the transmission of abdominal pressure to the urethra, proposed reduced closure of the bladder neck by the underlying vaginal wall
by Enhorning in 1961 and subsequently enhanced by McGuire’s and the pelvic floor musculature.
8
Integral theory has been the
studies on intrinsic sphincter deficiency, formed the basis for theoretical basis of the so-called tension-free mid-urethral slings,
retropubic suspensions (i.e. Marshall–Marchetti–Krantz vesico- aimed at enhancing the supporting role of pubourethral ligaments.
urethral suspension and Burch colposuspenison), which were the
most commonly performed surgical procedures for stress urinary Surgical Treatment of
incontinence for decades.
6
In the early 1990s a significant change Stress Urinary Incontinence
was proposed by Delancey, who suggested the ‘hammock’ theory. Since the first reports from the Ulmsten group,
9
Tension-free Vaginal
Following cadaveric studies showing the urethra as resting on a Tape (TVT
®
, Gynecare), the first polypropylene mid-urethral sling
78 © TOUCH BRIEFINGS 2009
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