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Surgical Treatment of Female Stress Urinary Incontinence
put on the market, has become one of the most commonly It should be noted that the meta-analyses did not take into account
performed procedures worldwide due to the ease of performance the peri-operative morbidity of the two procedures. Although
and high success rates; to date, several hundred thousand TVT extensive, accurate literature data are lacking, it is likely that a
procedures have been performed. Moreover, several devices have procedure such as TVT placement performed under local or loco-
been introduced onto the market to ensure that mid-urethral sling regional anaesthesia using the vaginal approach and on a one-day
procedures are now even less invasive, including the Suprapubic hospital basis can be considered less invasive than colposuspension.
Arc (SPARC™ Sling System [American Medical Systems UK Ltd,
Brentford, UK]) sling, the intra-vaginal (IVS) sling, transobturator Tension-free Mid-urethral Slings versus
slings, pre-pubic TVT and, more recently, the so-called mini-slings Pubovaginal Slings
(the TVT-Secur and Mini-Arc slings). The choice of the best surgical There is a large volume of published literature on pubovaginal
approach for each patient with stress urinary incontinence slings. The available literature included autologous materials such
depends on several issues, including the patient’s age, expectations as fascia lata or rectus fascia, allografts (fascia, dermis, dura) and
and co-morbidity, previous reconstructive procedures, symptom xenografts (porcine dermis, bovine pericardium, dura). In the
severity, risk of intraoperative and post-operative complications, largest published series, the reported subjective and objective cure
recovery time and long-term success rate. Although the choice of
approach should be based on what is best for the patient’s
individual variables according to the most consistent available Burch colposuspension is a time-
pieces of evidence, the experience of the surgeon and his or her
honoured procedure and is currently the
opinion can obviously steer patients towards a particular approach.
standard surgical procedure for female
Two recent meta-analyses of randomised controlled trials (RCTs)
stress urinary incontinence with the
comparing tension-free mid-urethral slings with other surgical
treatments for female patients with stress incontinence provided longest-term follow-up studies published.
solid evidence for the treatment of such patients.
10,11
Specifically,
the two meta-analyses were based on a systematic review of the
literature performed in January 2007 on Medline, Embase and Web rates range from 65 to 95%, although storage and voiding LUTS may
of Sciences using a complex search strategy using Mesh and free be highly prevalent sequelae.
12
Moreover, the procedure is
text protocol with 24 different keywords. The search identified 37 significantly more invasive that tension-free mid-urethral slings,
RCTs evaluating efficacy and 33 providing data on complications of especially in cases of autologous fascia harvesting.
the different procedures. Trials comparing tension-free tapes with
Burch colposuspension or pubovaginal slings were evaluated, as According to the data from the available meta-analyses of RCTs,
well as studies comparing retropubic tapes and retropubic to the continence rates after TVT and pubovaginal slings were similar
transobturator slings. (OR 0.82, 95% CI 0.42–1.59; p=0.55), even when considering only
the trials evaluating autologous slings (OR 1.03, 95% CI 0.42–2.55;
Tension-free Mid-urethral Sling versus p=0.94).
10
Surprisingly, the rates of voiding LUTS (OR 1.57, 95% CI,
Burch Colposuspension 0.54–4.61; p=0.77) and the need for clean intermittent
Burch colposuspension is a time-honoured procedure and is catheterisation (OR 1.79, 95% CI 0.50–6.40; p=0.91) turned out to be
currently the standard surgical procedure for female stress urinary similar for the two procedures.
11
incontinence with the longest-term follow-up studies published.
Although the reported long-term continence rates after Burch Comparisons of Retropubic Tension-free
colposuspension are usually fine, the prevalence rates of storage Mid-urethral Slings
and voiding lower urinary tract symptoms (LUTS) and pelvic organ Following the success of TVT, three further retropubic tension-free
prolapse after colposuspension are extremely high. Moreover, mid-urethral slings have been introduced: the SPARC sling, the IVS
although the procedure can be performed laparoscopically, sling and the I-Stop (CL Medical, Lyon, France). The SPARC sling
colposuspension is considerably more invasive than the tension- system is designed to be implanted topside-to-down, which may
free tapes. theoretically reduce the risk of retropubic haematoma. IVS is a sling
produced by Tyco that is designed to be implanted in the retropubic
With regard to efficacy, a meta-analysis of the available RCTs showed space downside-to-top, similar to the TVT. The main difference with
that TVT was followed by significantly higher continence rates than TVT is the texture of the polypropylene fibres constituting the mesh,
Burch colposuspension when considering success rates evaluated with IVS being multifilament and having a denser texture and
according to any definition of post-operative continence (odds ratio smaller pores (55–65mm), resulting in a more rigid mesh. Finally, the
[OR] 0.58, 95% confidence interval [CI] 0.42–0.79; p=0.0007), the I-Stop device is a macroporous (>75-micron pore size) non-elastic
presence of negative stress test (OR 0.38, 95% CI 0.25–0.57; monofilament polypropylene mesh that can be placed retropubically
p<0.0001) and negative pad test (OR 0.59, 95% CI 0.41–0.85; or through the transobturator route.
p=0.005).
10
TVT and Burch colposuspension were followed by similar
rates of complications, including pelvic haematoma, urinary tract With regard to the trials comparing TVT with IVS, our meta-analysis
infection, storage and voiding LUTS, although bladder perforation showed that TVT was more effective than IVS when evaluating the
was more common after TVT (OR 5.35, 95% CI 2.27–12.63; p=0.0001). success rates according to any definition of continence (OR 0.51,
However, the re-operation rate was significantly higher after Burch 95% CI 0.31–0.83; p=0.007) and presence of negative stress test (OR
colposuspension (OR 0.29, 95% CI 0.10–0.80; p=0.02).
11
0.47, 95% CI 0.28–0.82; p=0.007), whereas the subjective cure rates
EUROPEAN OBSTETRICS & GYNAECOLOGY 79
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