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Urogynaecology
were similar between the two procedures (OR 0.63, 95% CI reported more commonly after placement of retropubic tapes, as
0.37–1.09; p=0.10).10 Similarly, the figures regarding complication well as storage LUTS (OR 1.81, 95% CI 1.13–2.91; p=0.01), although
rates were overlapping in all the evaluable comparisons.
11
these figures were not re-confirmed in all the sensitivity analyses.
In contrast, the rates of vaginal erosions, urinary tract infections
With regard to the trials comparing TVT with SPARC, our meta- and re-operation were similar with the two approaches.
11
analyses demonstrated that TVT was followed by significantly
higher subjective (OR 0.56, 95% CI 0.35–0.92; p=0.02) and objective Conclusions
continence rates (OR 0.53, 95% CI 0.34–0.82; p=0.005).
10
However, Tension-free mid-urethral slings are the first surgical option in many
the results of the meta-analysis were significantly affected by a urological and gynaecological centres for most female patients with
single trial reported by Lord et al.,
13
which enrolled about 50% of the stress urinary incontinence. The currently available data suggest that
analysed patients and evaluated them only at two-month follow-up. retropubic and transobturator tapes are effective and safe
Excluding this study from the analysis, the two procedures turned procedures, with a small advantage for transobturator tape due to the
out to have similar results.
10
With regard to complications, voiding lower rates of bladder perforations and pelvic haematoma. However,
LUTS (OR 0.61, 95% CI 0.40–0.93; p=0.02) and re-operations (OR most of the currently available RCTs are methodologically low-quality
0.30, 95% CI 0.10–0.94; p=0.04) were significantly less common and were underpowered to detect statistically significant differences
after TVT, although in sensitivity analyses excluding the Lord’s study in many important outcomes. Moreover, clinically speaking only a few
from the analysis overlapping figures for all of the assessable studies used validated questionnaires to assess the symptoms of
complications were shown.
11
To date, no RCTl has compared urinary incontinence and their effect on quality of life, and the mean
TVT with I-Stop. follow-up of many studies was not enough to assess the long-term
success and complications of the evaluated surgical procedures for
Comparisons of Retropubic and stress urinary incontinence. Some interesting issues such as the
Transobturator Tension-free co-morbidities of patients, learning curve, timing of complications,
Mid-urethral Slings presence of complication-related symptoms and treatment of
The transobturator route for the placement of a tension-free mid- complications were not evaluable with the currently available data.
urethral sling was proposed in 2001 by Delorme with the purpose of
reducing the risk of visceral and vascular injuries that might occur in Consequently, according to the recommendations for the clinical
the TVT placement during the retropubic passage of the needles.
14
research provided by the 3rd International Consultation on
Specifically, Delorme described the outside-to-in approach, while De Incontinence,
16
further high-quality RCTs are needed using standardised
Leval reported the inside-to-out technique in 2003.
15
criteria to evaluate continence, success and complication rates after
surgery at longer follow-up. ■
To date, several transobturator tapes are on the market, including
Aris (Coloplast), the I-Stop (Uroplasty), In-Fast (AMS), Monarc (AMS),
Giacomo Novara is an Assistant Professor in the
PelviLace (Bard), Safyre (Promedon), TVT-O (Gynecare) and Uratape
Urology Clinic in the Department of Oncological and
(Mentor-Porges), and several RCTs have been published evaluating Surgical Sciences at the University of Padua. He is a
transobturator tapes (mainly TVTO, Uratape, Monarc and I-stop)
Fellow of the European Board of Urology. His major
fields of interest are urological oncology (with special
compared with the retropubic TVT.
regard to robotic surgery and outcome research in
kidney cancer, transitional cell carcinoma of the
In our meta-analysis, objective, subjective and overall cure rates
bladder and upper urinary tract and squamous cell
carcinoma of the penis), functional urology and
were similar after retropubic or transobturator placement of a
female urology. He is a member of various academic societies and national
tension-free sling.
10
As expected, evaluating the complication rates, committees, a member of the Editorial Board of European Urology and a reviewer
bladder perforations (OR 2.33, 95% CI 1.26–4.32; p=0.007) and
for several urological journals.
pelvic haematoma (OR 4.83, 95% CI 1.22–19.15; p=0.03) were
1. Olsen AL, Smith VJ, Bergstrom JO, et al., Epidemiology of hypothesis, Am J Obstet Gynecol, 1994;170:1713–23. for urinary incontinence in women. In: Abrams P,
surgically managed pelvic organ prolapse and urinary 8. Petros PE, Ulmsten UI, An integral theory of female Cardozo L, Khoury S, Wein A (eds), Incontinence,3rd
incontinence, Obstet Gynecol, 1997;89:501–6. urinary incontinence. Experimental and clinical International Consultation on Incontinence, Plymouth:
2. Waetjen LE, Subak LL, Shen H, et al., Stress urinary considerations, Acta Obstet Gynecol Scand, 1990;153:7–31. Health Publication Ltd, 2005;1297–1370.
incontinence surgery in the Us, Obstet Gynecol, 2003;101: 9. Ulmsten U, Henriksson L, Johnson P, Varhos G, An 13. Lord HE, Taylor JD, Finn JC, et al., A randomized
671–6. ambulatory surgical procedure under local anesthesia controller equivalence trial of short-term complications
3. Boyles SH, Weber AM, Meyn L, Procedures for pelvic for treatment of female urinary incontinence, Int and efficacy of tension-free vaginal tape and suprapubic
organ prolapse in the United States, 1979–1997, Am J Urogynecol J, 1996;7:81–6. uretra support sling for treating stress incontinence, BJU
Obstet Gynecol, 2003;188:108–15. 10. Novara G, Ficarra V, Boscolo-Berto R, et al., Tension-free Int, 2006;98:367–76.
4. Brown JS, Waetjen LE, Subak LL, et al., Pelvic organ midurethral slings in the treatment of female stress 14. Delorme E, La bandelette transobturatrice: un procédé
prolapse surgery in the United States, 1997, Am J Obstet urinary incontinence: a systematic review and meta- mini-invasif pour traiter l’incontinence urinaire de la
Gynecol, 2002;186:712–16. analysis of randomized controlled trials of effectiveness, femme, Prog Urol, 2001;11:1306–13.
5. Luber KM, Boero S, Choe JY, The demographics of pelvic Eur Urol, 2007;52:663–79. 15. de Leval J, Novel surgical technique for the treatment of
floor disorders: current observations and future 11. Novara G, Galfano A, Boscolo-Berto R, et al., female stress urinary incontinence: transobturator
projections, Am J Obstet Gynecol, 2001;184:1496–1503. Complication rates of tension-free midurethral slings in vaginal tape inside-out, Eur Urol, 2003;44:724–30.
6. Daneshgari F, Moore C, Advancing the understanding of the treatment of female stress urinary incontinence: a 16. Abrams P, Andersson KE, Brubaker L, et al.,
pathophysiological rationale for the treatment of stress systematic review and meta-analysis of randomized Recommendations for clinical research. In: Abrams P,
urinary incontinence in women: the ‘trampoline theory’, controlled trials comparing tension-free midurethral Cardozo L, Khoury S, Wein A (eds), Incontinence,3rd
BJU Int, 2006;98(Suppl. 1):8–14. tapes to other surgical procedures and different International Consultation on Incontinence, Plymouth:
7. DeLancey JO, Structural support of the urethra as it devices, Eur Urol, 2008;53:288–309. Health Publication Ltd, 2005;1624–6.
relates to stress urinary incontinence: the hammock 12. Smith ARB, Daneshgari F, Dmochowski R, et al., Surgery
80 EUROPEAN OBSTETRICS & GYNAECOLOGY
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