Laparoscopic colposuspension for urinary incontinence in women

Laparoscopic Burch colposuspension after failed sub-urethral tape procedures: a retrospective audit

Our objective was to evaluate the outcome of laparoscopic Burch colposuspension in women with recurrent stress urinary incontinence after failed primary sub-urethral tape procedures. A total of 16 patients were identified, and their data from symptom-specific questionnaires, urodynamic studies and urogynaecological assessment were collected. At a median follow-up of 24.5 months, objective and subjective cure rates were 54.5% and 92.9%, respectively. Average satisfaction score regarding outcome after surgery was 9.3 on a rating scale from 0 to 10. All but one patient had symptoms of urge incontinence pre-operatively with 64.3% experiencing cure or improvement post-operatively. Voiding difficulties were observed in one patient, and post-operative urodynamics revealed a significant decrease in urinary flow rate (p < 0.05) but with no difference in urinary residuals or maximum urethral closure pressure. Severe peri-urethral fibrosis was identified in 62.5% of the patients. Laparoscopic Burch colposuspension is an effective and safe surgical option.

Periurethral injection therapy for urinary incontinence in women

BACKGROUND

Periurethral or transurethral injection of bulking agents is a surgical procedure most often used for the treatment of stress urinary incontinence a common, troublesome symptom amongst adult women.

OBJECTIVES

To assess the effects of periurethral/transurethral injection therapy in the treatment of urinary incontinence in women.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group Specialised Trials Register (28 February 2007), MEDLINE (January 1996 to March 2007, PREMEDLINE (7 February 2007) and the reference lists of relevant articles.

SELECTION CRITERIA

All randomised or quasi-randomised controlled trials of treatment for urinary incontinence, in which at least one management arm involved periurethral/transurethral injection therapy.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed methodological quality of each study using explicit criteria. Data extraction was undertaken independently using a standard form and clarification concerning possible unreported data sought directly from the investigators.

MAIN RESULTS

We identified twelve trials including 1318 women that met the inclusion criteria. The limited data available were not suitable for meta-analysis. Injection of autologous fat was compared to placebo in a study of 68 women which was terminated early because of safety concerns. No differences in subjective or objective outcome were found in the two groups. No studies were found comparing injection therapy with conservative treatment. Two studies that compared injection with surgical management found significantly better objective outcome in the surgical group. Eight studies compared different agents - all results had wide confidence intervals. Silicone particles, calcium hydroxylapatite, ethylene vinyl alcohol and carbon spheres gave improvements equivalent to collagen. Porcine dermal implant gave improvements comparable to silicone at six months. A comparison of periurethral and transurethral methods of delivery of the bulking agent found similar outcome but a higher rate of early complications in the periurethral group.

AUTHORS' CONCLUSIONS

Despite five additional trials, this updated review is still an unsatisfactory basis for practice. The trials were small and generally of moderate quality. The only evidence of benefit comes for within-group short-term changes following injection. The finding that placebo saline injection was followed by a similar symptomatic improvement questions the mechanism of any effects. There were no trials in comparison with pelvic floor muscle training -the obvious non-surgical comparator. Greater symptomatic improvement was observed after surgery, although these advantages need to be set against likely higher risks. No clear-cut conclusions could be drawn from trials comparing alternative agents; one small trial suggests that periurethral injection may carry more risks than transurethral injection. The single trial of autologous fat provides a reminder that periurethral injections can occasionally cause serious side-effects. Pending further evidence, injection therapy may represent a useful option for short-term symptomatic relief amongst selected women with co-morbidity that precludes anaesthesia - two or three injections are likely to be required to achieve a satisfactory result.

Psychological morbidity and female urinary incontinence

Female urinary incontinence is a common yet distressing condition. It affects women of all ages, but is especially common in the elderly. Its prevalence ranges from 15 to 55%, depending on age and population studied. Despite the ubiquity of female urinary incontinence, many incontinent women do not voice their suffering, and urinary incontinence has therefore been dubbed 'the silent epidemic'. The physical impact and social isolation associated with urinary incontinence lead to impairment of quality of life and psychological well-being. It is the aim of this review to discuss the epidemiology and psychological impact of urinary incontinence. The recognition and management of incontinence-related psychological morbidity are also explored.

Bladder neck needle suspension for urinary incontinence in women

BACKGROUND

Bladder neck needle suspension is an operation traditionally used for moderate or severe stress urinary incontinence in women. About a third of adult women experience some urinary incontinence, and about a third of them have moderate or severe symptoms.

OBJECTIVES

To determine the effects of needle suspension on stress or mixed urinary incontinence in comparison with other management options.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group trials register (searched 18 September 2003). The reference lists of relevant articles were also searched.

SELECTION CRITERIA

Randomised or quasi-randomised trials that included needle suspension for the treatment of urinary incontinence.

DATA COLLECTION AND ANALYSIS

Trials were assessed and data extracted independently by at least two reviewers. Two trial investigators provided additional information.

MAIN RESULTS

Nine trials were identified which included 347 women having six different types of needle suspension procedures and 437 who received comparison interventions. Needle suspensions were more likely to fail than open abdominal retropubic suspension (higher subjective failure rate after the first year (91/313, 29% failed versus 47/297, 16% failed after open abdominal retropubic suspension: the relative risk (RR) was 2.00 (95% confidence interval (CI) 1.47 to 2.72) although the difference in peri-operative complications was not significant (17/75, 23% versus 12/77, 16%; RR 1.44, 95% CI 0.73 to 2.83): there were no significant differences for other outcome measures. This effect was seen in both women with primary incontinence and women with recurrent incontinence after failed primary operations. Needle suspensions may be as effective as anterior vaginal repair (46/128, 36% failed after needles versus 50/129, 39% after anterior repair; RR 0.93, 95% CI 0.68 to 1.26) but there was little information about morbidity. Data for comparison with suburethral slings were inconclusive because they came from a small and atypical population. No trials compared needle suspensions with conservative management, peri-urethral injections, sham or laparoscopic surgery.

REVIEWERS' CONCLUSIONS

Bladder neck needle suspension surgery is probably not as good as open abdominal retropubic suspension for the treatment of primary and secondary urodynamic stress incontinence because the cure rates were lower in the trials reviewed. However, the reliability of the evidence was limited by poor quality and small trials. There was not enough information to comment on comparisons with suburethral sling operations. Although cure rates were similar after needle suspension compared with after anterior vaginal repair, the data were insufficient to be reliable and inadequate to compare morbidity.

Anterior vaginal repair for urinary incontinence in women

BACKGROUND

Anterior vaginal repair (anterior colporrhaphy) is an operation traditionally used for moderate or severe stress urinary incontinence in women. About a third of adult women experience urinary incontinence.

OBJECTIVES

To determine the effects of anterior vaginal repair (anterior colporrhaphy) on stress or mixed urinary incontinence in comparison with other management options.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group's trials register, and the reference lists of relevant articles. Date of most recent search: September 2000.

SELECTION CRITERIA

Randomised or quasi-randomised trials that included anterior vaginal repair for the treatment of urinary incontinence.

DATA COLLECTION AND ANALYSIS

Both reviewers independently extracted data and assessed trial quality. Two trial investigators were contacted for additional information.

MAIN RESULTS

Nine trials were identified which included 333 women having an anterior vaginal repair and 599 who received comparison interventions. A single small trial provided insufficient evidence to assess anterior vaginal repair in comparison with physical therapy. The performance of anterior repair in comparison with needle suspension appeared similar but clinically important differences could not be confidently ruled out. No trials compared anterior repair with suburethral sling operations or laparoscopic retropubic suspensions, or compared alternative vaginal operations. Anterior vaginal repair was less effective than open abdominal retropubic suspension based on patient-reported cure rates in eight trials both in the short-term (failure rate within first year after anterior repair 82/279, 29% vs 50/346, 14%; RR 1.89, 95% CI 1.39 to 2.59) and long-term (after first year, 132/322, 41% vs 68/395, 17%; RR 2.50, 95% CI 1.92 to 3.26). There was evidence from three of these trials that this was reflected in more repeat operations for incontinence (25/107, 23% vs 4/164, 2%; RR 8.87, 95% CI 3.28 to 23.94). These findings held irrespective of the co-existence of prolapse (pelvic relaxation). Later prolapse operation appeared to be equally common after vaginal (3%) or abdominal (4%) operation. In respect of the type of open abdominal retropubic suspension, most data related to comparisons of anterior vaginal repair with Burch colposuspension. The few data describing comparison of anterior repair with the Marshall-Marchetti-Krantz procedure were consistent with those for Burch colposuspension.

REVIEWER'S CONCLUSIONS

There were not enough data to allow comparison of anterior vaginal repair with physical therapy or needle suspension for primary urinary stress incontinence in women. Open abdominal retropubic suspension appeared to be better than anterior vaginal repair judged on subjective cure rates in six trials, even in women who had prolapse in addition to stress incontinence (four trials). The need for repeat incontinence surgery was also less after the abdominal operation. However, there was not enough information about post-operative complications and morbidity.