Open retropubic colposuspension for urinary incontinence in women

Conservative interventions for treating urinary incontinence in women: an Overview of Cochrane systematic reviews

BACKGROUND

Urinary incontinence (UI) is the involuntary loss of urine and can be caused by several different conditions. The common types of UI are stress (SUI), urgency (UUI) and mixed (MUI). A wide range of interventions can be delivered to reduce the symptoms of UI in women. Conservative interventions are generally recommended as the first line of treatment.

OBJECTIVES

To summarise Cochrane Reviews that assessed the effects of conservative interventions for treating UI in women.

METHODS

We searched the Cochrane Library to January 2021 (CDSR; 2021, Issue 1) and included any Cochrane Review that included studies with women aged 18 years or older with a clinical diagnosis of SUI, UUI or MUI, and investigating a conservative intervention aimed at improving or curing UI. We included reviews that compared a conservative intervention with 'control' (which included placebo, no treatment or usual care), another conservative intervention or another active, but non-conservative, intervention. A stakeholder group informed the selection and synthesis of evidence. Two overview authors independently applied the inclusion criteria, extracted data and judged review quality, resolving disagreements through discussion. Primary outcomes of interest were patient-reported cure or improvement and condition-specific quality of life. We judged the risk of bias in included reviews using the ROBIS tool. We judged the certainty of evidence within the reviews based on the GRADE approach. Evidence relating to SUI, UUI or all types of UI combined (AUI) were synthesised separately. The AUI group included evidence relating to participants with MUI, as well as from studies that combined women with different diagnoses (i.e. SUI, UUI and MUI) and studies in which the type of UI was unclear.

MAIN RESULTS

We included 29 relevant Cochrane Reviews. Seven focused on physical therapies; five on education, behavioural and lifestyle advice; one on mechanical devices; one on acupuncture and one on yoga. Fourteen focused on non-conservative interventions but had a comparison with a conservative intervention. No reviews synthesised evidence relating to psychological therapies. There were 112 unique trials (including 8975 women) that had primary outcome data included in at least one analysis. Stress urinary incontinence (14 reviews) Conservative intervention versus control: there was moderate or high certainty evidence that pelvic floor muscle training (PFMT), PFMT plus biofeedback and cones were more beneficial than control for curing or improving UI. PFMT and intravaginal devices improved quality of life compared to control. One conservative intervention versus another conservative intervention: for cure and improvement of UI, there was moderate or high certainty evidence that: continence pessary plus PFMT was more beneficial than continence pessary alone; PFMT plus educational intervention was more beneficial than cones; more-intensive PFMT was more beneficial than less-intensive PFMT; and PFMT plus an adherence strategy was more beneficial than PFMT alone. There was no moderate or high certainty evidence for quality of life. Urgency urinary incontinence (five reviews) Conservative intervention versus control: there was moderate to high-certainty evidence demonstrating that PFMT plus feedback, PFMT plus biofeedback, electrical stimulation and bladder training were more beneficial than control for curing or improving UI. Women using electrical stimulation plus PFMT had higher quality of life than women in the control group. One conservative intervention versus another conservative intervention: for cure or improvement, there was moderate certainty evidence that electrical stimulation was more effective than laseropuncture. There was high or moderate certainty evidence that PFMT resulted in higher quality of life than electrical stimulation and electrical stimulation plus PFMT resulted in better cure or improvement and higher quality of life than PFMT alone. All types of urinary incontinence (13 reviews) Conservative intervention versus control: there was moderate to high certainty evidence of better cure or improvement with PFMT, electrical stimulation, weight loss and cones compared to control. There was moderate certainty evidence of improved quality of life with PFMT compared to control. One conservative intervention versus another conservative intervention: there was moderate or high certainty evidence of better cure or improvement for PFMT with bladder training than bladder training alone. Likewise, PFMT with more individual health professional supervision was more effective than less contact/supervision and more-intensive PFMT was more beneficial than less-intensive PFMT. There was moderate certainty evidence that PFMT plus bladder training resulted in higher quality of life than bladder training alone.

AUTHORS' CONCLUSIONS

There is high certainty that PFMT is more beneficial than control for all types of UI for outcomes of cure or improvement and quality of life. We are moderately certain that, if PFMT is more intense, more frequent, with individual supervision, with/without combined with behavioural interventions with/without an adherence strategy, effectiveness is improved. We are highly certain that, for cure or improvement, cones are more beneficial than control (but not PFMT) for women with SUI, electrical stimulation is beneficial for women with UUI, and weight loss results in more cure and improvement than control for women with AUI. Most evidence within the included Cochrane Reviews is of low certainty. It is important that future new and updated Cochrane Reviews develop questions that are more clinically useful, avoid multiple overlapping reviews and consult women with UI to further identify outcomes of importance.

Stress urinary incontinence in females. Diagnosis and treatment modalities – past, present and the future

Introduction:

Stress urinary incontinence (SUI) can be defined as involuntary and unintentional loss of urine through the urethra when vesical pressure exceeds the urethral sphincter pressure during instances of coughing, sneezing or physical exercise. Stress urinary incontinence is the most common form of incontinence in females with an estimated prevalence of 4.5–53% in adult women with urinary incontinence. Yet despite its distressing nature and a negative impact on quality of life, very few women present with their symptoms to a urologist.

Materials and methods:

A literature search of the MEDLINE, Cochrane Library, Embase, NLH, ClinicalTrials.gov and Google Scholar databases was done up to November 2020, using terms related to SUI, medical therapy, surgical therapy and treatment options. The search terms included female stress urinary incontinence, mid-urethral sling, tension-free vaginal tape and trans obturator tape. The search included original articles, reviews and meta-analyses.

Conclusion:

Current guidelines for the management of stress urinary incontinence propose a step-ladder pattern, based on treatment invasiveness starting from conservative therapies, then drugs followed by minimally invasive procedures and culminating in invasive surgeries. The surgical approach is to be considered only after conservative therapies fail. The recent advances in the treatment of stress urinary incontinence have brought to light newer modalities and newer technologies that can be utilized which include laser therapy, stem cell therapy, intravesical balloon and others that show a lot of promise. This paper provides an in-depth analysis and reviews the literature on the current modalities and the future prospects of female stress urinary incontinence.

Level of evidence:

Not applicable for this review article.

In-vitro cellular and in-vivo investigation of ascorbic acid and β-glycerophosphate loaded gelatin/sodium alginate injectable hydrogels for urinary incontinence treatment

Urinary incontinence is one of the most common disorders especially in adult women. In this study, cellular and in-vivo analyses were performed on (3-glycidyloxypropyl) trimethoxysilane (GPTMS) and CaCl2 cross-linked alginate and gelatin hydrogels containing β-glycerophosphate and ascorbic acid to evaluate the regenerative potential as injectable compression agents for the treatment of urinary incontinence. The hydrogels were prepared with different percentages of components and were named as GA1 (7.2% w/v gelatin, 6% w/v sodium alginate, 0.5:1w/w GPTMS, CaCl2 1% (wt) sodium alginate, 50 μg/mL ascorbic acid, 1.5 mg/mL β-glycerophosphate), GA2 (10% w/v gelatin, 8.5% w/v sodium alginate, 0.5:1 w/w GPTMS, CaCl2 1% (wt) sodium alginate, 50 μg/mL ascorbic acid, 1.5 mg/mL β-glycerophosphate), and GA3 (10% (w/v) gelatin, 8.5% w/v sodium alginate, 1:1 w/w GPTMS, CaCl2 1% (wt) sodium alginate, 50 μg/mL ascorbic acid, 1.5 mg/mL β-glycerophosphate) hydrogels. The results of cell studies showed that although all three samples supported cell adhesion and survival, the cellular behavior of the GA2 sample was better than the other samples. Animal tests were performed on the optimal GA2 sample, which showed that this hydrogel repaired the misfunction tissue in a rat model within 4 weeks and the molecular layer thickness was reached the normal tissue after this duration. It seems that these hydrogels, especially GA2 sample containing 10% (w/v) gelatin, 8.5% (w/v) sodium alginate, 0.5:1 (w/w) GPTMS, CaCl2 1% (wt) sodium alginate, 50 μg/mL ascorbic acid, and 1.5 mg/mL β-glycerophosphate, can act as an injetable hydrogel for urinary incontinence treatment without the need for repeating the injection.

Second-Line Surgical Management After Midurethral Sling Failure

Currently, the midurethral sling (MUS) is widely used as a standard treatment in patients with stress urinary incontinence (SUI). Several studies have reported the failure rate of MUS to be approximately 5%–20%. In general, sling failure can be defined as persistent SUI after surgery or a temporary improvement in incontinence followed by recurrence. Failure is also often considered to include cases requiring secondary surgery due to mesh exposure, postoperative voiding difficulty, de novo urgency/urge incontinence, and severe postoperative pain. Because of the lack of large-scale, high-quality research on this topic, no clear guidelines exist for second-line management. To date, transurethral bulking agent injections, tape shortening, repeat MUS, pubovaginal sling (PVS) using autologous fascia, and Burch colposuspension are available options for second-line surgery. Repeat MUS is the most widely used second-line surgical method at present. Bulking agent injections have lower durability and efficacy than other treatments. Tape shortening demonstrates a relatively low success rate, but comparable outcomes if the period from first treatment to relapse is short. In patients with intrinsic sphincter deficiency, PVS and retropubic (RP) MUS can be considered first as second-line management because of their higher success rate than other treatments. When revision or reoperation is required due to prior mesh-related complications, PVS or colposuspension, which is performed without a synthetic mesh, is appropriate for second-line surgery. For patients with detrusor underactivity, a readjustable sling can be a better option because of the high risk of postoperative voiding dysfunction in PVS or RP slings.

Single-Incision Mini-Sling for the Treatment of Female Stress Urinary Incontinence: Is it Actually Inferior to Transobturator Vaginal Tape and Tension-Free Vaginal Tape?

Objectives:

The aim of the study was to report the extended long-term results of the use of single-incision mini-sling (SIMS), tension-free vaginal tape (TVT), and transobturator tape (TOT) for the treatment of female stress urinary incontinence (SUI) at the Department of Gynecology and Obstetrics of the University Medical Center Ljubljana.

Materials and Methods:

Enrolled women were evaluated by Patient Global Impression of Severity (PGI-S), Patient Global Impression of Improvement (PGI-I), Sandvik severity scale, Urogenital Distress Inventory (UDI-6), Incontinence Impact Questionnaire (IIQ-7), and Incontinence Questionnaire-Urinary Incontinence (ICIQ-UI) Short Form and data about diagnosis, procedures, complications, reoperations, postoperative results, and satisfaction with procedure were recorded.

Results:

In analyzed group of patients (n = 357), 116 (32%) underwent SIMS procedure, 189 (53%) TOT, and 52 (15%) TVT. The SIMS, TOT, and TVT groups did not differ significantly from each other in PGI-S, PGI-I, Sandvik severity scale, UDI-6, IIQ-7, and ICIQ-UI Short Form or in postoperative complication rate. Repeat surgery was needed in 9.5% after SIMS, in 13.2% of TOT patients and in 23.1% of TVT patients (P = 0.194). Urinary retention occurred in 9.5% of the SIMS patients, in 9.5% of the TOT patients, and in 13.5% of the TVT patients (P = 0.682). Mesh erosion/inflammation occurred in 3.4% of the SIMS patients, in 6.3% of the TOT patients, and in 3.8% of the TVT patients (P = 0.485).

Conclusion:

The efficacy and safety of SIMS, TOT, and TVT in the surgical treatment of SUI are comparable. The choice of the technique should be based on the relative pros and cons of techniques and the surgeon's experience.

Surgical treatments for women with stress urinary incontinence: the ESTER systematic review and economic evaluation

BACKGROUND

Urinary incontinence in women is a distressing condition that restricts quality of life and results in a large economic burden to both the NHS and women themselves.

OBJECTIVE

To evaluate the clinical effectiveness, safety and cost-effectiveness of surgical treatment for stress urinary incontinence (SUI) in women and explore women's preferences.

DESIGN

An evidence synthesis, a discrete choice experiment (DCE) and an economic decision model, with a value-of-information (VOI) analysis. Nine surgical interventions were compared. Previous Cochrane reviews for each were identified and updated to include additional studies. Systematic review methods were applied. The outcomes of interest were 'cure' and 'improvement'. Both a pairwise and a network meta-analysis (NMA) were conducted for all available surgical comparisons. A DCE was undertaken to assess the preferences of women for treatment outcomes. An economic model assessed the cost-effectiveness of alternative surgeries and a VOI analysis was undertaken.

RESULTS

Data from 175 studies were included in the effectiveness review. The majority of included studies were rated as being at high or unclear risk of bias across all risk-of-bias domains. The NMA, which included 120 studies that reported data on 'cure' or 'improvement', showed that retropubic mid-urethral sling (MUS), transobturator MUS, traditional sling and open colposuspension were more effective than other surgical procedures for both primary outcomes. The results for other interventions were variable. In general, rate of tape and mesh exposure was higher after transobturator MUS than after retropubic MUS or single-incision sling, whereas the rate of tape or mesh erosion/extrusion was similar between transobturator MUS and retropubic MUS. The results of the DCE, in which 789 women completed an anonymous online questionnaire, indicate that women tend to prefer surgical treatments associated with no pain or mild chronic pain and shorter length of hospital stay as well as those treatments that have a smaller risk for urinary symptoms to reoccur after surgery. The cost-effectiveness results suggest that, over a lifetime, retropubic MUS is, on average, the least costly and most effective surgery. However, the high level of uncertainty makes robust estimates difficult to ascertain. The VOI analysis highlighted that further research around the incidence rates of complications would be of most value.

LIMITATIONS

Overall, the quality of the clinical evidence was low, with limited data available for the assessment of complications. Furthermore, there is a lack of robust evidence and significant uncertainty around some parameters in the economic modelling.

CONCLUSIONS

To our knowledge, this is the most comprehensive assessment of published evidence for the treatment of SUI. There is some evidence that retropubic MUS, transobturator MUS and traditional sling are effective in the short to medium term and that retropubic MUS is cost-effective in the medium to long term. The VOI analysis highlights the value of further research to reduce the uncertainty around the incidence rates of complications. There is a need to obtain robust clinical data in future work, particularly around long-term complication rates.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42016049339.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Surgical interventions for women with stress urinary incontinence: systematic review and network meta-analysis of randomised controlled trials

OBJECTIVES

To compare the effectiveness and safety of surgical interventions for women with stress urinary incontinence.

DESIGN

Systematic review and network meta-analysis.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Randomised controlled trials evaluating surgical interventions for the treatment of stress urinary incontinence in women.

METHODS

Identification of relevant randomised controlled trials from Cochrane reviews and the Cochrane Incontinence Specialised Register (searched May 2017), which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), Medline, Medline In-Process, Medline Epub Ahead of Print, CINAHL, ClinicalTrials.gov, and WHO ICTRP. The reference lists of relevant articles were also searched. Primary outcomes were "cure" and "improvement" at 12 months, analysed by means of network meta-analyses, with results presented as the surface under the cumulative ranking curve (SUCRA). Adverse events were analysed using pairwise meta-analyses. Risk of bias was assessed using the Cochrane risk of bias tool. The quality of evidence for network meta-analysis was assessed using the GRADE approach.

RESULTS

175 randomised controlled trials assessing a total of 21 598 women were included. Most studies had high or unclear risk across all risk of bias domains. Network meta-analyses were based on data from 105 trials that reported cure and 120 trials that reported improvement of incontinence symptoms. Results showed that the interventions with highest cure rates were traditional sling, retropubic midurethral sling (MUS), open colposuspension, and transobturator MUS, with rankings of 89.4%, 89.1%, 76.7%, and 64.1%, respectively. Compared with retropubic MUS, the odds ratio of cure for traditional sling was 1.06 (95% credible interval 0.62 to 1.85), for open colposuspension was 0.85 (0.54 to 1.33), and for transobtrurator MUS was 0.74 (0.59 to 0.92). Women were also more likely to experience an improvement in their incontinence symptoms after receiving retropubic MUS or transobturator MUS compared with other surgical procedures. In particular, compared with retropubic MUS, the odds ratio of improvement for transobturator MUS was 0.76 (95% credible interval 0.59 to 0.98), for traditional sling was 0.69 (0.39 to 1.26), and for open colposuspension was 0.65 (0.41 to 1.02). Quality of evidence was moderate for retropubic MUS versus transobturator MUS and low or very low for retropubic MUS versus the other two interventions. Data on adverse events were available mainly for mesh procedures, indicating a higher rate of repeat surgery and groin pain but a lower rate of suprapubic pain, vascular complications, bladder or urethral perforation, and voiding difficulties after transobturator MUS compared with retropubic MUS. Data on adverse events for non-MUS procedures were sparse and showed wide confidence intervals. Long term data were limited.

CONCLUSIONS

Retropubic MUS, transobturator MUS, traditional sling, and open colposuspension are more effective than other procedures for stress urinary incontinence in the short to medium term. Data on long term effectiveness and adverse events are, however, limited, especially around the comparative adverse events profiles of MUS and non-MUS procedures. A better understanding of complications after surgery for stress urinary incontinence is imperative.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016049339.

Contemporary diagnostics and treatment options for female stress urinary incontinence

Stress urinary incontinence is not a deadly disease, but for the large population of women suffering from it, it is a very important issue. Especially in the continuously aging population all over the world, there is more and more need for treatment of this serious medical condition. Treatment of female stress urinary incontinence exists already for ages. In the 20th century invasive treatments like Burch colposuspension and pubovaginal slings were the mainstay of surgical treatments. The introduction of the midurethral sling made the procedure less invasive and accessible for more caregivers. Luckily there are many options available and the field is developing quickly. In recent years many new medical devices have been developed, that increase the number of treatment options available and make it possible to find a suitable solution for the individual patient based on subjective and objective results and the chances of complications. This manuscript provides an introduction to the therapeutical options that are available nowadays for female stress urinary incontinence.

The Novel and Minimally Invasive Treatment Modalities for Female Pelvic Floor Muscle Dysfunction; Beyond the Traditional

Pelvic floor dysfunction is a clinical entity that is prevalent among female patients. Determining the exact underlying cause of pelvic floor dysfunction is difficult, and surgical intervention for this clinical entity may be challenging. Pelvic floor dysfunction can affect the quality of life of the patient by causing stress urinary incontinence, pelvic organ prolapse, or both. Well-defined surgical treatment options, minimally invasive approaches, and novel techniques for the treatment of pelvic floor dysfunction have been recently introduced. Here, we evaluated the management options available for patients with stress urinary incontinence and pelvic organ prolapse. We searched Medline and EMBASE databases for relevant articles by using the keywords “pelvic floor dysfunction,” “minimally invasive procedures,” “stress urinary incontinence,” “pelvic organ prolapse,” and “novel techniques”. Traditional treatment options for stress urinary incontinence and pelvic organ prolapse are beyond the scope of our review. Laparoscopic and robotic surgical treatments for pelvic floor dysfunction continue to evolve and develop. These minimally invasive techniques will soon replace open procedures. Alternative novel treatment modalities have also been developed from novel human-compatible materials and are emerging as successful treatments for stress urinary incontinence. The development of these various treatment options has implications for future surgical practice in the field of uro-gynecology.

[Not Available]

Zusammenfassung. Zusammenfassung: Eine Belastungsinkontinenz sollte immer zuerst konservativ behandelt werden. Schon eine Gewichtsreduktion, Hormonpräparate, Physiotherapie, Beckenbodentraining und/oder die Anwendung von Pessaren können zum Erfolg führen. Nach Ausschöpfen dieser Therapien werden heute Inkontinenzoperationen mit meist sehr guten Heilungschancen (ca. 80–90 %) angeboten. Der operative Goldstandard ist die suburethrale Schlingeneinlage. Die Pelvic-Floor-Sonografie liefert dazu sehr wichtige Hinweise zur Wahl der Operationstechnik und zur Behebung von Komplikationen. Ferner bildet die intra- oder paraurethrale Injektion von Bulking Agents eine vielversprechende, wenig invasive operative Alternative. In diesem Artikel werden Behandlungskonzepte, prä-, intra- und postoperative Untersuchungen, Wahl der Operationsmethode, operationstechnische Details für den Operationserfolg sowie Vorbeugung und Behandlung von Komplikationen diskutiert.

Adverse events after first, single, mesh and non-mesh surgical procedures for stress urinary incontinence and pelvic organ prolapse in Scotland, 1997-2016: a population-based cohort study

BACKGROUND

Concerns have been raised about the safety of surgery for stress urinary incontinence and pelvic organ prolapse using transvaginal mesh. We assessed adverse outcomes after first, single mesh procedures and comparable non-mesh procedures.

METHODS

We did a cohort study of women in Scotland aged 20 years or older undergoing a first, single incontinence procedure or prolapse procedure during 1997-98 to 2015-16 identified from a national hospital admission database. Primary outcomes were immediate postoperative complications and subsequent (within 5 years) readmissions for later postoperative complications, further incontinence surgery, or further prolapse surgery. Poisson regression models were used to compare outcomes after procedures carried out with and without mesh.

FINDINGS

Between April 1, 1997, and March 31, 2016, 16 660 women underwent a first, single incontinence procedure, 13 133 (79%) of which used mesh. Compared with non-mesh open surgery (colposuspension), mesh procedures had a lower risk of immediate complications (adjusted relative risk [aRR] 0·44 [95% CI 0·36-0·55]) and subsequent prolapse surgery (adjusted incidence rate ratio [aIRR] 0·30 [0·24-0·39]), and a similar risk of further incontinence surgery (0·90 [0·73-1·11]) and later complications (1·12 [0·98-1·27]); all ratios are for retropubic mesh. During the same time period, 18 986 women underwent a first, single prolapse procedure, 1279 (7%) of which used mesh. Compared with non-mesh repair, mesh repair of anterior compartment prolapse was associated with a similar risk of immediate complications (aRR 0·93 [95% CI 0·49-1·79]); an increased risk of further incontinence (aIRR 3·20 [2·06-4·96]) and prolapse surgery (1·69 [1·29-2·20]); and a substantially increased risk of later complications (3·15 [2·46-4·04]). Compared with non-mesh repair, mesh repair of posterior compartment prolapse was associated with a similarly increased risk of repeat prolapse surgery and later complications. No difference in any outcome was observed between vaginal and, separately, abdominal mesh repair of vaginal vault prolapse compared with vaginal non-mesh repair.

INTERPRETATION

Our results support the use of mesh procedures for incontinence, although further research on longer term outcomes would be beneficial. Mesh procedures for anterior and posterior compartment prolapse cannot be recommended for primary prolapse repair. Both vaginal and abdominal mesh procedures for vaginal vault prolapse repair are associated with similar effectiveness and complication rates to non-mesh vaginal repair. These results therefore do not clearly favour any particular vault repair procedure.

FUNDING

None.