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Schimpf MO, Rahn DD, Wheeler TL, Patel M, White AB, Orejuela FJ, El-Nashar SA, Margulies RU, Gleason JL, Aschkenazi SO, Mamik MM, Ward RM, Balk EM, Sung VW. Sling surgery for stress urinary incontinence in women: a systematic review and metaanalysis. Am J Obstet Gynecol 2014; 211:71.e1-71.e27. [PMID: 24487005 DOI: 10.1016/j.ajog.2014.01.030] [Citation(s) in RCA: 157] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2013] [Revised: 11/22/2013] [Accepted: 01/21/2014] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Understanding the long-term comparative effectiveness of competing surgical repairs is essential as failures after primary interventions for stress urinary incontinence (SUI) may result in a third of women requiring repeat surgery. STUDY DESIGN We conducted a systematic review including English-language randomized controlled trials from 1990 through April 2013 with a minimum 12 months of follow-up comparing a sling procedure for SUI to another sling or Burch urethropexy. When at least 3 randomized controlled trials compared the same surgeries for the same outcome, we performed random effects model metaanalyses to estimate pooled odds ratios (ORs). RESULTS For midurethral slings (MUS) vs Burch, metaanalysis of objective cure showed no significant difference (OR, 1.18; 95% confidence interval [CI], 0.73-1.89). Therefore, we suggest either intervention; the decision should balance potential adverse events (AEs) and concomitant surgeries. For women considering pubovaginal sling vs Burch, the evidence favored slings for both subjective and objective cure. We recommend pubovaginal sling to maximize cure outcomes. For pubovaginal slings vs MUS, metaanalysis of subjective cure favored MUS (OR, 0.40; 95% CI, 0.18-0.85). Therefore, we recommend MUS. For obturator slings vs retropubic MUS, metaanalyses for both objective (OR, 1.16; 95% CI, 0.93-1.45) and subjective cure (OR, 1.17; 95% CI, 0.91-1.51) favored retropubic slings but were not significant. Metaanalysis of satisfaction outcomes favored obturator slings but was not significant (OR, 0.77; 95% CI, 0.52-1.13). AEs were variable between slings; metaanalysis showed overactive bladder symptoms were more common following retropubic slings (OR, 1.413; 95% CI, 1.01-1.98, P = .046). We recommend either retropubic or obturator slings for cure outcomes; the decision should balance AEs. For minislings vs full-length MUS, metaanalyses of objective (OR, 4.16; 95% CI, 2.15-8.05) and subjective (OR, 2.65; 95% CI, 1.36-5.17) cure both significantly favored full-length slings. Therefore, we recommend a full-length MUS. CONCLUSION Surgical procedures for SUI differ for success rates and complications, and both should be incorporated into surgical decision-making. Low- to high-quality evidence permitted mostly level-1 recommendations when guidelines were possible.
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Affiliation(s)
- Megan O Schimpf
- Division of Gynecology and Urogynecology, Department of Obstetrics and Gynecology, University of Michigan Medical School, Ann Arbor, MI.
| | - David D Rahn
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Thomas L Wheeler
- Department of Obstetrics and Gynecology, University of South Carolina School of Medicine Greenville, Greenville, SC
| | - Minita Patel
- Department of Obstetrics and Gynecology, Kaiser Permanente, Roseville, CA
| | - Amanda B White
- Department of Obstetrics and Gynecology, University of Texas Southwestern at Seton Healthcare Family, Austin, TX
| | - Francisco J Orejuela
- Department of Obstetrics and Gynecology and Reproductive Sciences, University of Texas Health Science Center at Houston, Houston, TX
| | - Sherif A El-Nashar
- Division of Gynecologic Surgery, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN
| | - Rebecca U Margulies
- Division of Urogynecology, Department of Obstetrics and Gynecology, Kaiser Permanente, Oakland, CA
| | - Jonathan L Gleason
- Division of Urogynecology, Department of Obstetrics and Gynecology, Carilion Clinic, Roanoke, VA
| | - Sarit O Aschkenazi
- Department of Urogynecology, ProHealth Care, Women's Center, Medical College of Wisconsin, Waukesha, WI
| | - Mamta M Mamik
- Icahn School of Medicine at Mount Sinai, Department of Obstetrics and Gynecology, New York, NY
| | - Renée M Ward
- Vanderbilt University Medical Center, Department of Obstetrics and Gynecology, Nashville, TN
| | - Ethan M Balk
- Tufts Medical Center, Institute for Clinical Research and Health Policy Studies, Boston, MA
| | - Vivian W Sung
- Division of Urogynecology and Reconstructive Pelvic Surgery, Department of Obstetrics and Gynecology, Women and Infants Hospital of Rhode Island and Warren Alpert Medical School of Brown University, Providence, RI
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Abstract
PURPOSE OF REVIEW The diagnosis of intrinsic sphincter deficiency became important about 20 years ago when it influenced the choice of operative procedure for women with stress urinary incontinence. However, it was ill-defined and diagnosed by a variety of techniques. The contemporary surgical treatment of urinary stress incontinence is by suburethral sling; so this review addresses three questions: is it still important to identify intrinsic sphincter deficiency prior to surgical intervention for stress incontinence? What techniques are available to do so? How robust are these measurements? RECENT FINDINGS There is some evidence that women with intrinsic sphincter deficiency have a poorer outcome if they are treated by a transobturator tape compared with a tension-free vaginal tape or a pubovaginal sling. Intrinsic sphincter deficiency continues to be mainly identified by low urethral closure pressures or low abdominal leak point pressures or both but the methodology is variable. There have been some attempts at using ultrasound to identify intrinsic sphincter deficiency but without any definite conclusions. SUMMARY Intrinsic sphincter deficiency is an imprecise diagnosis, which continues to be defined by a low pressure urethra. This can be measured in different ways but there is poor standardization of the tests to do so. Intrinsic sphincter deficiency appears to be clinically important but the full implications of this diagnosis will remain unknown until this imprecision is addressed.
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Stoffel JT, Smith G, Crivellaro S, Smith JJ, Bresette JF. Self-reported pad use per day reflects patient quality of life after pubovaginal sling surgery. Int Urogynecol J 2009; 20:1321-5. [DOI: 10.1007/s00192-009-0939-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2009] [Accepted: 06/04/2009] [Indexed: 11/30/2022]
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