TVT versus laparoscopic mesh colposuspension: 5-year follow-up results of a randomized clinical trial

Long-term outcomes of surgical interventions for stress urinary incontinence: a systematic review and network meta-analysis

BACKGROUND

Stress urinary incontinence is common among women, and surgical interventions have significantly improved patients' symptoms. The long-term effectiveness of these surgeries is increasingly drawing attention, yet it remains sparsely documented in the literature.

OBJECTIVE

To compare the long-term effectiveness and safety of retropubic tension-free vaginal tape (TVT-RP), tension-free vaginal tape-obturator (TVT-O), transobturator tape (TOT), single-incision sling (SIS), Burch colposuspension, and pubovaginal sling (PVS).

METHODS

A comprehensive and systematic literature review was conducted in PubMed, EMBASE, MEDLINE, Cochrane Library, Medicine, and clinicaltrials.gov from inception to May 2023. Selected trials were evaluated for potential bias using the Cochrane tool. Treatment modalities were compared using network meta-analysis to assess objective success rate, subjective success rate, and complications as outcomes.

RESULTS

A total of 37 studies involving 5720 patients were included. No significant statistical differences were found among the interventions regarding objective success rate. PVS had the highest surface under the cumulative ranking curve SUCRA value (93.1). For subjective success rate, TVT-RP, TVT-O, and PVS demonstrated superiority over SIS, with PVS having the highest SUCRA value (80.1). SIS had lower overall complication and pain rates compared to other methods, with statistical significance. There were no differences in reoperation rate, exposure rate, and urinary tract infection occurrence among the surgical approaches.

CONCLUSIONS

In terms of long-term effectiveness and safety, TVT-RP and TVT-O appear to be the preferred options for patients opting for synthetic slings, while for patients seeking nonsynthetic slings, PVS may represent the optimal choice.

Predictors of Surgical Failure of Open Burch Colposuspension Versus Retropubic Midurethral Sling for Stress Urinary Incontinence

OBJECTIVE

To identify and compare long-term predictors for 'surgical failures' in matched groups of Midurethral sling (MUS) and Burch colposuspension (BC).

METHODS

A secondary analysis of patients with urodynamic stress incontinence who were treated either by open BC or retropubic MUS. The study had a cohort of 1344 women with a ratio of 1:3 (BC: MUS). We defined surgical success or failure by combining Patient Reported Outcome Measures and the need for repeat surgery. Risk factors for failure identified by multivariate analysis.

RESULTS

Of the 1344 women included, 336 had BC, and 1008 had MUS. Patients were followed-up for 13.1 and 10.1 years, and the rate of failure was 22% and 20%, for BC and MUS, respectively (P = 0.35). Significant predictors for MUS failure were Body mass index (BMI) > 30, preoperative anticholinergic medication use, smoking, diabetes, and previous surgery for incontinence (Hazard ratio 3.6, 2.6, 2.5, 1.8, 2.3, respectively). BMI > 25, preoperative use of anticholinergic medication, age > 60, previous surgery for incontinence, and loss of follow-up>5 years (Hazard ratio: 3.2, 2.8, 2.6, 2.5, 2.1, respectively), were significant predictors of BC failure.

CONCLUSION

This study shows similar predictors for surgical failure for BC and MUS, with high BMI, mixed urinary incontinence, and previous continence procedures being the most important.

Clinical Guidelines for Female Lower Urinary Tract Symptoms (second edition)

The present article is an abridged English translation of the Japanese Clinical Guidelines for Female Lower Urinary Tract Symptoms (second edition), published in September 2019. These guidelines consist of a total of 212 pages and are unique worldwide in that they cover female lower urinary tract symptoms other than urinary incontinence. They contain two algorithms for "primary treatment" and "specialized treatment," respectively. These guidelines, consisting of six chapters, address a total of 26 clinical questions including: (i) treatment algorithms; (ii) what are female lower urinary tract symptoms?; (iii) epidemiology and quality of life; (iv) pathology and illness; (v) diagnosis; and (vi) treatment. When the patient's symptoms mainly involve voiding and post-micturition symptoms, specialized treatment should be considered. In the event of voiding symptoms concurrent with storage symptoms, residual urine should be measured; if the residual urine volume is <100 mL, then diagnosis and treatment for storage symptoms is prioritized, and if the volume is ≥100 mL, then specialized treatment should be considered. When storage symptoms are the primary condition, then the patient is subject to the primary treatment algorithm. Specialized treatment for refractory overactive bladder includes botulinum toxin injection and sacral nerve stimulation. For stress urinary incontinence, surgical treatment is indicated, such as urethral slings. The two causes of voiding symptoms and post-micturition symptoms are lower urinary tract obstruction and detrusor underactivity (underactive bladder). Mechanical lower urinary tract obstruction, such as pelvic organ prolapse, is expected to improve with surgery.

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.

Is There Outcome Reporting Heterogeneity in Trials That Aim to Assess the Effectiveness of Surgical Treatments for Stress Urinary Incontinence in Women?

CONTEXT

Inconsistent reporting of effectiveness outcomes in surgical trials of stress urinary incontinence (SUI) has hindered direct comparisons of various surgical treatments for SUI.

OBJECTIVE

To systematically review the verbatim outcome names, outcome definitions, and tools used to measure the outcomes in surgical trials of SUI in women.

EVIDENCE ACQUISITION

Trials of women with SUI who have undergone surgical interventions were included. We conducted a systematic review (SR) on outcomes reported in randomized controlled trials of surgical management published in 2014-2019, covering the following databases: MEDLINE, EMBASE, CENTRAL, and CDSR. Verbatim outcome names extracted from the included studies were categorized and then grouped into domains using the Williamson-Clarke (W/C) outcome taxonomy. A matrix was also created to visualize and quantify the dimensions of outcome reporting heterogeneity in SUI trials.

EVIDENCE SYNTHESIS

A total of 844 verbatim outcome names were extracted, of which, 514 varied terms were reduced to 71 standardized outcome names. They were further categorized into 11 domains from the W/C taxonomy. There were 7.24 different terms on average to describe each outcome, and the four outcomes with the most heterogeneity evident in terms used to describe them were "urinary retention", "reoperation", "subjective cure rate" and "quality of life". Each of them had ≥20 different terms. Only 28% of the outcome definitions were reported and a variety of measuring tools was noted, particularly in subjective outcomes. High heterogeneity was found in the outcome names, outcome definitions, choice and number of measuring instruments of the outcomes, and choice and number of outcomes reported across studies.

CONCLUSIONS

This SR provides objective evidence of heterogeneity in outcome reporting in SUI surgical trials. Our categorization of outcomes highlights the difficulties in summarizing the current evidence base. A core outcome set, developed using the methods advocated by the Core Outcome Measures in Effectiveness Trials (COMET) and COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) initiatives, is required.

PATIENT SUMMARY

In this research, we have highlighted the diversity in outcomes reporting in stress urinary incontinence (SUI) surgical trials and have categorized the outcomes. We support the development of a core outcome set for SUI, which will promote future clinical researchers to measure the same outcome in the same way in all trials. This will, in turn, help researchers summarize the evidence more effectively and aid decision making for patients and doctors.

Management of mid-urethral tape complications: a retrospective study

Background/purpose of the study

Following mid-urethral tape insertion, for stress urinary incontinence (SUI), a proportion of women experience complications such as voiding dysfunction or tape erosion which fail to respond to conservative management approaches. These women thus require further surgical treatment. Our objective was to describe the outcomes of the surgical management of complications in these women.

Methods

This retrospective study describes the results obtained following the surgical management of mid-urethral tape complications. Twenty-nine consecutive women who required mid-urethral tape lysis, loosening or excision for tape-related complications in the period 2007-2017 were included. Primary outcomes were improvement in voiding dysfunction and resolution of pain, while secondary outcomes were evaluation of the recurrence of stress urinary incontinence and patient satisfaction. Patient outcomes were measured using the Patient Global Impression of Improvement questionnaire.

Results

There were 1459 mid-urethral tape procedures performed in the study period. Twenty-nine women (1.99%) who had revision surgery for tape complication were identified. Interventions included tape loosening or lysis in 19 women and tape excision in ten women. Twenty-three of the 29 patients reported a significant improvement in their symptoms postoperatively. Two women had a recurrence of SUI in the tape excision cohort; all patients following tape loosening or lysis remained continent.

Conclusions

Tape revision surgery is a safe and effective treatment for mid-urethral tape complications with the majority of women maintaining continence following revision. Early intervention and proactive management of complications, by the appropriate specialist, will improve outcomes.

Do we need better information to advise women with stress incontinence on their choice of surgery? Report from the ICI-RS 2018

AIMS

The regulatory warnings about the safety of the synthetic midurethral slings (MUS) had a significant effect on how patients and physicians approach surgical management of stress urinary incontinence (SUI). In this changing landscape, the purpose of this research Think Tank (TT) was to provide an update of the current knowledge about the safety and efficacy of SUI surgery, to review patient goals and expectations and to identify factors affecting the decision making for surgery.

METHODS

This is a consensus report of the proceedings of TT3: "Do we need better information to advise women with stress incontinence on their choice of surgery?" from the annual International Consultation on Incontinence-Research Society (ICI-RS), June 2018.

RESULTS

Despite the body of evidence supporting the continued use of MUS, the short follow-up of most of the studies and the lack of "real life" data regarding pain and sexual dysfunction make the development of recommendations challenging. Women with SUI are often happy to "trade" efficacy for a procedure with less associated morbidity and therefore it is not always the procedure with the highest success rate that is ultimately chosen. However, a number of factors influence treatment decision and there is limited evidence about what level of all these factors women are willing to tolerate for a given success rate, or how much success they are willing to trade for a lower complication rate.

CONCLUSIONS

The ICI-RS proposed research questions which may be able to assist in improving the counseling and management of women with SUI.

Laparoscopic colposuspension for urinary incontinence in women

BACKGROUND

Laparoscopic colposuspension was one of the first minimal access operations for treating stress urinary incontinence in women, with the presumed advantages of shorter hospital stays and quicker return to normal activities. This Cochrane Review was last updated in 2010.

OBJECTIVES

To assess the effects of laparoscopic colposuspension for urinary incontinence in women; and summarise the principal findings of relevant economic evaluations of these interventions.

SEARCH METHODS

We searched the Cochrane Incontinence Specialised Register (22 May 2019), which contains trials identified from CENTRAL, MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, CINAHL, ClinicalTrials.gov, WHO ICTRP and handsearching of journals and conference proceedings.

SELECTION CRITERIA

Randomised controlled trials of women with urinary incontinence that included laparoscopic surgery in at least one arm.

DATA COLLECTION AND ANALYSIS

We independently extracted data from eligible trials, assessed risk of bias and implemented GRADE.

MAIN RESULTS

We included 26 trials involving 2271 women. Thirteen trials (1304 women) compared laparoscopic colposuspension to open colposuspension and nine trials (412 women) to midurethral sling procedures. One trial (161 women) compared laparoscopic colposuspension with one suture to laparoscopic colposuspension with two sutures; and three trials (261 women) compared laparoscopic colposuspension with sutures to laparoscopic colposuspension with mesh and staples. The majority of trials did not follow up participants beyond 18 months. Overall, there was unclear risk of selection, performance and detection bias and generally low risk of attrition and reporting bias. There is little difference between laparoscopic colposuspension using sutures and open colposuspension for subjective cure within 18 months (risk ratio (RR) 1.04, 95% confidence interval (CI) 0.99 to 1.08; 6 trials, 755 women; high-quality evidence). We are uncertain whether laparoscopic colposuspension using mesh and staples is better or worse than open colposuspension for subjective cure within 18 months (RR 0.75, 95% CI 0.61 to 0.93; 3 trials, 362 women; very low-quality evidence) or whether there is a greater risk of repeat continence surgery with laparoscopic colposuspension. Laparoscopic colposuspension may have a lower risk of perioperative complications (RR 0.67, 95% CI 0.47 to 0.94; 11 trials, 1369 women; low-quality evidence). There may be similar or higher rates of bladder perforations with laparoscopic colposuspension (RR 1.72, 95% CI 0.90 to 3.29; 10 trials, 1311 women; moderate-quality evidence). Rates for de novo detrusor overactivity (RR 1.29, 95% CI 0.72 to 2.30; 5 trials, 472 women) and voiding dysfunction (RR 0.81, 95% CI 0.50 to 1.31; 5 trials, 507 women) may be similar but we are uncertain due to the wide confidence interval. Five studies reported on quality of life but we could not synthesise the data. There may be little difference between laparoscopic colposuspension using sutures and tension-free vaginal tape (TVT) for subjective cure within 18 months (RR 1.01, 95% CI 0.88 to 1.16; 4 trials, 256 women; low-quality evidence) or between laparoscopic colposuspension using mesh and staples and TVT (RR 0.71, 95% CI 0.55 to 0.91; 1 trial, 121 women; low-quality evidence). For laparoscopic colposuspension compared with midurethral slings, there may be lower rates of repeat continence surgery (RR 0.40, 95% CI 0.04 to 3.62; 1 trial, 70 women; low-quality evidence) and similar risk of perioperative complications (RR 0.99, 95% CI 0.60 to 1.64; 7 trials, 514 women; low-quality evidence) but we are uncertain due to the wide confidence intervals. There may be little difference in terms of de novo detrusor overactivity (RR 0.80, 95% CI 0.34 to 1.88; 4 trials, 326 women; low-quality evidence); and probably little difference in terms of voiding dysfunction (RR 1.06, 95% CI 0.47 to 2.41; 5 trials, 412 women; moderate-quality evidence) although we are uncertain due to the wide confidence interval. Five studies reported on quality of life but we could not synthesise the data. No studies reported on bladder perforations. Low-quality evidence indicates that there may be higher subjective cure rates within 18 months with two sutures compared to one suture (RR 1.37, 95% CI 1.14 to 1.64; 1 trial, 158 women). Comparing one suture and two sutures, one suture may have lower rates of repeat continence surgery (RR 0.35, 95% CI 0.01 to 8.37; 1 trial, 157 women) and similar risk of perioperative complications (RR 0.88, 95% CI 0.45 to 1.70) but we are uncertain due to the wide 95% CIs. There may be higher rates of voiding dysfunction with one suture compared to two sutures (RR 2.82; 95% CI 0.30 to 26.54; 1 trial, 158 women; low-quality evidence), but we are uncertain due to the wide confidence interval. This trial did not report bladder perforations, de novo detrusor overactivity or quality of life. We are uncertain whether laparoscopic colposuspension with sutures is better or worse for subjective cure within 18 months compared to mesh and staples (RR 1.24, 95% CI 0.96 to 1.59; 2 trials, 180 women; very low-quality evidence) or in terms of repeat continence surgery (RR 0.97, 95% CI 0.06 to 14.91; 1 trial, 69 women; very low-quality evidence). Laparoscopic colposuspension with sutures may increase the number of perioperative complications compared to mesh and staples (RR 1.94, 95% CI 1.09 to 3.48; 3 trials, 260 women; low-quality evidence) but rates of de novo detrusor overactivity may be similar (RR 0.72, 95% CI 0.17 to 3.06; 2 trials, 122 women; low-quality evidence), however, we are uncertain due to the wide confidence interval. None of the studies reported bladder perforations, voiding dysfunction or quality of life.

AUTHORS' CONCLUSIONS

The data indicate that, in terms of subjective cure of incontinence within 18 months, there is probably little difference between laparoscopic colposuspension and open colposuspension, or between laparoscopic colposuspension and midurethral sling procedures. Much of the evidence is low quality, meaning that a considerable degree of uncertainty remains about laparoscopic colposuspension. Future trials should recruit adequate numbers, conduct long-term follow-up and measure clinically important outcomes. A brief economic commentary identified three studies. We have not quality-assessed them and they should be interpreted in light of the findings on clinical effectiveness.

Burch colposuspension

Aims

To evaluate the historic and pathophysiologic issues which led to the development of Burch colposuspension, to describe anatomic and technical aspects of the operation and to provide an update on current evidence.

Methods

We have performed a focused literature review and have searched the current available literature about historic dimension, technical descriptions, and efficacy of Burch colposuspension.

Results

Burch colposuspension, performed either by an open or a laparoscopic approach, is an effective surgical treatment for stress urinary incontinence.

Conclusions

In current recommendations, Burch colposuspension remains an option for secondary treatment. Because midurethral slings have recently become under scrutiny, it may return as a first‐line treatment procedure. Both open and laparoscopic Burch colposuspension should therefore nowadays be provided in fellowship programs worldwide.

Updated Systematic Review and Meta-analysis of the Comparative Data on Colposuspensions, Pubovaginal Slings, and Midurethral Tapes in the Surgical Treatment of Female Stress Urinary Incontinence

CONTEXT

Retropubic (RP-TVT) and transobturator miurethral (TO-TVT) midurethral sling (MUS) are popular surgical treatments for female stress urinary incontinence. The long-term efficacy and safety of the procedures is still a topic of intense clinical research and several randomised controlled trials (RCTs) have been published in the last years OBJECTIVE: To evaluate the efficacy and safety of MUS compared with other surgical treatments for female stress urinary incontinence.

EVIDENCE ACQUISITION

A systematic review and meta-analysis of the literature was performed using the Medline, Scopus, and Web of Science databases to update our previously published analyses.

EVIDENCE SYNTHESIS

Twenty-eight RCTs were identified. In total, the meta-analyses included 15 855 patients. Patients receiving MUS had significantly higher overall (odds ratio [OR]: 0.59, p=0.0003) and objective (OR: 0.51, p=0.001) cure rates than those receiving Burch colposuspension. Patients undergoing MUS and pubovaginal slings had similar cure rates. Patients treated with RT-TVT had higher subjective (OR: 0.83, p=0.03) and objective (OR: 0.82, p=0.01) cure rates than those receiving TO-TVT. However, the latter had a lower risk of intraoperative bladder or vaginal perforation (OR: 2.4, p=0.0002), pelvic haematoma (OR: 2.61, p=0.002), urinary tract infections (OR: 1.31, p=0.04) and voiding lower urinary tract symptoms (OR: 1.66, p=0.002). Sensitivity analyses limited to RCTs with follow-up durations >60 mo demonstrated similar outcomes for RP-TVT and TO-TVT. No significant differences in efficacy were identified comparing inside-to-out and outside-to-in TO-TVT but vaginal perforations were less common with the former (OR: 0.21, p=0.0002).

CONCLUSIONS

The present analysis confirms the superiority of MUS over Burch colposuspension. The studies comparing insertion of RT-TVT and TO-TVT showed higher subjective and objective cure rates for the RP-TVT but at the cost of higher risks of some complications and voiding lower urinary tract symptoms. Efficacy of inside-out and outside-in techniques of TO-TVT insertion was similar, although the risk of vaginal perforation was lower in the inside-to-out TO-TVT.

PATIENT SUMMARY

Retropubic and transobturator midurethral slings are a popular treatment for female stress urinary incontinence. The available literature suggest that those slings are either more effective or safer than other older surgical procedures. Retropubic tapes are followed with slightly higher continence rates as compared with the transobturator tapes but are associated with higher risk of intra- and postoperative complications.

Sexual function after urinary incontinence surgery

Urinary incontinence (UI) affects between 42 and 71% of women. Sexual dysfunction is prevalent in the general population, but in women with UI, the prevalence is greater (42-56%). This review assesses the effects of urinary continence surgery on the sexual function of women with UI. Stress UI is surgically mostly managed via Burch colposuspension or a mid-urethral sling. These operations are as effective as each other with regards to maintaining or improving in sexual function. One of the main risks of these operations are that urgency UI (UUI) may be exacerbated or arise de novo and this has been shown to decrease sexual function. Severe refractory UUI requires complex surgery, such as percutaneous sacral nerve stimulation (SNS) then augmentation cystoplasty or urinary diversion. SNS may improve sexual function by direct action on the pudendal nerve as well as improving incontinence. Urinary diversion and augmentation cystoplasty are procedures of last resort in women who are refractory to all other UUI treatments. The majority of women report no change or improvement in sexual function as the urinary diversion negates the requirement for incontinence pads and indwelling catheters. Deteriorated sexual function has also been described in up to 37.5%. Thirty percent of women undergoing urinary diversion would have liked more 'sexological' counselling.

CONCLUSION

The majority of women enjoy maintained or improved sexual function after surgical treatment of UI. It is important to ensure women have appropriate pre-operative assessment and counselling so they may be advised of the risks of failed surgery including deteriorated sexual function.