Minimally invasive synthetic suburethral sling operations for stress urinary incontinence in women: a short version Cochrane review.

BACKGROUND: Stress urinary incontinence (SUI) is a common condition affecting up to 30% of women. Minimally invasive synthetic suburethral sling operations are among the latest forms of procedures introduced to treat SUI.
OBJECTIVES: To assess the effects of minimally invasive synthetic suburethral sling operations for treatment of SUI, urodynamic stress incontinence (USI), or mixed urinary incontinence (MUI) in women. SEARCH
METHODS: We searched the Cochrane Incontinence Group Specialised Register (searched March 20, 2008), MEDLINE (January 1950-April 2008), EMBASE (January 1988-April 2008), CINAHL (January 1982-April 2008), AMED (January 1985-April 2008), the UK National Research Register, ClinicalTrials.gov, and reference lists of relevant articles. SELECTION CRITERIA: Randomized or quasi-randomized controlled trials amongst women with SUI, USI, or symptoms of stress or MUI, in which at least one trial arm involved a minimally invasive synthetic suburethral sling operation. DATA COLLECTION AND ANALYSIS: Two review authors assessed the methodological quality of potentially eligible studies and independently extracted data from the included trials.
RESULTS: Sixty-two trials involving 7,101 women were included. The quality of evidence was moderate for most trials. Minimally invasive synthetic suburethral sling operations appeared to be as effective as traditional suburethral slings [8 trials, n=599, risk ratio (RR) 1.03, 95% confidence interval (CI) 0.94-1.13] but with shorter operating time and less postoperative voiding dysfunction and de novo urgency symptoms. Minimally invasive synthetic suburethral sling operations appeared to be as effective as open retropubic colposuspension (subjective cure rate at 12 months RR 0.96, 95% CI: 0.90-1.03; at 5 years RR 0.91, 95% CI: 0.74-1.12) with fewer perioperative complications, less postoperative voiding dysfunction, shorter operative time, and hospital stay but significantly more bladder perforations (6% vs. 1%, RR 4.24, 95% CI: 1.71-10.52). There was conflicting evidence about the effectiveness of minimally invasive synthetic suburethral sling operations compared to laparoscopic colposuspension in the short term (objective cure, RR 1.15, 95% CI: 1.06-1.24; subjective cure RR 1.11, 95% CI: 0.99-1.24). Minimally invasive synthetic suburethral sling operations had significantly less de novo urgency and urgency incontinence, shorter operating time, hospital stay, and time to return to daily activities. A retropubic bottom-to-top route was more effective than top-to-bottom route (RR 1.10, 95% CI: 1.01-1.20; RR 1.06, 95% CI: 1.01-1.11) and incurred significantly less voiding dysfunction, bladder perforations, and tape erosions. Monofilament tapes had significantly higher objective cure rates (RR 1.15, 95% CI: 1.02-1.30) compared to multifilament tapes and fewer tape erosions (1.3% vs. 6% RR 0.25, 95% CI: 0.06-1.00). The obturator route was less favorable than the retropubic route in objective cure (84% vs. 88%; RR 0.96, 95% CI: 0.93-0.99; 17 trials, n=2,434), although there was no difference in subjective cure rates. However, there was less voiding dysfunction, blood loss, bladder perforation (0.3% vs. 5.5%, RR 0.14, 95% CI: 0.07-0.26), and shorter operating time with the obturator route.
CONCLUSIONS: The current evidence base suggests that minimally invasive synthetic suburethral sling operations are as effective as traditional suburethral slings, open retropubic colposuspension and laparoscopic colposuspension in the short-term but with less postoperative complications. Objective cure rates are higher with retropubic tapes than with obturator tapes but retropubic tapes attract more complications. Most of the trials had short-term follow-up and the quality of the evidence was variable.