Editorial comment.

With the present plethora of publications on the surgical management of SUI in women, this prospective randomised study compares the results of three different types of mid-urethral sling. There is no doubt that SUI in women represents a substantial medical, social and economic burden [1]. A wide variety of surgical techniques, materials and routes has been described to achieve better success rates and to minimize the potential complications. Changing the reference standard of the surgical techniques used for treating SUI with time might reflect the logical way of science development, but it might also indicate the deficiency in understanding the actual pathogenesis of such disease. Do we treat the same disease in every patient? Or are there phenotypic issues and should treatment be individualized? The decrease in success rates over the long-term follow-up of any procedure for this condition might indicate the latter concept.

Despite the good design of the current study it has the same pitfalls of similar trials. The authors conclude that “Tailored prolene mesh, ARS and AVS are good alternatives for treating SUI in women, with comparable results in a short-term follow-up”. Nevertheless, the authors cannot answer the question ‘which sling for which patient?’ and this traditional problem remains unresolved .Thus, the phenotype of SUI in women should be considered. Moreover, the methods of assessing the outcome of different surgical techniques should be revised and appropriately standardized. The definition of success among published studies is not universal and there is a lack of standardization of objective and subjective variables [2]. For example, the authors of this study depend on a stress test to define success. In other studies more restricted criteria for definition of success were considered [3-5]. Such heterogeneity in evaluation methods might be responsible for the more extreme conclusions of these studies [3].

Finally, “a tapered prolene mesh” was used in one arm in this study and was only ‘slightly better’ in some aspects. It seems that using ‘home-made’ meshes is an interesting idea from an economic point of view. It might even have great support, especially in areas with limited financial resources. The major concern is that a high risk of infection is associated with micro-pore meshes [6,7] with subsequent risks of erosion and extrusion. Hence, the results on the safety of using such types of mesh are based on “short-term small population size” studies should be treated with great caution.