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Grand Rounds

Cochrane Review: Best Treatment Options for Stress Urinary Incontinence

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BACKGROUND AND PURPOSE:

  • The traditional suburethral sling operation is one surgical option for treatment of stress urinary incontinence in women
  • In this Cochrane review, Saraswat et al. (Cochrane Systematic Review – Intervention, 2020) examined the effectiveness of traditional suburethral sling procedures for treating stress urinary incontinence in women

METHODS:

  • Systematic review and meta-analysis
  • Sources
    • Cochrane Incontinence Specialized Register: Includes trials from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, CINAHL, ClinicalTrials.gov, and WHO ICTRP
    • Journals and conference proceedings, and references lists of relevant articles
  • Inclusion criteria
    • Randomized or quasi-randomized trials
    • Studies assessing traditional suburethral slings for treating stress or mixed urinary incontinence
  • Data collection and analysis
    • At least two review authors independently extracted data from included trials and assessed risk of bias
    • Summary statistics were calculated: risk ratio (RR) for dichotomous data, odds ratio (OR) for continence and cure rates that were expected to be high, and mean difference (MD) for continuous data
    • The GRADE criteria was used to assess the quality of evidence

RESULTS:

  • 34 trials | 3244 women
  • Traditional slings were compared with 10 other treatments and with each other

Traditional Suburethral Sling Operation vs Drugs

  • One small trial compared traditional suburethral sling operations with oxybutynin to treat women with MUI
  • Due to very low-quality evidence, uncertain whether surgery compared with oxybutynin leads to
    • More women being dry
      • 83% vs 0%; OR 195.89 (95% CI, 9.91 to 3871.03; very low-quality evidence)
    • More women having less urgency urinary incontinence
      • 13% vs 43%; RR 0.29 (95% CI 0.09 to 0.94; very low-quality evidence)

Traditional Suburethral Sling vs Injectables

  • One small trial compared traditional slings with suburethral injectable treatment
  • Results uncertain for surgery vs injectables due to very low-quality evidence
    • Number of women who remained dry  
      • 100% vs 71%; OR 11.57 (95% CI, 0.56 to 239.74; very low-quality evidence)
    • The need for repeat surgery for urinary incontinence
      • RR 0.52 (95% CI, 0.05 to 5.36; very low-quality evidence)
    • The occurrence of perioperative complications
      • RR 1.57 (95% CI, 0.29 to 8.49; very low-quality evidence)

Traditional Suburethral Sling vs Open Abdominal Retropubic Colposuspension

  • 8 trials compared slings with open abdominal retropubic colposuspension
  • The traditional suburethral sling probably leads to more continent women in the medium term (one to five year follow up )
    • 69% vs 59%;  OR 1.70 (95% CI, 1.22 to 2.37; medium-quality evidence)
  • Women were less likely to need repeat continence surgery after a traditional sling operation vs colposuspension
    • RR 0.15 (95% CI, 0.05 to 0.42; high-quality evidence)
  • No difference in perioperative complications between the two groups
    • RR 1.24 (95% CI, 0.83 to 1.86; very low-quality evidence)

Traditional Suburethral Sling Operation vs Mid-Urethral Slings

  • 14 trials compared traditional sling operations and mid-urethral sling operations
  • Traditional suburethral slings may be less effective than mid-urethral slings in the medium term (1 to 5 years)
    • Number of women who remained continent
      • 67% vs 74%; OR 0.67 (95% CI, 0.44 to 1.02; moderate-quality evidence)
  • Long-term follow-up (>10 years): 1 trial reported more continent women with the traditional sling
    • 51% vs 32%: OR 2.22 (95% CI, 1.07 to 4.61)
  • Mid-urethral slings may be associated with fewer perioperative complications
    • RR 1.74 (95% CI, 1.16 to 2.60; low-quality evidence)

One type of traditional sling operation versus another type of traditional sling operation 

  • Complications were reported by two trials
    • 1 comparing non-absorbable Gortex with a rectus fascia sling
    • 1 comparing Pelvicol with a rectus fascial sling
  • Impact was uncertain due to the very low quality of evidence

CONCLUSION:

  • Surgery appears to be a better option for treatment than drugs
  • Medium term continence (1 to 5 years)
    • Women may be more likely to be continent after a traditional suburethral sling operation vs colposuspension
  • Data regarding adverse effects is limited
  • Overall, the authors conclude

Long-term follow-up of randomised controlled trials (RCTs) comparing traditional slings with colposuspension and mid-urethral slings is essential

Evidence is insufficient to suggest whether traditional suburethral slings may be better or worse than other management techniques

Learn More – Primary Sources:

Traditional suburethral sling operations for urinary incontinence in women

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Related ObG Topics:

Prolapse and Stress Incontinence: Burch Procedure vs Midurethral Sling
Surgery for Stress Urinary Incontinence: Which Procedures are Most Effective and Safest?
Midurethral Tape and Repeat Surgery for Stress Incontinence: Is the 2nd Time the Charm?

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This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.

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