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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