Sling surgery for stress urinary incontinence in women: A systematic review and meta-analysis - Abstract

OBJECTIVE: Understanding the long-term comparative effectiveness of competing surgical repairs is essential as failures after primary interventions for stress urinary incontinence (SUI) may result in a third of women requiring repeat surgery.

STUDY DESIGN: We conducted a systematic review including English-language randomized controlled trials from 1990 to April 2013 with minimum 12 months of follow-up comparing a sling procedure for SUI to another sling or Burch urethropexy. When at least three RCTs compared the same surgeries for the same outcome, we performed random-effects model meta-analyses to estimate pooled odds ratios.

RESULTS: For midurethral slings vs. Burch, meta-analysis of objective cure showed no significant difference (OR 1.18, CI 0.73-1.89). Therefore, we suggest either intervention; the decision should balance potential adverse events and concomitant surgeries. For women considering pubovaginal sling vs. Burch, the evidence favored slings for both subjective and objective cure. We recommend pubovaginal sling to maximize cure outcomes. For pubovaginal vs. midurethral slings, meta-analysis of subjective cure favored midurethral sling (OR 0.40, CI 0.18-0.85). Therefore, we recommend a midurethral sling. For obturator vs. retropubic midurethral slings, meta-analyses for both objective (OR 1.16, CI 0.93-1.45) and subjective cure (OR 1.17, CI 0.91-1.51) favored retropubic slings but were not significant. Meta-analysis of satisfaction outcomes favored obturator slings but was not significant (OR 0.77, CI 0.52-1.13). Adverse events were variable between slings; meta-analysis showed overactive bladder symptoms were more common following retropubic slings (OR 1.413, CI 1.01-1.98, p=0.046). We recommend either retropubic or obturator slings for cure outcomes; the decision should balance adverse events. For minislings vs. full-length midurethral slings, meta-analyses of objective (OR 4.16, CI 2.15-8.05) and subjective cure (OR 2.65, CI 1.36-5.17) both significantly favored full-length slings. Therefore, we recommend a full-length midurethral sling.

CONCLUSION: Surgical procedures for SUI differ for success rates and complications, and both should be incorporated into surgical decision-making. Low to high-quality evidence permitted mostly level 1 recommendations when guidelines were possible.

Written by:
Schimpf MO, Rahn DD, Wheeler TL, Patel M, White AB, Orejuela FJ, El-Nashar SA, Margulies RU, Gleason JL, Aschkenazi SO, Mamik MM, Ward RM, Balk EM, Sung VW.   Are you the author?
University of Michigan, Department of Obstetrics and Gynecology, Division of Gynecology, Urogynecology, Ann Arbor, MI; University of Texas Southwestern Medical Center, Department of Obstetrics and Gynecology, Dallas, TX; University of South Carolina School of Medicine Greenville, Department of Obstetrics and Gynecology, Greenville, SC; Kaiser Permanente, Roseville, CA, Department of Obstetrics and Gynecology; University of Texas Southwestern at Seton Healthcare Family, Austin, TX; University of Texas Health Science Center at Houston, Department of Obstetrics and Gynecology and Reproductive Sciences; Mayo Clinic, Division of Gynecologic Surgery, Rochester, MN; Kaiser Permanente, Oakland, CA, Department of Obstetrics and Gynecology, Urogynecology Division; Carilion Clinic, Department of Obstetrics and Gynecology, Division of Urogynecology, Roanoke, VA; ProHealth Care, Women's Center, Urogynecology, Medical College of Wisconsin, Waukesha, WI; Icahn School of Medicine at Mount Sinai, Department of Obstetrics and Gynecology, New York, NY; Vanderbilt University Medical Center, Department of Obstetrics and Gynecology, Nashville, TN; Tufts Medical Center, Institute for Clinical Research and Health Policy Studies, Boston, MA; Women and Infants Hospital of Rhode Island and Warren Alpert Medical School of Brown University, Department of Obstetrics and Gynecology, Division of Urogynecology and Reconstructive Pelvic Surgery, Providence, RI.

Reference: Am J Obstet Gynecol. 2014 Jan 29. pii: S0002-9378(14)00059-3.
doi: 10.1016/j.ajog.2014.01.030

PubMed Abstract
PMID: 24487005

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