Q. How can my department tell if we providing effective urinary
incontinence procedures?

A. Two good benchmark times to re-evaluate are at 1 and 5 years post
operatively.

By the way, a Cochrane review concluded open retropubic colposuspension
was the most effective treatment modality for SUI, with 85 to 90 percent
of patients continent after one year and 70 percent after five years.

Please note that measures of success are not simply percent of patients
that require re-operation. Rather, one should utilize accepted benchmark
patient questionnaires for this purpose.

Here is information of outcomes on the 3 main types of urinary
incontinence procedures:

**-Retropubic procedures**

**-Suburethral slings**

**-Transvaginal needle suspensions**

 

**Retropubic procedures**

  **Outcome** --- A Cochrane review concluded open retropubic
colposuspension was the most effective treatment modality for SUI, with
85 to 90 percent of patients continent after one year and 70 percent
after five years. Open retropubic colposuspension was significantly more
effective than anterior colporrhaphy both in the shortterm and in
patients followed for more than five years. In two trials, failure was
less common after the Burch than the MMK (RR 0.38, 95 percent CI 0.18 to
0.76).

The open Burch procedure is the technique with the best documentation of
long-term success. Urodynamic testing confirms long-term success rates
of 70 to 90 percent for the Burch procedure. The results appear lower
(approximately 60 percent success) for women with mixed incontinence or
those who have had previous incontinence surgery. These findings were
illustrated by a meta-analysis of seven studies with follow-up of 5 to
12 years that reported a cure rate of 90 percent when the Burch
colposuspension was performed as a primary procedure versus 82 percent
for repeat surgery. Obesity, asthma, age over 65 years, and estrogen
deficiency are additional factors associated with lower success rates.

Subsequent to this meta-analysis, the largest multicenter prospective
randomized trial of surgical treatment of SUI compared the outcome of
170 TVT procedures and 146 Burch colposuspensions at six months
postoperatively. There were equivalent objective rates of cure based
upon a negative one hour pad test and no leakage during cystometrogram
(CMG) (66 versus 57 percent). The subjective cure rates were also
similar (59 and 53 percent, respectively). TVT was associated with more
intraoperative complications (eg, bladder or vaginal injury) than
colposuspension, but had a more favorable postoperative course: less use
of opiate analgesia (21 versus 91 percent), shorter duration of
catheterization and hospitalization (median 1 versus 5 days), and
quicker return to work and to full activity ( 3 to 4 weeks versus 6 to
10 weeks). These results are promising, but longterm data from
randomized studies are needed to determine the efficacy of TVT in
treatment of SUI.

Low urethral pressure and intrinsic sphincter deficiency are related to
an increased failure rate in many, but not all studies. For this reason,
a sling or a Burch-Ball procedure should be performed in cases of ISD
with hypermobility, rather than retropubic or needle suspension
procedures . Sling and Burch-Ball procedures are more effective because
the Burch-Ball procedure narrows the urethra, thus improving coaptation,
and slings provide a more firm and reliable backboard for urethral
compression during increased abdominal pressure. Although there is no
evidence that one works better than the other, slings are more commonly
performed. I prefer the sling procedure for ISD since injury to the
urethral muscle from scarring is a risk of the Burch-Ball procedure.

 

**Suburethral slings**

  **Outcome** --- There are no adequate data to demonstrate that one
material or technique is superior to another. However, it is clear that
procedures that require harvesting of fascia are longer and more
invasive than methods using exogenous materials. By comparison, some
synthetic slings are associated with increased rates of graft rejection,
erosion into the urethra, and development of fistulae.

Reported rates of cure or improvement at five years range from 70 to 95
percent. For example, a meta-analysis of 1712 patients with variable
follow-up showed objective cure in 85 percent and subjective cure in 82
percent of women. Although these rates appear similar to those for the
Burch procedure, the procedures are performed in different patient
populations; most sling series have a high percentage of patients with
intrinsic sphincter deficiency and other higher risk factors. Some
examples of outcome data include the following:

   One prospective randomized study comparing the Burch and lyodura
sling procedures in women with uncomplicated SUI reported similar cure
rates at four years, but more voiding difficulties among sling (29
percent) versus Burch (10 percent) patients.\
\
   Results of the tension-free vaginal tape procedure were examined in
404 women with SUI examined at median follow-up of 21 months Subjective
and objective cure rates were 92 and 90 percent respectively, with 4
percent significantly improved. Another study evaluating 90 patients
four to six years postoperatively reported 85 percent were completely
cured (subjectively and objectively), 11 percent improved significantly,
but 5 percent had no improvement\
\
   Another study using a Gore-Tex patch sling in 141 consecutive women
with SUI described cure in 89 percent and persistent SUI in 4 percent at
27 to 84 months post procedure. Eleven patients required modification or
removal of the patch due to complications.

A Mersilene mesh suburethral sling procedure performed on 200 women with
SUI complicated by recurrence, intrinsic sphincter deficiency, or
chronically increased intraabdominal pressure resulted in a 93 percent
objective cure rate after at a mean follow-up of 30 months

 

 

**Transvaginal needle suspensions**

  **Outcome** --- There does not appear to be a significant difference
in outcome among the various Pereyra modifications. A literature review
involving more than 4000 women provided data to compare subjective and
objective outcomes following the Pereyra and Stamey procedures. The
subjective assessment of continence was similar for both procedures.

Transvaginal needle suspension is less effective than retropubic
suspension (eg, Burch colposuspension) in most but not all studies.

   A meta-analysis of 213 studies showed subjective and objective cure
rates of 78 and 70 percent, respectively, for endoscopic needle
suspension and 90 and 84 percent, respectively, for the Burch
procedure.\
\
   A randomized trial involving 93 women who underwent either surgical
treatment by anterior colporrhaphy and Kelly plication, modified Pereyra
urethropexy, or Burch colposuspension reported objective success rates
of 37, 43, and 82 percent, respectively, after five years. However,
absorbable suture was used for the modified Pereyra in this study,
rather than the permanent suture recommended by most surgeons. Unlike
the Burch procedure, which produces a lot of scarring, thereby holding
up even when absorbable sutures dissolve, needle suspensions are highly
dependent upon the suture itself.\
\
   A meta-analysis by the Female Stress Urinary Incontinence Clinical
Guidelines Panel of the the American Urological Association found that
the \"cure/dry/improved\" rates after a minimum four year follow-up
period were 82 percent for transvaginal suspensions, 90 percent for
retropubic suspensions, and 87 percent for sling procedures. Those
studies with follow-up of only 24 to 47 months showed
\"cure/dry/improved\" rates of 65 percent for transvaginal suspensions,
84 percent for retropubic suspensions, and 82 percent for sling
procedures. However, sling and retropubic procedures were associated
with higher complication rates, such as longer convalescence and voiding
dysfunction.\
\
   A Cochrane systematic review also concluded that bladder neck needle
suspension surgery has a lower first year subjective cure rate than open
abdominal retropubic suspension (74 versus 86 percent) and was
associated with more perioperative complications 48 versus 30 percent)
in women having a primary procedure. Needle suspension appeared as
effective as anterior repair (subjective cure rates 64 and 61 percent,
respectively). An insufficient number of patients limited the
reliability of this data and comparison with sling surgery.

The long-term failure rate of transvaginal needle suspension procedures
appears to be the result of sutures eroding through the rectus fascia or
endopelvic fascia and fibroblast reaction after surgery may be
inadequate to maintain urethral support.

 

**Surgical treatment of stress urinary incontinence in women**

George Flesh, MD UpToDate Online 12.1

<http://www.uptodateonline.com/application/topic.asp?file=gen_gyne/7640>