Treating stress urinary incontinence with suburethral slings

In Sweden and Finland, where the TVT procedure was developed,¹¹ 85 patients who had undergone the procedure were evaluated at 48 to 70 months. Of those, 84.7% were completely cured of stress incontinence, 10.6% had significantly improved symptoms, and 4.7% were regarded as failures.

A recent well-designed, multicenter, randomized, prospective trial in the U.K. and Ireland compared 146 open Burch colposuspensions to 170 TVTs. Similar cure rates (57% and 66%, respectively) were reported.¹² Although these rates are low compared to the Nordic nonrandomized TVT studies mentioned, the U.K./Ireland outcome criteria were particularly stringent and included a negative cystometrogram for stress incontinence and negative pad test. These differences in reported success rates highlight the importance of clearly defining objective outcomes criteria from randomized trials.

Nonetheless, the U.K./Ireland study showed that TVT is less invasive than the Burch procedure and is associated with shorter recovery periods and greater cost savings. Follow-up on complications (bladder perforation and hematoma in TVTs and incisional hernia formation in Burch colposuspensions) will be the most crucial aspect of this study.¹³

Clearly, the question of whether a Burch retropubic urethropexy or a suburethral sling procedure is better for SUI needs to be further investigated. Weber and Walters sought to answer this question by developing a decision analytical model (without the aid of randomized, controlled trials) and discovered similar cure rates.¹⁴ However, there were higher rates of urinary retention and detrusor instability associated with the traditional pubovaginal sling. But, most importantly, sensitivity analyses proved that if the rate of permanent urinary retention after a sling procedure was less than 9%—as in most sling series—the overall effectiveness of slings was higher than that of the Burch.

Conclusion

The suburethral sling procedure has undergone many modifications since its first description nearly a century ago. As such, Ob/Gyns need to familiarize themselves with the current options. Typically, we perform up to 6 suburethral sling procedures per month. Of those, 50% are referrals from failed incontinence procedures. Recently, we have made the switch from using autologous slings to tension-free type slings due to ease and good outcomes. While more data from randomized, prospective, multicenter trials are needed to determine the best approach for individual patients, surgeons should become comfortable with the technique that works best for them.

The authors report no financial relationship with any companies whose products are mentioned in this article.