EURURO Vol. 72 No. 4

568 656

1. Introduction
Surgical treatment is often the preferred option for women
with stress urinary incontinence (SUI) who have failed
conservative management strategies .
Several different surgical procedures have been reported,
with synthetic midurethral slings (MUS) being the most
commonly adopted surgical procedures. Several systematic
reviews and meta-analyses of randomised controlled trials
(RCTs) comparing the different surgical approaches have
been reported . In our previous systematic review, we
have shown that women treated with retropubic tension-
free vaginal tapes (RP-TVT) had slightly higher objective
continence rates than those treated with Burch colposus-
pension (BC) but they faced a higher risk of intraoperative
complications. RP-TVT and pubovaginal slings (PVS) were
similarly effective, although patients with PVS were more
likely to experience postoperative storage lower urinary
tract symptoms (LUTS). RP-TVT were associated with
objective cure rates slightly higher than transobturator
tension-free vaginal tapes (TO-TVT) but subjective cure
rates were similar. TO-TVT, however, had a lower risk of
bladder/vaginal perforations and postoperative storage
LUTS .
Furthermore, concerns have been raised on the use of
synthetic mesh for surgical treatment of female SUI and
prolapse surgery. That was primarily due to the risk of
complications, including mesh exposure/erosion, dyspar-
eunia, infections, and pain. The Food and Drug Administra-
tion issued a series of statements concluding that serious
complications associated with transvaginal mesh for pelvic
organ prolapse repair and are not uncommon; nevertheless,
they emphasised that this does not apply to the use of mesh
for SUI or abdominal surgery. However, very recently, a
Scottish population-based study demonstrated that mesh
surgical procedures for SUI were associated with a lower
risk of early postoperative complications and subsequent
prolapse surgery, as well as similar risks of further
incontinence surgery and later complications, as compared
with open colposuspension In late 2015, various
working groups worldwide reported on the use of
transvaginal mesh in Scotland, England, and Europe
(SCENIHR) in the surgical treatment of SUI and pelvic
organ prolapse . All have emphasised the need of
further research in the field. Therefore, we elected to update
our previous meta-analyses of the literature in the field of
primary surgical treatment of female SUI.
2. Evidence acquisition
The updated systematic review of the literature was
performed in July 2014 and last updated on November 1,
2016 using the Medline, Scopus, and Web of Science
databases. The Medline search used a complex search
strategy including both medical subject heading (MeSH) and
free text protocols, as was done in the previous reviews
Specifically, the MeSH search was conducted by
combining the following terms retrieved from the MeSH
browser provided by Medline: Urinary Incontinence, Stress,
and Suburethral Slings. Multiple free text searches were also
performed, searching for the following terms individually in
the fields title and abstract of the records: Urinar*incont*,
TVT, tension-free vaginal tape*, Tension-free vaginal sling*,
Transobturator tape*, Trans-obturator sling*, TVT-obturator,
TVT-O, TOT, suprapubic arc sling*, SPARC sling*, intravaginal
slingplasty, IVS sling, Uratape, ObTAPE, Prepubic sling*,
Prepubic TVT, Prepubic tape*, PelviLace, Ureter, Aris, In-Fast,
Monarc, I-Stop, and BioArc. Subsequently, the search results
were pooled, and the following limits used: humans, Entrez
Date from 2009/08/01. No limitations regarding language of
publication or type of publication were used. The searches
on Scopus, and Web of Science used only the free-text
protocol, with the same keywords. Subsequently, the query
results were pooled and the same temporal limit applied.
Moreover, the Cochrane Database of Systematic Review was
searched using the keyword ‘‘urinary incontinence.’’ Hand-
search of congress abstracts was not performed.
A total of 958 records were retrieved from Medline,
1789 from Scopus, and 1477 from Web of Science. Four of
the authors reviewed the full texts to select the papers
relevant to the review topic. Specifically, all the RCTs,
discussing outcomes (ie, continence rates, satisfaction rates,
complication rates) from the use of MUS as predominantly
primary surgical treatment of SUI were selected. RCTs
reporting on the use of MUS exclusively in patients who had
previously failed other surgical treatments were excluded.
The selected papers were categorised according to the grade
of evidence: an adequately sampled single RCT was
considered to have Level 1b evidence; a low-quality RCT
to have Level 2b evidence The quality of the retrieved
RCTs was assessed using the Jadad score
To evaluate the efficacy of the different procedures, both
objective criteria (stress test, pad test, urodynamics) and
subjective criteria (patients’ perception of the clinical
improvement, expressed by validated questionnaires,
complications and voiding lower urinary tract symptoms. Efficacy of inside-out and
outside-in techniques of TO-TVT insertion was similar, although the risk of vaginal
perforation was lower in the inside-to-out TO-TVT.
Patient summary: Retropubic and transobturator midurethral slings are a popular treat-
ment for female stress urinary incontinence. The available literature suggest that those
slings are either more effective or safer than other older surgical procedures. Retropubic
tapes are followed with slightly higher continence rates as compared with the transob-
turator tapes but are associated with higher risk of intra- and postoperative complications.
# 2017 European Association of Urology. Published by Elsevier B.V. All rights reserved.
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