EURURO Vol. 72 No. 4

588 656

between MUS and PVS showed similar overall and
subjective cure rates although the safety profile was
different. MUS were associated with higher risk of bladder
perforation while the incidence of storage LUTS and the
reoperation rate were higher among patients undergoing
PVS . The comparison between retropubic and transob-
turator routes for MUS placement showed a slightly higher
objective cure rate in favour of the former, although
subjective cure rates were similar. Again, the safety profile
was different: TO-TVT were associated with a lower risk of
bladder and vaginal perforations, haematoma, and storage
LUTS. Conversely, the incidence of vaginal erosion was
higher among patients receiving TO-TVT and was mainly
due to the higher risk of vaginal erosions in outside-to-in
TO-TVT. The reoperation rate, the incidence of urinary tract
infections, and the need for clean intermittent catheterisa-
tion or recatheterisation was similar between the two
techniques. Finally, based only on the evidences from three
available RCTs, the meta-analysis demonstrated similar
outcomes for the inside-out and outside-in procedures in
terms of objective and subjective cure rates and safety
profile .
Despite being based on many trials of good methodo-
logical quality, that meta-analysis had some limitations
such as heterogeneity of outcomes measures and the lack of
RCTs with long-term follow-up as only two studies reported
data at follow-up 60 mo. Due to the fact that several RCTs
have been published in the field since the publication of that
report, we elected to update our previous meta-analysis.
The updated comparison among MUS and BC reconfirmed
the superiority of MUS in terms of overall and objective
continence rates as well as the equivalence in terms of
subjective continence rates. Those results were mainly
determined by the differences observed between MUS and
open BC. Similarly, there was a trend towards more
favourable outcomes with MUS compared with laparoscop-
ic BC in all subanalyses. Sensitivity analyses limited to the
RCTs with follow-up duration 60 mo reconfirmed the
advantages in terms of objective continence rates, whereas
only nonstatistically significant trend in favour of MUS was
found for overall and subjective continence rates.
With regards of the comparison among MUS and PVS, the
present analysis reconfirmed the absence of significant
differences between both groups in terms of overall and
subjective continence rates, as well as prevalence of pelvic
haematoma, vaginal erosions, and voiding LUTS. Converse-
ly, the incidence of storage LUTS was significantly lower in
patients treated with MUS. Notably, while the previous
meta-analysis showed higher reoperation rate in patients
receiving PVS, the present report showed a similar trend but
did not reach statistical significance.
On comparing RP-TVT and TO-TVT, we found overall
higher objective and subjective continence rates in patients
treated with RP-TVT. However, although statistically
significant, such difference in success rates were minimal
(just 2% and 4% difference in objective and subjective cure
rates, respectively) and probably of marginal clinical
relevance if we consider the difference in complication
rates. Interestingly, the study by Costantini et al found
that the long-term continence rate after MUS placement
tended to decrease in patients who underwent TO-TVT,
whereas remained stable for those who underwent RP-TVT.
Yet, our estimations including only RCTs with at least 5-yr
follow-up did not show any difference in objective or
subjective cure rates between the retropubic and transob-
turator approaches. Except for vaginal erosions, our results
showed the transobturator approach to be associated with
lower risk of most intraoperative and postoperative
complications, which is the main reason why TO-TVT is
now preferred by most surgeons for the primary surgical
treatment of female over RP-TVT. Reassuringly, the above
results pertained on sensitivity analyses limited to the RCTs
of highest methodological quality. In the end, retropubic
approach might offer a slight advantage over the transob-
turator approach in terms of objective success rates but at
the costs of higher complication rate.
With regard to the comparison between inside-out and
outside-in TO-TVT, we found no statistically significant
differences between the two surgical approaches in terms of
continence rates, whereas the risk of vaginal perforation was
lower in inside-to-out TO-TVT. Moreover, there was also a
clear trend in favour of inside-to-out TO-TVT for vaginal
erosions, although it did not reach statistical significance.
There has been a growing interest in the likelihood of
chronic pain and dyspareunia following MUS. In our review,
only a limited number of RCTs reported on long-term pain
following surgery for SUI. Kenton et al reported a few
cases of long-term pain at 5-yr follow-up following RP-TVT
or TO-TVT. Interestingly, Khan et al reported presence
of scar pain also following autologous PVS, indicating that
such risk is not limited to MUS. Two recent studies reported
6.4% and 9% groin/inguinal pain/discomfort at 7-yr and
10-yr follow-up, respectively, following TO-TVT . In-
tractable suprapubic pain has been previously described
following colposuspension and defined as postcolposus-
pension syndrome. Even less data are available on the long-
term prevalence of dyspareunia in patients receiving MUS
for SUI. The available RCTs have reported just a few cases of
de novo dyspareunia . However, the available
literature seems to suggest improvements in sexual
function for sexually active patients treated with MUS for
SUI .
The present study has several strengths. First, represents
the most up-to-date and most comprehensive summary of
the currently available evidence in surgical treatments of
female SUI, including the most commonly adopted surgical
treatments, with the only exception of the single-incision
mini-sling. That choice was in line with the inclusion and
exclusion criteria set at the moment of the original
systematic reviews and meta-analyses . Moreover, a
recent systematic review and meta-analysis published by
Mostafa et al , demonstrating similar outcome for mini-
slings and traditional MUS. However, most of the available
RCTs reported only short- or intermediate-term follow-up
data. Secondly, the paper complies with the currently
available standard to report systematic review and meta-
analysis . Finally, the review included a relatively high
number of RCTs with long-term follow-up ( 60 mo) which
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