Sling surgery for stress urinary incontinence in women: a systematic review and metaanalysis.
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.


METHODS
We conducted a systematic review including English-language randomized controlled trials from 1990 through April 2013 with a minimum 12 months of follow-up comparing a sling procedure for SUI to another sling or Burch urethropexy. When at least 3 randomized controlled trials compared the same surgeries for the same outcome, we performed random effects model metaanalyses to estimate pooled odds ratios (ORs).


RESULTS
For midurethral slings (MUS) vs Burch, metaanalysis of objective cure showed no significant difference (OR, 1.18; 95% confidence interval [CI], 0.73-1.89). Therefore, we suggest either intervention; the decision should balance potential adverse events (AEs) 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 slings vs MUS, metaanalysis of subjective cure favored MUS (OR, 0.40; 95% CI, 0.18-0.85). Therefore, we recommend MUS. For obturator slings vs retropubic MUS, metaanalyses for both objective (OR, 1.16; 95% CI, 0.93-1.45) and subjective cure (OR, 1.17; 95% CI, 0.91-1.51) favored retropubic slings but were not significant. Metaanalysis of satisfaction outcomes favored obturator slings but was not significant (OR, 0.77; 95% CI, 0.52-1.13). AEs were variable between slings; metaanalysis showed overactive bladder symptoms were more common following retropubic slings (OR, 1.413; 95% CI, 1.01-1.98, P = .046). We recommend either retropubic or obturator slings for cure outcomes; the decision should balance AEs. For minislings vs full-length MUS, metaanalyses of objective (OR, 4.16; 95% CI, 2.15-8.05) and subjective (OR, 2.65; 95% CI, 1.36-5.17) cure both significantly favored full-length slings. Therefore, we recommend a full-length MUS.


CONCLUSIONS
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.
Division of Gynecology and Urogynecology, Department of Obstetrics and Gynecology, University of Michigan Medical School, Ann Arbor, MI. Electronic address: mschimpf@umich.edu.
Megan O
MO
Schimpf
Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX.
David D
DD
Rahn
Department of Obstetrics and Gynecology, University of South Carolina School of Medicine Greenville, Greenville, SC.
Thomas L
TL
Wheeler
Department of Obstetrics and Gynecology, Kaiser Permanente, Roseville, CA.
Minita
M
Patel
Department of Obstetrics and Gynecology, University of Texas Southwestern at Seton Healthcare Family, Austin, TX.
Amanda B
AB
White
Department of Obstetrics and Gynecology and Reproductive Sciences, University of Texas Health Science Center at Houston, Houston, TX.
Francisco J
FJ
Orejuela
Division of Gynecologic Surgery, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN.
Sherif A
SA
El-Nashar
Division of Urogynecology, Department of Obstetrics and Gynecology, Kaiser Permanente, Oakland, CA.
Rebecca U
RU
Margulies
Division of Urogynecology, Department of Obstetrics and Gynecology, Carilion Clinic, Roanoke, VA.
Jonathan L
JL
Gleason
Department of Urogynecology, ProHealth Care, Women's Center, Medical College of Wisconsin, Waukesha, WI.
Sarit O
SO
Aschkenazi
Icahn School of Medicine at Mount Sinai, Department of Obstetrics and Gynecology, New York, NY.
Mamta M
MM
Mamik
Vanderbilt University Medical Center, Department of Obstetrics and Gynecology, Nashville, TN.
Renée M
RM
Ward
Tufts Medical Center, Institute for Clinical Research and Health Policy Studies, Boston, MA.
Ethan M
EM
Balk
Division of Urogynecology and Reconstructive Pelvic Surgery, Department of Obstetrics and Gynecology, Women and Infants Hospital of Rhode Island and Warren Alpert Medical School of Brown University, Providence, RI.
Vivian W
VW
Sung
D005260:Female; D006801:Humans; D015233:Models, Statistical; D016017:Odds Ratio; D016032:Randomized Controlled Trials as Topic; D053825:Suburethral Slings; D016896:Treatment Outcome; D014521:Urethra / Q000601:surgery*; D014550:Urinary Incontinence, Stress / Q000601:surgery*
Burch urethropexy; midurethral sling; pubovaginal sling; single-incision sling; stress urinary incontinence