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Review finds pros and cons for continence surgery methods

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Two common surgical procedures result in similar cure rates for stress urinary continence, but there are differences in complications and the need for repeat operations, according to a review.

A Cochrane systematic review has concluded that inserting a mid-urethral sling – a type of tape – to support the muscles of the bladder results in similar cure rates in either the groin or abdomen, but suggests they have different associated risks.

Researchers said the review represented an important contribution to the debate on surgery for SUI and would help women to make more informed choices about treatment.

“This is a very significant review informing women about the minimally invasive surgical options available for the treatment of this very debilitating condition”

Abigail Ford

The team reviewed 81 trials, of which 55 directly compared the insertion of a sling behind the pubic bone coming out via the abdomen – the retropubic route – or alternatively from side-to-side coming out through the groin – the transobturator route.

They found moderate quality evidence that at around 12 months, both routes had successfully cured symptoms in 80% of women but this fell to 70% in the few studies that had reported five-year data.

They said transobturator insertion seemed to carry a lower risk of bladder damage, with around six women in 1,000 experiencing it, compared with 50 in 1,000 in the retropubic groups.

Meanwhile, 40 in 1,000 women in the transobturator group had persistent difficulty in being able to empty their bladder completely, compared with around 70 in 1,000 in the retropubic group.

In contrast, the reviewers said the transobturator operation led to more short-term groin pain and there was some evidence that transobturator route insertion was more likely to need a repeat operation.

The overall rate of erosion of the tape into the vagina was 2% following either surgery when the studies had completed follow-up at between one and five years, they said.

The rate of pain during sexual intercourse was also low in both groups, they added.

Over the last few years many questions have been raised about the safety of continence surgery, because it involves implanting a sling made of an artificial mesh.

There have been reports of women suffering pain and injury after surgery, resulting in many court actions worldwide.

An independent review was set up in Scotland in 2014 to review the safety of these operations will publish its findings later this year.

Lead author Abigail Ford, from Bradford Teaching Hospitals NHS Foundation Trust, said the review  would help give women “more information to make an informed choice” about treatment options.

“It helps to clarify the pre-existing evidence on the effectiveness of these approaches and their side effects in the short term, as well as introducing longer term evidence of efficacy and safety,” she said.

Dr Ford added: “Women must weigh up carefully how much they are troubled by their urine leakage against taking a small chance that things may go wrong as a result of surgery.”

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