426 476
(MUS) surgery in women with SUI and showed a
significantly higher patient-reported success rate in women
who underwent MUS surgery at 1-yr follow-up (91% vs 65%;
95% confidence interval [CI] 18.1–34.5). Similarly, the
objective cure rates were higher in the MUS group.
Interestingly, the favourable results with MUS pertained
in a per-protocol analysis, which showed that women who
crossed over to the surgery group had outcomes similar to
those of women initially assigned to surgery and that both
these groups had outcomes superior to those of women who
underwent PFMT only
[11]. In addition, PFMT requires
persistence and some form of maintenance programme to
preserve the curative effect. Such an effort may lead a
substantial number of women to abandon the PFMT
programme and seek alternative forms of treatment that
may provide more rapid cure
[11].
Open retropubic colposuspension was commonly used
until 15 yr ago and has been a widely evaluated surgical
technique for SUI. Open retropubic colposuspension is
associated with high rates of objective and subjective cure,
especially in the long term
[12]. After 5 yr, approximately
70% of women remained ‘‘dry’’. Laparoscopic colposuspen-
sion is associated with similar cure rates of SUI when
compared with open colposuspension if undertaken in the
same way, but with a lower risk of complications and a
shorter hospital stay
[13]. Colposuspension, however,
involves significant repositioning of the anterior pelvic
compartment and is associated with a significant incidence
of secondary POP of the posterior pelvic compartment
[14] .A
most recent systematic review and meta-analysis showed
that synthetic MUSs were associated with significantly
higher cure rates compared with colposuspension in both
patient-reported outcomes (any definition of continence:
81.8% vs 73.6%, odds ratio [OR]: 0.59; 95% CI: 0.45–0.79;
p
= 0.0003) and objective continence rates (negative stress
test: 79.7% vs 67.8%, OR: 0.51; 95% CI: 0.34–0.76;
p
= 0.001).
Notably, stratifying the colposuspension outcomes accord-
ing to the surgical approach (open vs laparoscopic), the
differences in favour of synthetic MUS pertained
[15].
Several techniques have been described using needle
suspension; however, this is now rarely used due to poor
long-term durability as well as complications associated
with the synthetic cuffs used
[16].
The pubovaginal and autologous fascial sling techniques
have been used for many years and are usually performed
via an abdominal route. The autologous sling is made of a
strip of tissue from the abdominal rectus fascia or fascia lata.
Autologous fascial slings are associated with similar cure
rates of SUI for women when compared with open
colposuspension, but with a higher risk of postoperative
complications (bladder outlet obstruction, need for self-
catheterisation, etc.)
[17,18]. In recent years, a shorter sling
(sling on a string) has been used based on a needle
suspension technique, in a more minimally invasive manner,
placed loosely and midurethrally
[19] .The updated system-
atic review and meta-analysis showed that, on the whole,
synthetic MUSs and autologous slings were associated with
similar effectiveness and similar prevalence of complica-
tions. However, there was a clear trend towards lower
reoperation rates and lower postoperative storage symp-
toms with synthetic MUSs
[15].
MUS using synthetic PP tape is the recommended
method of surgical approach for the correction of SUI in
the 2016 EAU guidelines. Both retropubic and transobtura-
tor (TO) approaches are well-established standard MUSs
within clinical practice. The 2015 Cochrane review
[20]and
the recent SCENIHR report
[21]concluded that synthetic
MUSs are the most extensively researched surgical treat-
ment for SUI, with over 200 published clinical trials
establishing its effectiveness and good safety profile.
Long-term outcomes for the TO approach have since been
published
[22–24] .In recent years, some surgeons used
single-incision mini-slings in clinical practice; however, no
long-term data exist on their efficacy
[21,25]. One system-
atic review have shown that excluding TVT-Secur, there was
no evidence of significant differences in patient-reported
and objective cure compared with MUSs at 18-mo follow-
up, while they were associated with more favourable
recovery
[26].
Urethral balloons and injectables are not recommended
as first-line therapy for SUI
[25]. Bulking agents are
associated with lower cure rates of SUI when compared
with colposuspension or autologous fascial slings
[27]. There are insufficient data concerning periurethral
stem cells (autologous myoblasts, muscle-derived stem
cells, and autologous fibroblasts) injection that is supposed
to treat intrinsic sphincteric deficiency
[28].
The artificial urinary sphincter (AUS)
[29]in women has
not yet been widely used or evaluated in an RCT. This
technique is not recommended as a first-line surgical
treatment for SUI
[25,30–32].
4.
Treatment of POP in women
Spontaneous progression of symptoms and/or anatomical
status in women with POP is common, but a large
prospective cohort study concluded that only a small
proportion of women with symptomatic POP show progres-
sion within 5 yr
[33,34].
Whilst local vaginal oestrogen therapy can provide good
symptomatic relief for urogenital atrophy, there is no
evidence that it is beneficial in correcting POP
[35].
PFMT, with or without pessary use, should be considered
as treatment for stage 1 or 2 POP (there is evidence that
PFMT does not work well for stage 3 or 4 POP), but the
training needs proper instruction from a specialist in
women’s health physiotherapy and close follow-up to be
effective. PFMT is associated with some improvement in
symptoms in the short term (12 mo) for early-stage POP and
a marginal decrease in International Continence Society POP
quantification system stage
[36] .Lifestyle advice to patients
such as weight loss and improving general physical fitness is
recommended, to attempt to improve symptoms and
prevent progression of POP. However, irrespective of initial
PFMT, many patients will require surgical intervention.
Pessary use is an effective and patient-reported satisfactory
treatment albeit with side effects, but the discontinuation
rate is high at long-term follow-up
[37] .E U R O P E A N U R O L O G Y 7 2 ( 2 0 1 7 ) 4 2 4 – 4 3 1
426