Cochrane reviews evidence on surgery for stress incontinence after controversy in Scotland

BMJ 2015; 351 doi: (Published 02 July 2015) Cite this as: BMJ 2015;351:h3578
  1. Nigel Hawkes
  1. 1London

Surgery for urinary stress incontinence in women that involves mesh slings to support the muscles of the bladder is effective and has low rates of complications, an updated Cochrane review has found.1

A year after the operation more than 80% of women were cured, though the benefits declined slowly with time. At five years the cure rate fell to around 70%. Two common operations were used, differing in the way the sling was supported: either behind the pubic bone (the retropubic route) or side to side (the transobturator route). Both had similar success rates, the review found.

The operation became controversial after some women reported pain and injury, leading to court actions. In Scotland the chief medical officer asked hospitals to consider suspending mesh operations while an independent review looked at their safety. The review will report later this year and will be informed by the findings of the Cochrane review, Cathryn Glazener of the University of Aberdeen told a briefing at the Science Media Centre in London.

She is a member of both review groups but declined to anticipate the outcome of the Scottish review. “If it presents evidence in an unbiased way, then it will be up to women to decide, and the doctor’s job will be to counsel them,” she said.

Stress urinary incontinence is common and disabling, affecting six million women in the United Kingdom, said Abigail Ford from Bradford Teaching Hospitals NHS Foundation Trust, who led the Cochrane review. “Understanding this evidence in context is really important for women. They need to be aware of less invasive alternatives, such as pelvic floor exercises, which should be tried first before contemplating any type of surgery. As all surgery carries some risk, 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.”

Choosing between the two surgical routes is not straightforward. Both had identical risks of vaginal tape erosion, which occurred in around 20 in 1000 cases. The transobdurator route has a lower risk of bladder perforation and voiding dysfunction but a higher risk of groin pain and of the need for repeat surgery. “Both are highly effective and remain effective for five years and beyond and have similar low rates of complications,” Ford said.

The team examined 81 randomised controlled trials to reach their conclusions and said that this was one of the most often investigated procedures in medicine. There was no need for more randomised controlled trials, the team said, but it would be valuable to have longer term follow-up of the existing trials.

Joseph Ogah, a consultant gynaecologist at University Hospitals of Morecambe Bay NHS Foundation Trust, said, “We need to know more about what happens to women in the long term. This review found 35 trials carried out more than five years ago: if all the women in these trials were followed up we would know much more about how long the operations last and, crucially, whether they had developed late but important side effects.”


Cite this as: BMJ 2015;351:h3578


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