Ja-Hong Kim, MD
|
Urologists have witnessed a remarkable evolution in the treatment of female stress urinary incontinence (SUI) culminating
in the contemporary mid-urethral sling, a monofilament, thinly woven mesh tape that is inserted either through the retropubic
space or obturator foramen to support the hypermobile urethra at the mid- to distal position in a tension-free fashion. A
steady stream of new, commercially available sling kits has entered the market, each promising to be faster, safer, and better.
But what does the evidence say?
Shlomo Raz, MD
|
Recently, Dmochowski summarized interim data on the new single-incision mid-urethral sling (TVT-SECUR, Ethicon) based on a
world-wide registry of more than 642 women, of whom 253 were available at 1-year follow-up (see, "Single-incision sling shows
positive 1-year results"). Objective cure was 87.5%, defined by negative standing cough test. Subjective assessment, based
on patient responses to the Incontinence Quality of Life instrument, revealed 84% patient satisfaction.
Although this prospective study has the advantage of a large, multicenter registry, it is limited by a short length of follow-up
and low patient response of 39% at 1 year, which may under-represent early failure rate. Further, as Dmochowski suggests,
these results may not translate to the general urology or gynecology practice, due to the inherent and possibly significant
variations in technique, such as degree of tension, incision type, and sling position.
Several authors have critically reviewed and compared the outcomes of various mid-urethral slings and concluded that, irrespective
of type, slings are safe and efficacious. At UCLA, we published our long-term, prospective data with the distal urethral polypropylene sling, which is inexpensively
assembled in the operating room without the need for a prepackaged kit. The data showed over 80% subjective cure rate, based
on patient-driven questionnaires. It is clear from our collective sling experience that we can symptomatically improve continence
for a durable length of time with minimal morbidity. What remains uncertain is who, when, and why an SUI patient fails intervention.
As we await the next major innovation in SUI, the practicing urologist should commit to the most successful sling approach
based on his or her experience to consistently deliver the best outcome. Future research efforts aimed at tissue engineering,
gene therapy, and injectable stem cells may be the next paradigm shift to regeneration of the damaged continence mechanism.
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