Minimally invasive synthetic suburethral sling operations for stress urinary incontinence in women (Review)

Minimally invasive synthetic suburethral sling operations for stress urinary incontinence in women (Review) Ogah J, Cody JD, Rogerson L This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library 2010, Issue 1 http://www.thecochranelibrary.com

T A B L E O F C O N T E N T S HEADER....................................... 1 ABSTRACT...................................... 1 PLAIN LANGUAGE SUMMARY.............................. 2 SUMMARY OF FINDINGS FOR THE MAIN COMPARISON................... 2 BACKGROUND.................................... 6 OBJECTIVES..................................... 8 METHODS...................................... 8 RESULTS....................................... 10 Figure 1...................................... 13 Figure 2...................................... 14 ADDITIONAL SUMMARY OF FINDINGS.......................... 22 DISCUSSION..................................... 45 AUTHORS CONCLUSIONS............................... 47 ACKNOWLEDGEMENTS................................ 48 REFERENCES..................................... 48 CHARACTERISTICS OF STUDIES............................. 59 DATA AND ANALYSES.................................. 120 Analysis 1.1. Comparison 1 Minimally invasive synthetic suburethral sling operation versus traditional slings, Outcome 1 Subjective cure within 12 months............................ 128 Analysis 1.2. Comparison 1 Minimally invasive synthetic suburethral sling operation versus traditional slings, Outcome 2 Subjective cure & improvement within 12 months...................... 129 Analysis 1.3. Comparison 1 Minimally invasive synthetic suburethral sling operation versus traditional slings, Outcome 3 Subjective cure after 12 months............................ 129 Analysis 1.4. Comparison 1 Minimally invasive synthetic suburethral sling operation versus traditional slings, Outcome 4 Subjective cure & improvement after 12 months...................... 130 Analysis 1.5. Comparison 1 Minimally invasive synthetic suburethral sling operation versus traditional slings, Outcome 5 Pad test: mean weight of urine............................. 130 Analysis 1.6. Comparison 1 Minimally invasive synthetic suburethral sling operation versus traditional slings, Outcome 6 Objective cure after 12 months............................ 131 Analysis 1.7. Comparison 1 Minimally invasive synthetic suburethral sling operation versus traditional slings, Outcome 7 Perioperative complications.............................. 131 Analysis 1.8. Comparison 1 Minimally invasive synthetic suburethral sling operation versus traditional slings, Outcome 8 Operative time (mins)................................ 132 Analysis 1.9. Comparison 1 Minimally invasive synthetic suburethral sling operation versus traditional slings, Outcome 9 Length of hospital stay (days)............................. 132 Analysis 1.10. Comparison 1 Minimally invasive synthetic suburethral sling operation versus traditional slings, Outcome 10 Bladder or urethral perforation........................... 133 Analysis 1.11. Comparison 1 Minimally invasive synthetic suburethral sling operation versus traditional slings, Outcome 11 De novo urgency or urgency incontinence........................ 133 Analysis 1.12. Comparison 1 Minimally invasive synthetic suburethral sling operation versus traditional slings, Outcome 12 Detrusor overactivity............................... 134 Analysis 1.13. Comparison 1 Minimally invasive synthetic suburethral sling operation versus traditional slings, Outcome 13 Voiding dysfunction............................... 134 Analysis 1.14. Comparison 1 Minimally invasive synthetic suburethral sling operation versus traditional slings, Outcome 14 Vaginal erosion................................. 135 Analysis 1.15. Comparison 1 Minimally invasive synthetic suburethral sling operation versus traditional slings, Outcome 15 Bladder/urethral erosion.............................. 135 Analysis 1.16. Comparison 1 Minimally invasive synthetic suburethral sling operation versus traditional slings, Outcome 16 Groin pain.................................. 136 Analysis 2.1. Comparison 2 Minimally invasive synthetic suburethral sling operation versus open colposuspension, Outcome 1 Subjective cure within 12 months....................... 136 i

Analysis 2.2. Comparison 2 Minimally invasive synthetic suburethral sling operation versus open colposuspension, Outcome 2 Subjective cure after 12 months and less than 5 years................. 137 Analysis 2.3. Comparison 2 Minimally invasive synthetic suburethral sling operation versus open colposuspension, Outcome 3 Subjective cure after 5 years......................... 137 Analysis 2.4. Comparison 2 Minimally invasive synthetic suburethral sling operation versus open colposuspension, Outcome 4 Subjective cure & improvement within 12 months.................. 138 Analysis 2.5. Comparison 2 Minimally invasive synthetic suburethral sling operation versus open colposuspension, Outcome 5 Objective cure within 12 months........................ 138 Analysis 2.6. Comparison 2 Minimally invasive synthetic suburethral sling operation versus open colposuspension, Outcome 6 Objective cure after 12 months and less than 5 years................. 139 Analysis 2.7. Comparison 2 Minimally invasive synthetic suburethral sling operation versus open colposuspension, Outcome 7 Objective cure after 5 years.......................... 139 Analysis 2.8. Comparison 2 Minimally invasive synthetic suburethral sling operation versus open colposuspension, Outcome 8 Objective cure & improvement within 12 months.................. 140 Analysis 2.9. Comparison 2 Minimally invasive synthetic suburethral sling operation versus open colposuspension, Outcome 9 Perioperative complications.......................... 140 Analysis 2.10. Comparison 2 Minimally invasive synthetic suburethral sling operation versus open colposuspension, Outcome 10 Operative time (mins)........................... 141 Analysis 2.11. Comparison 2 Minimally invasive synthetic suburethral sling operation versus open colposuspension, Outcome 11 Length of hospital stay (days)........................ 141 Analysis 2.12. Comparison 2 Minimally invasive synthetic suburethral sling operation versus open colposuspension, Outcome 12 Bladder or urethral perforation........................ 142 Analysis 2.13. Comparison 2 Minimally invasive synthetic suburethral sling operation versus open colposuspension, Outcome 13 De novo urgency or urgency incontinence.................... 143 Analysis 2.14. Comparison 2 Minimally invasive synthetic suburethral sling operation versus open colposuspension, Outcome 14 Detrusor overactivity........................... 143 Analysis 2.15. Comparison 2 Minimally invasive synthetic suburethral sling operation versus open colposuspension, Outcome 15 Voiding dysfunction............................ 144 Analysis 2.16. Comparison 2 Minimally invasive synthetic suburethral sling operation versus open colposuspension, Outcome 16 Repeat incontinence surgery......................... 144 Analysis 2.17. Comparison 2 Minimally invasive synthetic suburethral sling operation versus open colposuspension, Outcome 17 Later prolapse surgery........................... 145 Analysis 2.18. Comparison 2 Minimally invasive synthetic suburethral sling operation versus open colposuspension, Outcome 18 Vaginal erosion............................. 145 Analysis 2.19. Comparison 2 Minimally invasive synthetic suburethral sling operation versus open colposuspension, Outcome 19 Groin pain............................... 146 Analysis 3.1. Comparison 3 Minimally invasive synthetic suburethral sling operation versus laparoscopic colposuspension, Outcome 1 Subjective cure within 12 months....................... 146 Analysis 3.2. Comparison 3 Minimally invasive synthetic suburethral sling operation versus laparoscopic colposuspension, Outcome 2 Subjective cure and improvement within 12 months................. 147 Analysis 3.3. Comparison 3 Minimally invasive synthetic suburethral sling operation versus laparoscopic colposuspension, Outcome 3 Subjective cure after 12 months........................ 148 Analysis 3.4. Comparison 3 Minimally invasive synthetic suburethral sling operation versus laparoscopic colposuspension, Outcome 4 Incontinence episodes (per week) at 1 year.................... 149 Analysis 3.5. Comparison 3 Minimally invasive synthetic suburethral sling operation versus laparoscopic colposuspension, Outcome 5 Incontinence episodes (per week) at 2 years.................... 150 Analysis 3.6. Comparison 3 Minimally invasive synthetic suburethral sling operation versus laparoscopic colposuspension, Outcome 6 Objective cure within 12 months........................ 151 Analysis 3.7. Comparison 3 Minimally invasive synthetic suburethral sling operation versus laparoscopic colposuspension, Outcome 7 Objective cure and improvement within 12 months................. 152 Analysis 3.8. Comparison 3 Minimally invasive synthetic suburethral sling operation versus laparoscopic colposuspension, Outcome 8 Objective cure after 12 months........................ 152 ii

Analysis 3.9. Comparison 3 Minimally invasive synthetic suburethral sling operation versus laparoscopic colposuspension, Outcome 9 Entero rectocele............................. 153 Analysis 3.10. Comparison 3 Minimally invasive synthetic suburethral sling operation versus laparoscopic colposuspension, Outcome 10 Peri-operative complications......................... 153 Analysis 3.11. Comparison 3 Minimally invasive synthetic suburethral sling operation versus laparoscopic colposuspension, Outcome 11 Economic: Total costs........................... 154 Analysis 3.12. Comparison 3 Minimally invasive synthetic suburethral sling operation versus laparoscopic colposuspension, Outcome 12 Operative time (minutes).......................... 155 Analysis 3.13. Comparison 3 Minimally invasive synthetic suburethral sling operation versus laparoscopic colposuspension, Outcome 13 Length of hospital stay (days)........................ 156 Analysis 3.14. Comparison 3 Minimally invasive synthetic suburethral sling operation versus laparoscopic colposuspension, Outcome 14 Time to return to normal activity level(days)................... 157 Analysis 3.15. Comparison 3 Minimally invasive synthetic suburethral sling operation versus laparoscopic colposuspension, Outcome 15 Operative blood loss........................... 158 Analysis 3.16. Comparison 3 Minimally invasive synthetic suburethral sling operation versus laparoscopic colposuspension, Outcome 16 Major vascular or visceral injury........................ 159 Analysis 3.17. Comparison 3 Minimally invasive synthetic suburethral sling operation versus laparoscopic colposuspension, Outcome 17 Bladder or urethral perforation........................ 159 Analysis 3.18. Comparison 3 Minimally invasive synthetic suburethral sling operation versus laparoscopic colposuspension, Outcome 18 De novo urgency or urgency incontinence.................... 160 Analysis 3.19. Comparison 3 Minimally invasive synthetic suburethral sling operation versus laparoscopic colposuspension, Outcome 19 Detrusor overactivity........................... 161 Analysis 3.20. Comparison 3 Minimally invasive synthetic suburethral sling operation versus laparoscopic colposuspension, Outcome 20 Voiding dysfunction............................ 162 Analysis 3.21. Comparison 3 Minimally invasive synthetic suburethral sling operation versus laparoscopic colposuspension, Outcome 21 Repeat incontinence surgery......................... 163 Analysis 3.22. Comparison 3 Minimally invasive synthetic suburethral sling operation versus laparoscopic colposuspension, Outcome 22 Later prolapse surgery........................... 163 Analysis 3.23. Comparison 3 Minimally invasive synthetic suburethral sling operation versus laparoscopic colposuspension, Outcome 23 Vaginal erosion............................. 164 Analysis 4.1. Comparison 4 Retropubic bottom-to-top approach versus retropubic top-to-bottom approach, Outcome 1 Subjective cure within 12 months............................ 166 Analysis 4.2. Comparison 4 Retropubic bottom-to-top approach versus retropubic top-to-bottom approach, Outcome 2 Objective cure within 12 months............................ 167 Analysis 4.3. Comparison 4 Retropubic bottom-to-top approach versus retropubic top-to-bottom approach, Outcome 3 Perioperative complications.............................. 168 Analysis 4.4. Comparison 4 Retropubic bottom-to-top approach versus retropubic top-to-bottom approach, Outcome 4 Operative time (mins)................................ 168 Analysis 4.5. Comparison 4 Retropubic bottom-to-top approach versus retropubic top-to-bottom approach, Outcome 5 Bladder or urethral perforation............................. 169 Analysis 4.6. Comparison 4 Retropubic bottom-to-top approach versus retropubic top-to-bottom approach, Outcome 6 Length of hospital stay (days)............................. 169 Analysis 4.7. Comparison 4 Retropubic bottom-to-top approach versus retropubic top-to-bottom approach, Outcome 7 Voiding dysfunction................................ 170 Analysis 4.8. Comparison 4 Retropubic bottom-to-top approach versus retropubic top-to-bottom approach, Outcome 8 De novo urgency or urgency incontinence......................... 171 Analysis 4.9. Comparison 4 Retropubic bottom-to-top approach versus retropubic top-to-bottom approach, Outcome 9 Detrusor overactivity................................ 171 Analysis 4.10. Comparison 4 Retropubic bottom-to-top approach versus retropubic top-to-bottom approach, Outcome 10 Vaginal erosion.................................. 172 Analysis 4.11. Comparison 4 Retropubic bottom-to-top approach versus retropubic top-to-bottom approach, Outcome 11 QoL specific................................... 172 iii

Analysis 5.1. Comparison 5 Obturator medial-to-lateral approach versus obturator lateral-to-medial approach, Outcome 1 Subjective cure within 12 months............................ 173 Analysis 5.2. Comparison 5 Obturator medial-to-lateral approach versus obturator lateral-to-medial approach, Outcome 2 Subjective cure and improvement within 12 months..................... 173 Analysis 5.3. Comparison 5 Obturator medial-to-lateral approach versus obturator lateral-to-medial approach, Outcome 3 Objective cure within 12 months............................ 174 Analysis 5.4. Comparison 5 Obturator medial-to-lateral approach versus obturator lateral-to-medial approach, Outcome 4 Objective cure and improvement within 12 months..................... 174 Analysis 5.5. Comparison 5 Obturator medial-to-lateral approach versus obturator lateral-to-medial approach, Outcome 5 Time to return to normal activity level.......................... 175 Analysis 5.6. Comparison 5 Obturator medial-to-lateral approach versus obturator lateral-to-medial approach, Outcome 6 Operative time (mins)................................ 175 Analysis 5.7. Comparison 5 Obturator medial-to-lateral approach versus obturator lateral-to-medial approach, Outcome 7 Operative blood loss (ml).............................. 176 Analysis 5.8. Comparison 5 Obturator medial-to-lateral approach versus obturator lateral-to-medial approach, Outcome 8 Perioperative complications.............................. 176 Analysis 5.9. Comparison 5 Obturator medial-to-lateral approach versus obturator lateral-to-medial approach, Outcome 9 Bladder or urethral perforation............................. 177 Analysis 5.10. Comparison 5 Obturator medial-to-lateral approach versus obturator lateral-to-medial approach, Outcome 10 De novo urgency or urgency incontinence........................ 177 Analysis 5.11. Comparison 5 Obturator medial-to-lateral approach versus obturator lateral-to-medial approach, Outcome 11 Voiding dysfunction............................... 178 Analysis 5.12. Comparison 5 Obturator medial-to-lateral approach versus obturator lateral-to-medial approach, Outcome 12 Detrusor overactivity............................... 178 Analysis 5.13. Comparison 5 Obturator medial-to-lateral approach versus obturator lateral-to-medial approach, Outcome 13 Vaginal erosion................................. 179 Analysis 5.14. Comparison 5 Obturator medial-to-lateral approach versus obturator lateral-to-medial approach, Outcome 14 Groin / Thigh pain............................... 179 Analysis 5.15. Comparison 5 Obturator medial-to-lateral approach versus obturator lateral-to-medial approach, Outcome 15 QoL specific.................................. 180 Analysis 6.1. Comparison 6 Monofilament versus multifilament tapes, Outcome 1 Subjective cure within 12 months. 180 Analysis 6.2. Comparison 6 Monofilament versus multifilament tapes, Outcome 2 Objective cure within 12 months. 181 Analysis 6.3. Comparison 6 Monofilament versus multifilament tapes, Outcome 3 Operative time (mins)..... 181 Analysis 6.4. Comparison 6 Monofilament versus multifilament tapes, Outcome 4 Perioperative complications... 182 Analysis 6.5. Comparison 6 Monofilament versus multifilament tapes, Outcome 5 Bladder or urethral perforation.. 182 Analysis 6.6. Comparison 6 Monofilament versus multifilament tapes, Outcome 6 Length of hospital stay (days).. 183 Analysis 6.7. Comparison 6 Monofilament versus multifilament tapes, Outcome 7 De novo urgency or urgency incontinence................................... 183 Analysis 6.8. Comparison 6 Monofilament versus multifilament tapes, Outcome 8 Detrusor overactivity..... 184 Analysis 6.9. Comparison 6 Monofilament versus multifilament tapes, Outcome 9 Voiding dysfunction...... 184 Analysis 6.10. Comparison 6 Monofilament versus multifilament tapes, Outcome 10 Vaginal erosion...... 185 Analysis 7.1. Comparison 7 Transobturator (TOR) versus retropubic (RPR) route, Outcome 1 Subjective cure within 12 months..................................... 185 Analysis 7.2. Comparison 7 Transobturator (TOR) versus retropubic (RPR) route, Outcome 2 Subjective cure and improvement within 12 months............................ 186 Analysis 7.3. Comparison 7 Transobturator (TOR) versus retropubic (RPR) route, Outcome 3 Objective cure within 12 months..................................... 187 Analysis 7.4. Comparison 7 Transobturator (TOR) versus retropubic (RPR) route, Outcome 4 Pad test: mean weight of urine..................................... 188 Analysis 7.5. Comparison 7 Transobturator (TOR) versus retropubic (RPR) route, Outcome 5 Objective cure and improvement within 12 months............................ 188 Analysis 7.6. Comparison 7 Transobturator (TOR) versus retropubic (RPR) route, Outcome 6 Perioperative complications.................................. 189 iv

Analysis 7.7. Comparison 7 Transobturator (TOR) versus retropubic (RPR) route, Outcome 7 Operative time (mins). 190 Analysis 7.8. Comparison 7 Transobturator (TOR) versus retropubic (RPR) route, Outcome 8 Length of hospital stay (days)..................................... 191 Analysis 7.9. Comparison 7 Transobturator (TOR) versus retropubic (RPR) route, Outcome 9 Time to return to normal activity level (weeks)................................ 191 Analysis 7.10. Comparison 7 Transobturator (TOR) versus retropubic (RPR) route, Outcome 10 Operative blood loss (ml)...................................... 192 Analysis 7.11. Comparison 7 Transobturator (TOR) versus retropubic (RPR) route, Outcome 11 Major vascular or visceral injury..................................... 192 Analysis 7.12. Comparison 7 Transobturator (TOR) versus retropubic (RPR) route, Outcome 12 Bladder or urethral perforation................................... 193 Analysis 7.13. Comparison 7 Transobturator (TOR) versus retropubic (RPR) route, Outcome 13 De novo urgency or urgency incontinence................................ 194 Analysis 7.14. Comparison 7 Transobturator (TOR) versus retropubic (RPR) route, Outcome 14 Detrusor overactivity. 195 Analysis 7.15. Comparison 7 Transobturator (TOR) versus retropubic (RPR) route, Outcome 15 Voiding dysfunction. 195 Analysis 7.16. Comparison 7 Transobturator (TOR) versus retropubic (RPR) route, Outcome 16 Repeat incontinence surgery..................................... 196 Analysis 7.17. Comparison 7 Transobturator (TOR) versus retropubic (RPR) route, Outcome 17 Vaginal erosion.. 197 Analysis 7.18. Comparison 7 Transobturator (TOR) versus retropubic (RPR) route, Outcome 18 Bladder/urethral erosion..................................... 198 Analysis 7.19. Comparison 7 Transobturator (TOR) versus retropubic (RPR) route, Outcome 19 Groin pain (TOR) versus suprapubic pain (RPR)............................... 198 APPENDICES..................................... 200 WHAT S NEW..................................... 200 HISTORY....................................... 201 CONTRIBUTIONS OF AUTHORS............................. 201 DECLARATIONS OF INTEREST.............................. 201 INDEX TERMS.................................... 201 v

[Intervention Review] Minimally invasive synthetic suburethral sling operations for stress urinary incontinence in women Joseph Ogah 1, June D Cody 2, Lynne Rogerson 3 1 Department of Gynaecology, Leeds University Teaching Hospital, Leeds, UK. 2 Cochrane Incontinence Review Group, University of Aberdeen, Foresterhill, UK. 3 Gynaecology Department, St James University Hospital, Leeds, UK Contact address: Joseph Ogah, Department of Gynaecology, Leeds University Teaching Hospital, Gledwhow wing Level 6, Beckett Street, Leeds, LS9 7TF, UK. jogah@nhs.net. Editorial group: Cochrane Incontinence Group. Publication status and date: Edited (no change to conclusions), published in Issue 1, 2010. Review content assessed as up-to-date: 30 June 2009. Citation: Ogah J, Cody JD, Rogerson L. Minimally invasive synthetic suburethral sling operations for stress urinary incontinence in women. Cochrane Database of Systematic Reviews 2009, Issue 4. Art. No.: CD006375. DOI: 10.1002/14651858.CD006375.pub2. Background A B S T R A C T Stress urinary incontinence (SUI) is a common condition affecting up to 30% of women. Minimally invasive synthetic suburethral sling operations are among the latest forms of procedures introduced to treat SUI. Objectives To assess the effects of minimally invasive synthetic suburethral sling operations for treatment of SUI, urodynamic stress incontinence (USI) or mixed urinary incontinence (MUI) in women. Search strategy We searched the Cochrane Incontinence Group Specialised Register (searched 20 March 2008), MEDLINE (January 1950 to April 2008), EMBASE (January 1988 to April 2008), CINAHL (January 1982 to April 2008), AMED (January 1985 to April 2008), the UK National Research Register, ClinicalTrials.gov, and reference lists of relevant articles. Selection criteria Randomised or quasi-randomised controlled trials amongst women with SUI, USI or symptoms of stress or mixed urinary incontinence, in which at least one trial arm involved a minimally invasive synthetic suburethral sling operations. Data collection and analysis Two review authors assessed the methodological quality of potentially eligible studies and independently extracted data from the included trials. Main results Sixty two trials involving 7101 women were included. The quality of evidence was moderate for most trials. Minimally invasive synthetic suburethral sling operations appeared to be as effective as traditional suburethral slings ( trials, n = 599, Risk Ratio (RR) 1.03, 95% Confidence Interval (CI) 0.94 to 1.13) but with shorter operating time and less post-operative voiding dysfunction and de novo urgency symptoms. 1

Minimally invasive synthetic suburethral sling operations appeared to be as effective as open retropubic colposuspension (subjective cure rate at 12 months RR 0.96, 95% CI 0.90 to 1.03; at 5 years RR 0.91, 95% CI 0.74 to 1.12) with fewer perioperative complications, less postoperative voiding dysfunction, shorter operative time and hospital stay but significantly more bladder perforations (6% versus 1%, RR 4.24, 95% CI 1.71 to 10.52). There was conflicting evidence about the effectiveness of minimally invasive synthetic suburethral sling operations compared to laparoscopic colposuspension in the short term (objective cure, RR 1.15, 95% CI 1.06 to 1.24; subjective cure RR 1.11, 95% CI 0.99 to 1.24). Minimally invasive synthetic suburethral sling operations had significantly less de novo urgency and urgency incontinence, shorter operating time, hospital stay and time to return to daily activities. A retropubic bottom-to-top route was more effective than top-to-bottom route (RR 1.10, 95% CI 1.01 to 1.20; RR 1.06, 95% CI 1.01 to 1.11) and incurred significantly less voiding dysfunction, bladder perforations and tape erosions. Monofilament tapes had significantly higher objective cure rates (RR 1.15, 95% CI 1.02 to 1.30) compared to multifilament tapes and fewer tape erosions (1.3% versus 6% RR 0.25, 95% CI 0.06 to 1.00). The obturator route was less favourable than the retropubic route in objective cure (84% versus 88%; RR 0.96, 95% CI 0.93 to 0.99; 17 trials, n = 2434), although there was no difference in subjective cure rates. However, there was less voiding dysfunction, blood loss, bladder perforation (0.3% versus 5.5%, RR 0.14, 95% CI 0.07 to 0.26) and shorter operating time with the obturator route. Authors conclusions The current evidence base suggests that minimally invasive synthetic suburethral sling operations are as effective as traditional suburethral slings, open retropubic colposuspension and laparoscopic colposuspension in the short term but with less postoperative complications. Objective cure rates are higher with retropubic tapes than with obturator tapes but retropubic tapes attract more complications. Most of the trials had short term follow up and the quality of the evidence was variable. P L A I N L A N G U A G E S U M M A R Y. Stress urinary incontinence (involuntary leakage of urine on effort, or exertion, or on sneezing or coughing or laughing) is the commonest form of incontinence in women and reduces their quality of life. One in three women over the age of 18 years will be affected by stress urinary incontinence. Over the years surgery has become less invasive but there are many different types of operations. Minimally invasive synthetic suburethral sling operations are effective and relatively safe with cure rates of about 80% in the short term. They are also suitable for women who have had unsuccessful previous incontinence surgery. There is some evidence to suggest that operations using certain types of tape materials (type 1 meshes) are more effective with fewer complications (such as infections and tape erosions into the vagina or urethra) than other types. There are two ways of carrying out these operations, either behind the pubic bone or through the groin. Those passing behind the pubic bone are more effective and longer follow-up results are available, but they result in more problems with passing urine after operation and more cases of bladder injury. A major limitation is that long term follow-up data for the effectiveness of many of these procedures are lacking. 2

S U M M A R Y O F F I N D I N G S F O R T H E M A I N C O M P A R I S O N [Explanation] Minimally invasive synthetic suburethral sling operation compared to traditional slings for stress urinary incontinence in women Patient or population: patients with stress urinary incontinence in women Settings: secondary care Intervention: minimally invasive synthetic suburethral sling operation traditional suburethral slings Outcomes Illustrative comparative risks*(95% CI) Relative effect (95% CI) Subjective cure within 12 months Follow-up: mean 10.5 months Assumed risk traditional suburethral slings Studypopulation 1 710per1000 Mediumriskpopulation 1 712per1000 Corresponding risk minimally invasive synthetic suburethral sling operation 731per1000 (667to802) 733per1000 (669to805) RR1.03 (0.94 to 1.13) No of Participants (studies) 599 (8 studies) Quality of the evidence (GRADE) moderate 2 Comments Denovo urgency or urgency incontinence Studypopulation 1 RR0.36 (0.16 to 0.79) 236 (3 studies) moderate 2 3

168per1000 Mediumriskpopulation 1 143per1000 60per1000 (27to133) 51per1000 (23to113) VoidingDysfunction Studypopulation 1 RR0.75 (0.38 to 1.48) Peri-operative complications 134per1000 Mediumriskpopulation 1 108per1000 Studypopulation 1 41per1000 Mediumriskpopulation 1 100per1000 (51to198) 81per1000 (41to160) 45per1000 (9to214) RR1.09 (0.23 to 5.21) 254 (3 studies) 142 (1 study) moderate 2 low 2,3 41per1000 45per1000 (9to214) Bladder or urethral perforation Studypopulation 1 RR2.15 (0.75 to 6.16) 401 (4 studies) moderate 2 4

22per1000 Mediumriskpopulation 1 20per1000 47per1000 (17to136) 43per1000 (15to123) *The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention(and its 95% CI). CI: Confidence interval; RR: Risk ratio; GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Lowquality:Furtherresearchisverylikelytohaveanimportantimpactonourconfidenceintheestimateofeffectandislikelytochangetheestimate. Very low quality: We are very uncertain about the estimate. 1 Theassumedriskcalculatedasthemediancontrolgroupriskacrossthestudies 2 Uncertaintyinmoststudiesaboutmethodofsequencegenerationandallocationconcealment 3 wideconfidenceintervalincludepossiblebenefitfrombothsurgicalprocedures 5

B A C K G R O U N D The prevalence of urinary incontinence in adult women has been estimated to be between 10% and 40%, and is considered severe in about 3% to 17%, with annual incidence ranging from 2% to 11% (Hunskaar 2002; Milsom 2009). This is a potentially debilitating social problem with significant cost implications to the individuals and the healthcare service estimated in billions of dollars in the United States (Fantl 1996). The estimated total annual cost to the United Kingdom s National Health Service for treating clinically significant urinary incontinence in community dwelling women was GBP 233 million in 1999 to 2000 (Turner 2004). There is also significant cost borne by women on an individual basis with one estimate as high as GBP 178 million annually (Turner 2004). The average total urinary incontinence-related costs for each individual per year in the UK and Ireland, for patients predominantly treated in the primary care setting in 2003 and 2004, was estimated at EUR 359 Papanicolaou 2005). Continence is achieved through interplay of the normal anatomical and physiological properties of the bladder, urethra, urethral sphincter and pelvic floor, with the nervous system coordinating these organs. The urethra and its sphincter act as a closure mechanism during filling and contain urine within the bladder, allowing storage of urine until a convenient time and place to void is reached. The pelvic floor provides support to the bladder and urethra, and allows normal abdominal pressure transmission to the proximal urethra which is essential in the maintenance of continence. Crucial to the healthy functioning of the bladder, urethra, sphincter and pelvic floor is coordination between them, facilitated by an intact nervous system control (Lapitan 2009). Recent findings on the pathophysiology of urinary incontinence have demonstrated that mid-urethral support, provided by the pubo-urethral ligaments, also plays an important role in maintaining continence when the intra-abdominal pressure rises (Ulmsten 1995). Description of the condition Incontinence occurs when this normal relationship between the lower urinary tract components is disrupted, resulting from nerve damage or direct mechanical trauma to the pelvic organs (Lapitan 2009). Advancing age, higher parity, vaginal delivery, obesity and menopause are associated with an increase in risk of urinary incontinence (Wilson 1996). There are different forms of urinary incontinence. Stress urinary incontinence is the most common type (Wilson 1996). It is the complaint of involuntary leakage of urine on effort, or exertion, or on sneezing or coughing (Abrams 2002). Urodynamic stress incontinence is the involuntary loss of urine from the urethra during physical activities that increase abdominal pressure, in the absence of a detrusor (bladder wall muscle) contraction or an over-distended bladder. Two mechanisms for stress incontinence are recognized: hyper-mobility or significant displacement of the urethra and bladder neck during exertion, and intrinsic urethral sphincter deficiency (Blaivas 1988). In women, these mechanisms may coexist (O Donnell 1994). Few clinical trials have distinguished between the two conditions, probably because there is no standardised and validated test available to date (Blaivas 1988; McGuire 1993), and the distinction is not recognised by the International Continence Society (Abrams 2002). Women whose incontinence may be due to either mechanism were considered together in this review. The diagnosis of urodynamic stress incontinence implies that urodynamic investigation was done to confirm stress incontinence; it may also identify the presence of detrusor overactivity, in mixed incontinence. Standard clinical assessment includes history taking, physical examination, frequency/volume charts and urine analysis. Some authors described women with just the symptom of stress urinary incontinence (diagnosis made on clinical evaluation without urodynamics). Women with stress urinary incontinence and those with urodynamic stress incontinence were included in this review. Urgency incontinence is the symptom of involuntary loss of urine associated with a sudden, strong desire (urgency) to void. Detrusor overactivity is a diagnosis that denotes involuntary detrusor contractions observed during the filling phase of a urodynamic assessment. It may be spontaneous or provoked and can be qualified according to cause - neurogenic or idiopathic (Abrams 2002). Women with the symptom of urgency incontinence and the formal urodynamic diagnosis of detrusor overactivity were included in the review only if they had co-existing stress incontinence (so called mixed incontinence). Women with mixed incontinence included in this review either had symptoms of stress plus urgency incontinence or other urinary symptoms (diagnosed clinically), or urodynamic stress incontinence plus detrusor overactivity (urodynamic diagnosis). Description of the intervention Management of stress urinary incontinence includes conservative, mechanical, pharmacological and surgical interventions. Conservative management centres on physical methods, including pelvic floor muscle training, electrical stimulation, biofeedback and the use of weighted cones. Mechanical devices which prevent or reduce urinary leakage are available, such as metal plugs or patches and urethral or vaginal inserts. Drug therapies, such as oestrogens and alpha adrenergic agents, have been used in the past. Recently, inhibitors of serotonin and norepinephrine reuptake have been proposed as new drug therapy for urinary stress incontinence, used alone or in combination with other conservative management (Ghoniem 2005). A trial of such conservative treatments should be undertaken before resorting to surgery. These interventions are the subject of separate 6

Cochrane reviews. Adrenergic drugs for urinary incontinence in adults ( Alhasso 2005). Bladder training for urinary incontinence in adults (Wallace 2004). Mechanical devices for urinary incontinence in women ( Shaikh 2006). Oestrogens for urinary incontinence in women (Moehrer 2003). Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women (Hay- Smith 2006). Serotonin and noradrenaline reuptake inhibitors (SNRI) for stress urinary incontinence in adults (Mariappan 2005). Weighted vaginal cones for urinary incontinence (Herbison 2009). Surgical procedures to remedy stress incontinence generally aim to lift and support the urethro-vesical junction but in the last decade the emphasis has been of suburethral support at the mid urethral level. Owing to disagreement on the precise mechanism by which continence is achieved, the choice of surgical procedure is influenced by co-existent problems, surgeon s preference and the physical features of the person affected. Numerous surgical methods for stress incontinence have been described and evaluated in Cochrane reviews. Essentially they fall into seven categories: open abdominal retropubic suspension (e.g. colposuspension (Burch/ modified Burch), Marshall-Marchetti- Krantz (MMK)) (Lapitan 2009); laparoscopic retropubic suspension (Dean 2006); anterior vaginal repair (anterior colporrhaphy - e.g. Kelly, Pacey) (Glazener 2001); suburethral slings (including traditional suburethral slings and minimally invasive sling operations) (Bezerra 2005); needle suspensions (e.g. Pereyra, Stamey) ( Glazener 2004); peri-urethral injections (Pickard 2003); and artificial sphincters (Keegan 2007). This is the second of two reviews focusing on sling operations. The first review concentrates on traditional suburethral sling operations (Bezerra 2005). A traditional suburethral sling operation requires a combined abdominal and vaginal approach. Strips of material are tunnelled under the proximal urethra. They are attached either to the rectus muscle or the iliopectineal ligaments, resulting in a tightening of the sling and increased bladder support every time the woman strains. The materials that have been used for slings may be biological or synthetic. They are applied under open surgery and are fixed with sutures. How the intervention might work A modification of the suburethral sling procedure is the minimally invasive approach. Minimally invasive synthetic suburethral sling operations (minimally invasive synthetic suburethral sling operations) involve the insertion of a tape covered by a plastic sheath around the mid-urethra without suture fixation, performed in some centres under local anaesthesia (Ulmsten 1995; Ulmsten 1996; Smith 2002). The aim is to restore or enhance the patient s urethral support during a sudden movement, such as a cough or sneeze. This prevents the involuntary loss of urine. Ultrasound studies suggest that the mechanism of action is intermittent or dynamic obstruction of the urethra by the tape when increased abdominal pressure occurs (such as when coughing or sneezing) ( Dietz 2004). The procedure involves the insertion of two needles passed through the retropubic space blindly from vagina to abdomen or from abdomen to vagina. Cystoscopy is recommended to detect any perforation of the bladder or urethra. Another type of minimally invasive synthetic suburethral sling operations has been developed in which the tape is inserted in a horizontal plane underneath the middle of the urethra between the two obturator foramina. The ends of the tape are tunnelled percutaneously with a tunneller (curved needle), again without suture fixation. As the retropubic space is not breached, it is argued that cystoscopy is not required ( Delorme 2001; Delorme 2003; Delorme 2004). Shortly after this a similar operation was described which allows the passage of a tape through the obturator foramina, from inside to outside (de Leval 2003; de Leval 2005). Only mid-urethral sling operations, with synthetic tape materials applied by minimally invasive surgeries, either through the retropubic space or the transobturator route were included in this review. A concern of using synthetic material is the potential risk of complications caused by infection and tissue reaction to the tapes. Some aspects of the material that may vary include pore size, mono- or multifilament design, and biocompatibility. All types of mesh used in different minimally invasive slings were included in this review and possible differences between the risk of complications were addressed by the outcome measures. Why it is important to do this review There is a plethora of minimally invasive synthetic tapes available and used worldwide for treatment of stress urinary incontinence. The reported effectiveness and safety of these procedures have made them very popular but controversy exists on which of these procedures is best. The introduction of many of these procedures and tapes have been market driven and in the past have not been accompanied by rigorous prospective randomised controlled studies of effectiveness. Recently though there have been more randomised controlled trials assessing their effectiveness, but many are too small to draw definitive conclusions. Meta-analysis 7

of the trials available is necessary to help make judgements on their efficacy and safety. Some systematic reviews and meta-analyses have been carried out, but some have concentrated only on certain types of minimally invasive synthetic suburethral sling operations, e.g. retropubic versus trans obturator operations (Latthe 2007; Sung 2007), others have compared minimally invasive synthetic suburethral sling operations to other surgical treatments (Novara 2007; Novara 2008) but used quality scales such as Jadad 1996 to assess the quality of studies for inclusion. The use of scales leaves room for selection bias and lends more weight to the quality of reporting rather than the conduct or actual methodological quality and this has been shown to be an unreliable method of assessment of validity (Juni 1999). We have carried out a review of minimally invasive synthetic suburethral sling operations, performing a comprehensive search, reporting the criteria used to include studies, avoiding bias in the inclusion of studies, using domain-based evaluating criteria for assessing the validity of studies and in addition having regular updating capability. As new evidence comes to light, we will systematically search for and identify new evidence to incorporate into this systematic review. O B J E C T I V E S To assess the clinical effects of minimally invasive synthetic suburethral sling operations for the treatment of: urodynamic stress urinary incontinence (urodynamic diagnosis), or for symptoms of stress or mixed incontinence (clinical diagnosis) in women. The following comparisons were made: 1. Minimally invasive synthetic suburethral sling operations versus traditional sub-urethral slings. 2. Minimally invasive synthetic suburethral sling operations versus colposuspension (abdominal surgery). 3. Minimally invasive synthetic suburethral sling operations versus laparoscopic procedures. 4. One type of minimally invasive synthetic suburethral sling operations versus another, sub-grouped as: monofilament versus multifilament; retropubic versus transobturator. 5. Minimally invasive synthetic suburethral sling operations versus no treatment. 6. Minimally invasive synthetic suburethral sling operations versus conservative treatment. M E T H O D S Criteria for considering studies for this review Types of studies Randomised or quasi-randomised controlled trials amongst women with urodynamic stress incontinence (urodynamic diagnosis), or symptoms of stress or mixed urinary incontinence (clinical diagnosis), in which at least one trial arm involves minimally invasive synthetic suburethral sling operations. Types of participants Adult women with stress urinary incontinence due to hyper-mobility and intrinsic sphincter deficiency, or both, diagnosed clinically or with urodynamics, or with mixed incontinence. Classification of diagnoses were accepted as defined by the trialists. Types of interventions At least one arm of a study must involve minimally invasive synthetic suburethral sling operations to treat stress or mixed urinary incontinence. Comparison interventions may include other surgical techniques and non-surgical interventions. Types of outcome measures Outcome measures used in this review were selected on the basis of their relevance to the clinical cure or improvement of incontinence. We regarded the principal measures of effectiveness as the proportion of women cured (continent or dry) following surgery, and the proportion of women whose incontinence is improved. retropubic bottom-to-top approach versus retropubic topto-bottom approach; obturator medial-to-lateral approach versus obturator lateral-to-medial approach; 1. Women s observations Perception of cure and improvement in the short term (less than 12 months) and longer term (more than 12 months). Urgency symptoms or urgency incontinence. 8

2. Quantification of symptoms Pad changes (from self-reported number of pads used). Incontinent episodes (from self-completed bladder chart). Pad tests of quantified leakage (mean volume or weight of urine loss). 3. Clinician s observations Objective cure rates in the short term (less than 12 months) and longer term (more than 12 months). 4. Surgical outcome measures Duration of operation. Length of inpatient stay. Time to return to normal activity level. Operative blood loss. Major vascular or visceral injury. Bladder, urethra or bowel perforation. Nerve damage. Perioperative surgical complications (e.g. infection, bacteriuria, haemorrhage with or without major vessel lesion). 5. Adverse events De novo detrusor overactivity (urodynamic diagnosis). Voiding dysfunction / difficulty after three months (with or without urodynamic confirmation). Pelvic organ prolapse (e.g. cystocoele, rectocoele, enterocoele). Repeat incontinence surgery. Later prolapse surgery. Infection related to use of synthetic mesh. Erosion to vagina. Erosion to bladder or urethra. 6. Quality of life General health status measures (e.g. Short Form 36 (Ware 1993)), or specific instruments designed to assess incontinence, e.g. the Bristol Female Lower Urinary Tract Symptoms questionnaire (BFLUTS) (Jackson 1996). 7. Economic measures Costs of interventions. Cost-effectiveness of interventions. Resource implications. 8. Other outcomes Non-prespecified outcomes judged important when performing the review. Search methods for identification of studies We did not impose language or other restrictions on any of these searches which are described below. Electronic searches This review drew on the search strategy developed for the Incontinence Review Group. Relevant trials were identified from the Incontinence Group Specialised Register of controlled trials which is described under the Incontinence Group s details in The Cochrane Library (For more details please see the Specialized Register section of the Group s module in The Cochrane Library). The register contains trials identified from MEDLINE, CINAHL, the Cochrane Central Register of Controlled Trials (CENTRAL) and handsearching of journals and conference proceedings. The date of the last search of the Specialised Register for this review was 20 March 2008. We also searched MEDLINE (January 1950 to April 2008), EM- BASE (January 1988 to April 2008), CINAHL (January 1982 to April 2008), AMED (January 1985 to April 2008), the UK National Research Register, and ClinicalTrials.gov on 28 April 2008. Further details of the searches including the search terms used can be found in Appendix 1. Searching other resources We searched the reference lists of relevant articles. Data collection and analysis Trial selection Randomised and quasi-randomised trials were identified using the above search strategy. We excluded studies from the review if they were not randomised or quasi-randomised controlled trials for incontinent people or if they made comparisons other than those pre-specified. Excluded studies are listed in the Characteristics of excluded studies table with reasons for their exclusion. All possibly eligible studies were evaluated for appropriateness for inclusion by the reviewers without prior consideration of the results. Reports of potentially eligible trials were retrieved in full. Quality assessment We (JO and JC) independently assessed methodological quality using the Incontinence Group s assessment criteria. This system is based on an assessment of the three principal potential sources of bias. These are: selection bias from insecure random allocation of treatments; attrition bias from dropouts or losses to follow-up, particularly if there is a differential dropout rate between groups; and 9

biased ascertainment (detection bias) of outcome where knowledge of the allocation might have influenced the measurement of outcome. We assessed the validity of the included studies using the risk of bias tool. We assessed the risk of bias in the results of the included studies by examining the following features: sequence generation, allocation sequence concealment, blinding, incomplete outcome data and selective outcome reporting. These were presented in the risk of bias tables, graphs and summary figures. obesity, previous incontinence surgery, presence or absence of prolapse, anaesthesia used, or experience of the surgeon might all influence the outcomes of surgery and may be taken into account in future reviews. R E S U L T S Data extraction We (JO & JC) extracted data independently using a standard form containing pre-specified outcomes. Where data may have been collected but not reported, we sought clarification from the trialists. Included trial data was processed as described in the Cochrane Handbook for Systematic Reviews of Interventions ( Higgins 2008). Differences of opinion related to study inclusion, methodological quality or data extraction were resolved by discussion among the reviewers, and when necessary, referred to a third party for arbitration. Data analysis The review was conducted using the standard Cochrane software Revman version: 5.0.20. Quantitative synthesis was done when more than one eligible study was identified. Where appropriate, a combined estimate of treatment effect across similar studies was calculated for each pre-specified outcome. For categorical (dichotomous) outcomes, the numbers reporting an outcome was related to the numbers at risk in each group to derive a risk ratio (RR). For continuous variables, means and standard deviations were used to derive a weighted mean difference (WMD). A narrative review of eligible studies was undertaken where statistical synthesis of data from more than one study was not possible or considered inappropriate. An intention-to-treat analysis was used, in that participants remained in the group to which they were randomly allocated, but we did not impute missing data. We used a fixed-effect approach to the analysis unless there was evidence of heterogeneity across studies. Differences between trials were investigated when apparent from either visual inspection of the results or when statistically significant heterogeneity was demonstrated by using the Chi 2 test at the 10% probability level or assessment of the I 2 statistic (Higgins 2003). Where there was no obvious reason for heterogeneity to exist (after consideration of populations, interventions, outcomes and settings of the individual trials) or it persisted despite the removal of trials that were clearly different from the others, we used a random-effects model. There were no pre-planned subgroup analyses but clinical factors such as symptoms of urinary stress incontinence, urodynamic stress incontinence, mixed urinary incontinence, diagnosis of intrinsic urethral sphincter deficiency or urethral hypermobility, Description of studies See: Characteristics of included studies; Characteristics of excluded studies. Included/excluded studies We identified 109 studies. Sixty two of these were randomised trials which met the criteria for inclusion. A further 47 were excluded either because they were not randomised or did not include minimally invasive sling operations or the participants did not have urinary incontinence. The details for exclusion are given in the Characteristics of excluded studies table. Nine trials compared minimally invasive synthetic suburethral sling operations with traditional suburethral slings ( Arunkalaivanan 2003; Lucas 2004; Song 2004; Bai 2005; Wadie 2005; Kondo 2006; Silva-Filho 2006; Amaro 2007; Basok 2008). Nine trials compared minimally invasive synthetic suburethral sling operations to open retropubic colposuspension (Han 2001; Koelbl 2002; Liapis 2002; Ward 2002; Wang 2003; Drahoradova 2004; Bai 2005; El-Barky 2005; Sivaslioglu 2007). Eight trials compared minimally invasive synthetic suburethral sling operations with laparoscopic colposuspension (Persson 2002; Adile 2003; Ustun 2003; Maher 2004; Paraiso 2004; Valpas 2004; Mirosh 2005; Foote 2006). Trials that compared one type of minimally invasive synthetic suburethral sling operations with another type were further divided into four groups: The first group made a comparison between retropubic bottom-to-top approach, e.g. tension-free vaginal tape (TVT T M ): tape inserted from the vagina through the retropubic space and exiting onto the abdominal skin in the suprapubic region compared with a retropubic top-to-bottom approach, e.g. suprapubic urethral support sling (SPARC T M ): tape inserted from the abdomen in the suprapubic region through the retropubic space and exiting in the vagina. There were five such trials (Kim 2004; Andonian 2005; Lim 2005; Tseng 2005; Lord 2006 ). The next group compared tapes transversing the obturator route: obturator lateral-to-medial approach, e.g. TOT T M (tape inserted in the thigh crease and through the obturator route 10

exiting in the vagina) with obturator medial-to-lateral approach, e.g. TVT-O T M (tape inserted in the vagina and through the obturator route exiting in the thigh crease). There were four such trials (But 2007; Houwert 2007; Lee 2008; Liapis 2008). The third group compared different minimally invasive synthetic suburethral sling operations based on their tape properties, i.e. monofilament tapes versus multifilament tapes. There were three such trials (Rechberger 2003; Lim 2005; Meschia 2006). The last group compared minimally invasive synthetic suburethral sling operations based on the routes that the tapes transverse, i.e. trans obturator route versus retropubic route. There were 24 such trials (Andonian 2007; Araco 2008; Barber 2007; Barry 2008; Cervigni 2006; Darai 2007; Deffieux 2007; de Tayrac 2004; Enzelsberger 2005; Kim 2005; Lee 2007; Liapis 2006; Mansoor 2003; Meschia 2007; Oliveira 2006; Porena 2007; Rechberger 2007; Rinne 2008; Riva 2006; Schierlitz 2007; Teo 2007; Wang 2006; Zhu 2007; Zullo 2007). One trial (Campeau 2007) compared minimally invasive synthetic suburethral sling operations with no treatment. There were no randomised controlled trials comparing minimally invasive synthetic suburethral sling operations with periurethral injection therapy and none compared with conservative measures such as physiotherapy or lifestyle modification. Publication type and sample characteristics Minimally invasive synthetic suburethral sling operation versus traditional suburethral slings: Three of the nine studies were reported only as abstracts (Amaro 2007; Lucas 2004; Song 2004). The sample sizes ranged from 20 to 142, the average sample size for the minimally invasive synthetic suburethral sling operations group was 39 ± 21 and for the traditional sling group it was 36 ± 22. Inclusion and exclusion criteria were not clearly stated in two trials (Lucas 2004; Song 2004). All studies had women either presenting with SUI or had USI confirmed; two trials (Kondo 2006; Basok 2008) included women with mixed incontinence. Basok 2008 excluded women with pelvic organ prolapse (POP), Wadie 2005 and Kondo 2006 excluded women who had concomitant pelvic or POP surgery. Follow-up for women ranged from six months to three years. Further characteristics of the trials are reported in the Characteristics of included studies table. Minimally invasive synthetic suburethral sling operation versus open retropubic colposuspension: Three of the nine studies were reported only as abstracts ( Drahoradova 2004; Han 2001; Koelbl 2002;. The sample sizes ranged from 50 to 316; the average sample size for the minimally invasive synthetic suburethral sling operations group was 49 ± 23 and for the open retropubic colposuspension group it was 55 ± 39. Inclusion and exclusion criteria were not clearly stated in two trials (Han 2001; Drahoradova 2004). All studies had women either presenting with SUI or had USI confirmed, none included women with mixed incontinence nor women with previous incontinence surgery. Five of the nine studies (Bai 2005; El-Barky 2005; Liapis 2002; Sivaslioglu 2007; Ward 2002) included women with minor degrees of POP. None of the studies had concomitant pelvic or POP surgery. Follow-up for women ranged from six months to five years. Further characteristics of the trials are reported in the Characteristics of included studies table. Minimally invasive synthetic suburethral sling operation versus laparoscopic colposuspension: Three of the eight studies were reported only as abstracts (Adile 2003; Maher 2004; Mirosh 2005). The sample sizes ranged from 30 to 133; the average sample size for the minimally invasive synthetic suburethral sling operations group was 42 ± 19 and for the laparoscopic colposuspension group it was 39 ± 17. Inclusion and exclusion criteria were not clearly stated in one trial (Ustun 2003). All studies had women with USI confirmed, two included women with mixed incontinence (Adile 2003; Maher 2004) and only one study (Maher 2004) included women with previous incontinence surgery. All studies included women with minor degrees of POP. Maher 2004 and Paraiso 2004 had concomitant pelvic or POP surgery performed. Follow-up for women ranged from six months to two years with a median follow-up of 12 months. Further characteristics of the trials are reported in the Characteristics of included studies table. Retropubic bottom-to-top approach versus retropubic topto-bottom approach: One of the five studies was reported only as an abstract (Kim 2004) and this was the only study without clear inclusion and exclusion criteria. The sample sizes ranged from 62 to 304; the average sample size for retropubic in-out was 62 ± 49 and for retropubic out-in was 64 ± 53. All studies had women either presenting with SUI or had USI confirmed. All except Tseng 2005 included women with mixed incontinence. Andonian 2005 and Lord 2006 included women with previous incontinence surgery. All the studies included women with minor degrees of POP and had concomitant pelvic or POP surgery. Follow-up for women ranged from 1.5 months to 2 years with a median of 12 months. Further characteristics of the trials are reported in the Characteristics of included studies table. Obturator medial-to-lateral approach versus obturator lateral-to-medial approach: 11

With the exception of But 2007, reported only as an abstract, all the other studies were reported as full article publications. The sample sizes ranged from 68 to 114; the average sample size for obturator in-out was 48 ± 14 and for obturator out-in was 46 ± 9. Inclusion and exclusion criteria were not clearly stated in two trials (But 2007; Houwert 2007). All studies had women either presenting with SUI or had USI confirmed. Two studies (But 2007; Lee 2008) included women with mixed incontinence and women with previous incontinence surgery. Liapis 2008 included women with minor degrees of POP and women with concomitant pelvic or POP surgery. All studies followed women up at 12 months. Further characteristics of the trials are reported in the Characteristics of included studies table. Minimally invasive synthetic suburethral sling operation versus no treatment : Campeau 2007 compared minimally invasive synthetic suburethral sling operations with no treatment. It was reported as a full publication article and included 66 women aged over 75 years with SUI or MUI. Women who had had previous incontinence surgery were included. No woman had concomitant surgery performed. The no treatment control group were women who had already failed conservative therapy or refused it but agreed to surgical therapy and were willing to wait. Follow-up was at six months. Further characteristics of the study are reported in the Characteristics of included studies table. Monofilament tape versus multifilament tape: All three studies were reported as full article publications.the sample sizes ranged from 100 to 179; the average sample size for the monofilament tape was 68 ± 21 and for the multifilament tape was 66 ± 19. The trials had women either presenting with SUI or had USI confirmed, all had clear inclusion and exclusion criteria and included women with mild POP. Two trials (Lim 2005; Meschia 2006) included women with mixed incontinence. Rechberger 2003 and Lim 2005 included women with previous incontinence surgery. Only Lim 2005 had concomitant pelvic or POP surgery. Follow-up for women ranged from three months to two years. Further characteristics of the trials are reported in the Characteristics of included studies table. Retropubic route versus transobturator route: Nine of the twenty four studies were reported only as abstracts (Barber 2007; Cervigni 2006;Deffieux 2007; Mansoor 2003; Oliveira 2006; Rechberger 2007; Riva 2006; Schierlitz 2007; Teo 2007) The sample sizes ranged from 45 to 296; the average sample size for the transobturator tapes was 65 ± 33 and for retropubic tapes it was 66 ± 33. Inclusion and exclusion criteria were not clearly stated in five trials (Barber 2007; Cervigni 2006; Deffieux 2007; Mansoor 2003; Oliveira 2006; ) All studies had women either presenting with SUI or had USI confirmed. Seven studies (Andonian 2007; Barry 2008; Darai 2007; Kim 2005; Porena 2007; Rinne 2008; Riva 2006) included women with mixed incontinence. Six studies (Andonian 2007; Barry 2008; Darai 2007; de Tayrac 2004; Kim 2005; Lee 2007) included women with previous incontinence surgery. Twelve studies (Andonian 2007; Barry 2008; Darai 2007; Mansoor 2003; Meschia 2007; Porena 2007; Rechberger 2007; Rinne 2008; Wang 2006; Zhu 2007; Zullo 2007) included women with minor degrees of POP. In four studies (Andonian 2007; Barry 2008; Darai 2007; Schierlitz 2007) women had concomitant pelvic or POP surgery. Follow-up for women ranged from 1 month to 12 months, with a median followup of 12 months. Further characteristics of the trials are reported in the Characteristics of included studies table. Risk of bias in included studies The risk of bias in the trials included was variable and in general there was lack of clarity with regard to randomisation and allocation concealment in many of the studies. In most of the trials comparing minimally invasive synthetic suburethral sling operations and traditional suburethral slings it was unclear if randomisation and allocation concealment were performed adequately, with the exception of Wadie 2005 where this was adequate and Kondo 2006 where this was clearly inadequate. In the majority of cases participants and outcome assessors were unblinded. Nearly half of the trials comparing open retropubic colposuspension with minimally invasive synthetic suburethral sling operations had adequate randomisation and allocation concealment (Koelbl 2002; Sivaslioglu 2007; Wang 2001; Ward 2002). Blinding was not employed in most trials. In the laparoscopic colposuspension trials, only three (Persson 2002; Maher 2004; Paraiso 2004) used adequate random sequence generation and adequately concealed group allocation. Persson 2002 and Paraiso 2004 blinded outcome assessors. In the comparison between retropubic bottom-to-top and top-tobottom approaches, none of the studies had adequate randomisation and allocation concealment and none were blinded. Three studies compared monofilament with multifilament tapes: in only one (Meschia 2006) was sequence generation and allocation concealment adequate. In the comparison between minimally invasive synthetic suburethral sling operations using either the retropubic or the transobturator approach, only 4 out of the 24 studies (Mansoor 2003; de Tayrac 2004; Meschia 2007; Rinne 2008) had adequate sequence generation and allocation concealment. In six studies (Cervigni 2006; Darai 2007; Porena 2007; Wang 2006; Zhu 2007; Zullo 2007) there was adequate randomisation but it was unclear if allocation to the groups was concealed. Women were said to have been blinded to the procedures carried out in two studies (Wang 2006; Barry 2008) but there was no description of how this blinding was achieved. Outcome assessors were blinded in 3 of the 26 trials (de 12

Tayrac 2004; Porena 2007; Zhu 2007). Details on the criteria used to assess the risk of bias and the ratings for each study is reported in the risk of bias tables in the Characteristics of included studies. Further information on the risk of bias in included studies is shown in Figure 1 Risk of bias graph and Figure 2 Risk of bias summary. Figure 1. Risk of bias graph: review authors judgments about each risk of bias item presented as percentages across all included studies. 13

Figure 2. Risk of bias summary: review authors judgments about each risk of bias item for each included study. 14