Anterior vaginal repair for urinary incontinence in women

Urinary incontinence is the inability to prevent urine leakage. Stress urinary incontinence is loss of urine when a person coughs or exercises. A significant amount of a woman's or her families income can be spent on management of stress urinary incontinence. Damage to the muscles that hold up the bladder, and injuries to the nerves during childbirth, may be causes. When non-surgical methods, such as exercising the muscles in the pelvic floor (the base of the abdomen), have not worked, surgery is sometimes used to lift and support the bladder. Anterior vaginal repair aims to achieve this, operating through the vaginal wall. The review of 10 trials in 1012 women found some evidence that surgery through the abdomen may be better than vaginal repair. However, there was not enough information about side-effects, or in comparison with other physical or surgical methods of treating urine leakage.

Authors' conclusions: 

There were not enough data to allow comparison of anterior vaginal repair with physical therapy or needle suspension for primary urinary stress incontinence in women. Open abdominal retropubic suspension appeared to be better than anterior vaginal repair judged on subjective cure rates in eight trials, even in women who had prolapse in addition to stress incontinence (six trials). The need for repeat incontinence surgery was also less after the abdominal operation. However, there was not enough information about postoperative complications and morbidity.A Brief Economic Commentary (BEC) identified one study suggesting that vaginoplasty may be more cost-effective compared with tension-free vaginal tape (TVT-O).

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Background: 

Anterior vaginal repair (anterior colporrhaphy) is an operation traditionally used for moderate or severe stress urinary incontinence (SUI) in women. About a third of adult women experience urinary incontinence. SUI imposes significant health and economic burden to the society and the women affected.

Objectives: 

To determine the effects of anterior vaginal repair (anterior colporrhaphy) on urinary incontinence in comparison with other management options.

Search strategy: 

We searched the Cochrane Incontinence Group Specialised Trials Register (searched 1 September 2009) and the reference lists of relevant articles.

Selection criteria: 

Randomised or quasi-randomised trials that included anterior vaginal repair for the treatment of urinary incontinence.

Data collection and analysis: 

Two review authors independently extracted data and assessed trial quality. Three trial investigators were contacted for additional information.

Main results: 

Ten trials were identified which included 385 women having an anterior vaginal repair and 627 who received comparison interventions.

A single small trial provided insufficient evidence to assess anterior vaginal repair in comparison with physical therapy. The performance of anterior repair in comparison with bladder neck needle suspension appeared similar (risk ratio (RR) for failure after one year 1.16, 95% confidence interval (CI) 0.86 to 1.56), but clinically important differences could not be confidently ruled out. No trials compared anterior repair with suburethral sling operations or laparoscopic colposuspensions, or compared alternative vaginal operations.

Anterior vaginal repair was less effective than open abdominal retropubic suspension based on patient-reported cure rates in eight trials both in the medium term (failure rate within one to five years after anterior repair 97/259 (38%) versus 57/327 (17%); RR 2.29, 95% confidence Interval (CI) 1.70 to 3.08) and in the long term (after five years, (49/128 (38%) versus 31/145 (21%); RR 2.02, 95% CI 1.36 to 3.01). There was evidence from three of these trials that this was reflected in a need for more repeat operations for incontinence (25/107 (23%) versus 4/164 (2%); RR 8.87, 95% CI 3.28 to 23.94). These findings held, irrespective of the co-existence of prolapse (pelvic relaxation). Although fewer women had a prolapse after anterior repair (RR 0.24, 95% CI 0.12 to 0.47), later prolapse operation appeared to be equally common after vaginal (3%) or abdominal (4%) operation.

In respect of the type of open abdominal retropubic suspension, most data related to comparisons of anterior vaginal repair with Burch colposuspension. The few data describing comparison of anterior repair with the Marshall-Marchetti-Krantz procedure were consistent with those for Burch colposuspension.

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