Keyhole (laparoscopic) surgery through the abdomen for treating urinary incontinence in women

Urinary incontinence is a common and often debilitating problem for many women. Around a third of women of child-bearing age are incontinent during physical exertion or when they cough, laugh or sneeze. When such 'stress' incontinence persists despite non-surgical treatment, surgery is often recommended. A significant amount of a woman's and their family's income can be spent on management of stress urinary incontinence.

Laparoscopic colposuspension is an operation carried out through a small incision in the abdomen to hold and support the tissues around the neck of the bladder. Women recover more quickly from laparoscopic colposuspension for urinary incontinence than from traditional, open surgery, with similar initial improvement. Longer-term success rates may be lower but this is uncertain. However, when laparoscopic colposuspension is compared with newer 'self-fixing' sling procedures, it appears that in the short term the sling procedures offer the greater benefits of minimal access techniques with similar, if not better cure rates.

The review of trials found that both traditional colposuspension and newer 'self-fixing' slings had technically better results in the short term when compared with laparoscopic colposuspension. However, women's experience of improvement, both in the short and long term was similar for each type of operation. Using two stitches in laparoscopic colposuspensions was better than both one suture or the use of mesh. A trend was shown towards better outcomes for the laparoscopic operation when compared to open surgery, such as less postoperative pain, shorter hospital stay, quicker time to return to normal activities and shorter duration of catheterisation. When the laparoscopic technique was compared to the newer vaginal sling procedures, all the aforementioned trends were in favour of the sling procedure.

In terms of costs, a non-systematic review of economic studies suggested that tension-free vaginal tape and open colposuspension would be cheaper than laparoscopic colposuspension.

The value of the review is limited by the size and quality of the trials and the few data about long-term results.

Authors' conclusions: 

Currently available evidence suggests that laparoscopic colposuspension may be as good as open colposuspension at two years post surgery. However, the newer vaginal sling procedures appear to offer even greater benefits, better objective outcomes in the short term and similar subjective outcomes in the longer term. If laparoscopic colposuspension is performed, the use of two paravaginal sutures appears to be the most effective method. The place of laparoscopic colposuspension in clinical practice should become clearer when there are more data available describing long-term results. A brief economic commentary (BEC) identified three studies suggesting that tension-free vaginal tape (TVT) may be more cost-effective compared with laparoscopic colposuspension but laparoscopic colposuspension may be slightly more cost-effective when compared with open colposuspension after 24 months follow-up.

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Background: 

Stress urinary incontinence (SUI) imposes significant health and economic burden on society and the women affected. Laparoscopic colposuspension was one of the first minimal access operations for the treatment of women with SUI, with the presumed advantages of avoiding major incisions, shorter hospital stays and quicker return to normal activities.

Objectives: 

To determine the effects of laparoscopic colposuspension for urinary incontinence in women.

Search strategy: 

We searched the Cochrane Incontinence Group Trials Register (searched 2 July 2009), and sought additional trials from other sources and by contacting study authors for unpublished data and trials.

Selection criteria: 

Randomised or quasi-randomised controlled trials in women with symptomatic or urodynamic diagnosis of stress or mixed incontinence that included laparoscopic surgery as the intervention in at least one arm of the studies.

Data collection and analysis: 

The review authors evaluated trials for methodological quality and their appropriateness for inclusion in the review. Two review authors extracted data and another cross checked them. Where appropriate, we calculated a summary statistic.

Main results: 

We identified 22 eligible trials. Ten involved the comparison of laparoscopic with open colposuspension. Whilst the women's subjective impression of cure seemed similar for both procedures, in the short- and medium-term follow-up, there was some evidence of poorer results of laparoscopic colposuspension on objective outcomes. The results showed trends towards fewer perioperative complications, less postoperative pain and shorter hospital stay for laparoscopic compared with open colposuspension, however, laparoscopic colposuspension was more costly.

Eight studies compared laparoscopic colposuspension with newer 'self-fixing' vaginal slings. There were no significant differences in the reported short- and long-term subjective cure rates of the two procedures but objective cure rates at 18 months favoured slings. We observed no significant differences for postoperative voiding dysfunction and perioperative complications. Laparoscopic colposuspension had a significantly longer operation time and hospital stay.

We found significantly higher subjective and objective one-year cure rates for women randomised to two paravaginal sutures compared with one suture in a single trial. Three studies compared sutures with mesh and staples for laparoscopic colposuspension and showed a trend towards favouring the use of sutures.

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