Treatment of recurrent stress urinary incontinence in women after a failed midurethral tape operation

Review question

What is the best way to treat women whose stress urinary incontinence is not cured or recurs after surgery to insert a tape underneath the bladder outlet (midurethral tape)?

Background

Stress urinary incontinence (SUI) is the loss of urine when a person coughs or exercises. It can be caused by damage to the pelvic floor muscles or their nerve supply, particularly during childbirth. Simple treatments, such as exercising pelvic floor muscles or medication, may be tried at first. If these methods have not worked, surgery is often performed, which can be done using a midurethral tape. This usually involves placing a tape made from polypropylene (a synthetic material like nylon that is used in some surgical stitches and other medical devices) underneath the bladder outlet. This operation is usually very successful, but not all women will be cured. There is currently no agreement amongst experts on how to treat women with recurrent stress urinary incontinence problems following unsuccessful midurethral tape surgery.

How up-to-date is this review?

The evidence is current up to 9 November 2018.

Study characteristics

Our search identified one study for this review, including a total of 341 women. Of these, just 46 women met our inclusion criteria by having undergone previous continence surgery with a midurethral tape or colposuspension (a type of surgery used to support the tissues around the neck of the bladder with stitches). This review only focused on the results from these 46 women, extracted from the overall trial results.

Study funding sources

The one included study was funded by the Henry Smith Charity. A published correction indicated commercial support from the manufacturer of a device used in the study, which could be a source of bias.

Key results

We wanted to assess the effects of conservative treatment (such as pelvic floor muscle training or bladder training), surgery and medication on the number of women who reported that their incontinence was improved or cured after treatment, along with other outcomes such as quality of life and adverse events. We were also interested in the effects on our outcomes of different types of midurethral tapes.

Of the 46 eligible women in the included study, two-thirds were reported to have received a midurethral tape in their first surgery. However, the data in the report did not differentiate between women who had previously undergone surgery with a midurethral tape and those who had had colposuspension. This means that we cannot be certain that the results were due to the midurethral tape, so we could not use the data in this review.

We planned to summarise evidence about which treatments might be considered worthwhile uses of healthcare resources but we did not identify any studies that asked this question.

Certainty of the evidence

The lack of useable data means that we were unable to assess the certainty of the body of evidence.

Authors' conclusions

We did not find enough data to accurately assess the effects of any of the different management strategies for recurrent or persistent stress incontinence after failed midurethral tape surgery. Evidence from high-quality studies is required to address this area of uncertainty.

Authors' conclusions: 

There were insufficient data to assess the effects of any of the different management strategies for recurrent or persistent stress incontinence after failed midurethral tape surgery. No published papers have reported exclusively on women whose first operation was a midurethral tape. Evidence from further RCTs and economic evaluations is required to address uncertainties about the effects and costs of these treatments.

Read the full abstract...
Background: 

Surgery is a common treatment modality for stress urinary incontinence (SUI), usually offered to women for whom conservative treatments have failed. Midurethral tapes have superseded colposuspension because cure rates are comparable and recovery time is reduced. However, some women will not be cured after midurethral tape surgery. Currently, there is no consensus on how to manage the condition in these women.

This is an update of a Cochrane Review first published in 2013.

Objectives: 

To assess the effects of interventions for treating recurrent stress urinary incontinence after failed minimally invasive synthetic midurethral tape surgery in women; and to summarise the principal findings of economic evaluations of these interventions.

Search strategy: 

We searched the Cochrane Incontinence Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, ClinicalTrials.gov, WHO ICTRP and handsearching of journals and conference proceedings (searched 9 November 2018). We also searched the reference lists of relevant articles.

Selection criteria: 

We included randomised and quasi-randomised controlled trials in women who had recurrent stress urinary incontinence after previous minimally invasive midurethral tape surgery. We included conservative, pharmacological and surgical treatments.

Data collection and analysis: 

Two review authors checked the abstracts of identified studies to confirm their eligibility. We obtained full-text reports of relevant studies and contacted study authors directly for additional information where necessary. We extracted outcome data onto a standard proforma and processed them according to the guidance in the Cochrane Handbook for Systematic Reviews of Interventions.

Main results: 

We included one study in this review. This study was later reported in an originally unplanned secondary analysis of 46 women who underwent transobturator tape for recurrent SUI after one or more previous failed operations. We were unable to use the data, as they were not presented according to the nature of the first operation.

We excluded 12 studies, five because they were not randomised controlled trials (RCTs) and four because previous incontinence surgery was not performed using midurethral tape. We considered a further three to be ineligible because neither the trial report nor personal communication with the trialists could confirm whether any of the participants had previously undergone surgery with tape.

We had also planned to develop a brief economic commentary summarising the principal findings of relevant economic evaluations but supplementary systematic searches did not identify any such studies.

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