May 19, 2010 - Women who decide on sling surgery for stress incontinence face another daunting decision: Which surgery is best?
Surgeons have devised several different ways to improve the physical abnormalities of the urinary system that cause women to urinate involuntarily when they cough, laugh, or exercise. These surgical approaches use a sling made of synthetic materials that support the bladder.
Since its introduction in 1996, the retropubic-sling procedure has increasingly been considered the gold standard. In this surgery, the mesh sling is passed behind the pubic bone.
But the retropubic approach isn't perfect. In 2001, the transobturator approach was developed. This approach reduces the angle of the sling by passing it through the obturator canals -- the large "holes" on either side of the pubic bone.
This approach reduces the potential for bladder and bowel injuries associated with the retropubic sling. So is the transobturator approach better?
Not necessarily, find University of Alabama, Birmingham, researcher Holly E. Richter, MD, PhD, and colleagues. The researchers compared outcomes for some 600 women randomly assigned to one procedure or the other.
The bottom line: The two procedures are equally effective in relieving stress incontinence. But they differ in the side effects patients are most likely to suffer.
What this means for patients is that before surgery, they should discuss these possible complications with their doctor.
Most women will not suffer severe complications. But women should decide which complications would most bother them, and choose the surgery with the lowest risk of such complications:
Patients treated via the retropubic approach have a higher rate of voiding dysfunction -- difficulty urinating.
The retropubic approach also is more likely to result in bladder perforations and had a higher overall complication rate.
Patients treated via the transobturator approach have a higher rate of neurological complications, including numbness and weakness in the legs.
What this means is that the best surgery for an individual woman depends on her preferences and on her doctor's assessment of her condition.
In an editorial accompanying the Richter study, Rebecca G. Rogers, MD, of the University of New Mexico Health Sciences Center, sums up the findings.
"What is the best incontinence surgery? It depends," Rogers concludes.
The Richter study, and the Rogers editorial, appear in the May 17 online issue of the New England Journal of Medicine.