Editorial Comment on: Prospective Clinical Trial Comparing Obtape® and DUPS to TVT: One-year Safety and Efficacy Results

Abstract

Suburethral sling procedures are specifically designed to address both urethral hypermobility and intrinsic sphincteric deficiency components of stress urinary incontinence (SUI) in women. Although further studies are needed to establish their long-term efficacy and safety, these procedures seem more efficient than the ones adopted in the era before the development of tension-free vaginal tape (TVT). In their paper, Andonian et al [1] report the outcomes of three types of suburethral sling to treat female SUI. In a prospective, randomised, controlled, clinical trial Obtape and DUPS were compared to the original TVT procedure. The DUPS arm of the randomised clinical trial (RCT) was discontinued after 32 patients because they observed a high postoperative retention rate (18.8%) combined with suprapubic discomfort. This study demonstrates that, at 1-yr follow-up, no statistically significant differences in cure rates were evident, but Obtape, DUPS, and TVT were associated with postoperativecomplications in 14%, 28%, and 8% of patients, respectively (p 0.025). TVT was the only procedure associated with bladder perforation, and this complication was higher in patients who had undergone previous surgery [1]. The perivesical tissue hydrodissection due to local anaesthesia could reduce the risk of bladder perforation, but I agree with the authors that regional anaesthesia is better tolerated by patients. A recurrent SUI is reported in 23 patients (12.1%), but the outcome after retropubic and trans-obturator procedures is not available, so I suppose that the authors do not find any significant differences [1]. The International Consultation on Incontinence underlines that TVT procedure on recurrent SUI has shown promising results, whereas few data on this issue regarding the other type of suburethral slings efficacy are available in literature [2]. Urinary incontinence and pelvic organ prolapse (POP) commonly coexist [3]. SUI is observed in up to 60% of women with POP and prolapse in up to 40% of women presenting with SUI [3–5]. In this study a concomitant prolapse surgery (anterior and posterior colporrhaphy and vaginal hysterectomy) was performed in 29 patients (15.2%) and was associated with postoperative retention only in the Obtape group (38% vs. 4%) [1]. There are no data in the literature, obtained from comparative RCTs, that could clarify whether POP surgery and antiincontinence surgery have to be performed at the same or different times and which anti-incontinence procedure is better. The authors report no statistically significant differences among the three groups in terms of persistent or de novo urgency, but the overall rate of the persistent urgency ranges from 19% to 23% [1]. Recently, Costantini et al [6] reported on the efficacy of the retropubic or trans-obturator approach in the treatment of mixed urinary incontinence (MUI). They compared TVT and trans-obturator tape procedures and found that at a mean follow-up of 24 mo the outcome after TVT seems slightly worse in patients with MUI. ‘‘Urgency remains a postoperative problem especially in the TVT group’’ [6]. IbelievethatmulticentreRCTswithlongerfollowup are needed to establish which suburethral sling procedure in the treatment of MUI or recurrent SUI is better. In addition, comparative RCTs are needed to determine whether POP surgery and the retropubic or trans-obturator anti-incontinence procedure should be performed simultaneously or not.