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Retropubic versus Transobturator Midurethral Slings for Stress Incontinence ? Imprimer
Richter et al for Urinary Incontinence Treatment Network (www.nejm.org May 17, 2010 (10.1056/NEJMoa0912658) performed a multicenter, randomized equivalence trial comparing outcomes with retropubic and transobturator midurethral slings in women (n=597) with stress incontinence. The primary outcome was treatment success at 12 months according to both objective criteria (a negative stress test, a negative pad test, and no retreatment) and subjective criteria (self-reported absence of symptoms, no leakage episodes recorded, and no retreatment). The predetermined equivalence margin was ±12 percentage points. 565 (94.6%) completed the 12-month assessment. The rates of objectively assessed treatment success were 80.8% in the retropubic-sling group and 77.7% in the transobturator-sling group (3.0 % -point difference; 95% CI, -3.6 to 9.6). The rates of subjectively assessed success were 62.2% and 55.8%, respectively (6.4% -point difference; 95% CI, -1.6 to 14.3). The rates of voiding dysfunction requiring surgery were 2.7% in those who received retropubic slings and 0% in those who received transobturator slings (P=0.004), and the respective rates of neurologic symptoms were 4.0% and 9.4% (P=0.01). There were no significant differences between groups in postoperative urge incontinence, satisfaction with the results of the procedure, or quality of life.

In summary, the rates of objectively assessed success of treatment for stress incontinence with a transobturator-sling approach and a retropubic-sling approach were equivalent at 1 year. The rates of subjectively assessed treatment success were slightly higher in the retropubic-sling group than in the transobturator-sling group and did not meet the predefined criteria for equivalence. However, the complications associated with the two procedures differ, and clinicians should counsel patients regarding these complications when discussing surgical options for stress urinary incontinence.

 
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