Traditional suburethral sling operations for urinary incontinence in women
Abstract
Background
Stress urinary incontinence constitutes a significant health and economic burden to society. Traditional suburethral slings are surgical operations used to treat women with symptoms of stress urinary incontinence.
Objectives
To assess the effectiveness of traditional suburethral sling procedures for treating stress urinary incontinence in women; and summarise the principal findings of relevant economic evaluations.
Search methods
We searched the Cochrane Incontinence Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), as well as MEDLINE, MEDLINE In‐Process, MEDLINE Epub Ahead of Print, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP); we handsearched journals and conference proceedings (searched 27 February 2017) and the reference lists of relevant articles. On 23 January 2019, we updated this search; as a result, several additional reports of studies are awaiting classification.
Selection criteria
Randomised or quasi‐randomised trials that assessed traditional suburethral slings for treating stress or mixed urinary incontinence.
Data collection and analysis
At least two review authors independently extracted data from included trials and assessed risk of bias. When appropriate, a summary statistic was calculated: risk ratio (RR) for dichotomous data, odds ratio (OR) for continence and cure rates that were expected to be high, and mean difference (MD) for continuous data. We adopted the GRADE approach to assess the quality of evidence.
Main results
A total of 34 trials involving 3244 women were included. Traditional slings were compared with 10 other treatments and with each other.
We did not identify any trials comparing suburethral slings with no treatment or sham treatment, conservative management, anterior repair, or laparoscopic retropubic colposuspension. Most trials did not distinguish between women having surgery for primary or recurrent incontinence. One trial compared traditional slings with bladder neck needle suspension, and another trial compared traditional slings with single‐incision slings. Both trials were too small to be informative.
Traditional suburethral sling operation versus drugs
One small trial compared traditional suburethral sling operations with oxybutynin to treat women with mixed urinary incontinence. This trial did not report any of our GRADE‐specific outcomes. It is uncertain whether surgery compared with oxybutynin leads to more women being dry (83% vs 0%; OR 195.89, 95% confidence interval (CI) 9.91 to 3871.03) or having less urgency urinary incontinence (13% vs 43%; RR 0.29, 95% CI 0.09 to 0.94) because the quality of this evidence is very low.
Traditional suburethral sling versus injectables
One small trial compared traditional slings with suburethral injectable treatment. The impact of surgery versus injectables is uncertain in terms of the number of continent women (100% were dry with a traditional sling versus 71% with the injectable after the first year; OR 11.57, 95% CI 0.56 to 239.74), the need for repeat surgery for urinary incontinence (RR 0.52, 95% CI 0.05 to 5.36) or the occurrence of perioperative complications (RR 1.57, 95% CI 0.29 to 8.49), as the quality of evidence is very low.
Traditional suburethral sling versus open abdominal retropubic colposuspension
Eight trials compared slings with open abdominal retropubic colposuspension. Moderate‐quality evidence shows that the traditional suburethral sling probably leads to more continent women in the medium term (one to five years) (69% vs 59% after colposuspension: OR 1.70, 95% CI 1.22 to 2.37). High‐quality evidence shows that women were less likely to need repeat continence surgery after a traditional sling operation than after colposuspension (RR 0.15, 95% CI 0.05 to 0.42). We found no evidence of a difference in perioperative complications between the two groups, but the CI was very wide and the quality of evidence was very low (RR 1.24, 95% CI 0.83 to 1.86).
Traditional suburethral sling operation versus mid‐urethral slings
Fourteen trials compared traditional sling operations and mid‐urethral sling operations. Depending on judgements about what constitutes a clinically important difference between interventions with regard to continence, traditional suburethral slings are probably no better, and may be less effective, than mid‐urethral slings in terms of number of women continent in the medium term (one to five years) (67% vs 74%; OR 0.67, 95% CI 0.44 to 1.02; n = 458; moderate‐quality evidence). One trial reported more continent women with the traditional sling after 10 years (51% vs 32%: OR 2.22, 95% CI 1.07 to 4.61). Mid‐urethral slings may be associated with fewer perioperative complications (RR 1.74, 95% CI 1.16 to 2.60; low‐quality evidence).
One type of traditional sling operation versus another type of traditional sling operation
Nine trials compared one type of traditional sling operation with another. The different types of traditional slings, along with the number of different materials used, mean that trial results could not be pooled due to clinical heterogeneity. Complications were reported by two trials ‐ one comparing non‐absorbable Goretex with a rectus fascia sling, and the second comparing Pelvicol with a rectus fascial sling. The impact was uncertain due to the very low quality of evidence.
Authors' conclusions
Low‐quality evidence suggests that women may be more likely to be continent in the medium term (one to five years) after a traditional suburethral sling operation than after colposuspension. It is very uncertain whether there is a difference in urinary incontinence after a traditional suburethral sling compared with a mid‐urethral sling in the medium term. However, these findings should be interpreted with caution, as long‐term follow‐up data were not available from most trials. Long‐term follow‐up of randomised controlled trials (RCTs) comparing traditional slings with colposuspension and mid‐urethral slings is essential. Evidence is insufficient to suggest whether traditional suburethral slings may be better or worse than other management techniques. This review is confined to RCTs and therefore may not identify all of the adverse effects that may be associated with these procedures.
A brief economic commentary (BEC) identified three eligible economic evaluations, which are not directly comparable due to differences in methods, time horizons, and settings. End users of this review will need to assess the extent to which methods and results of identified economic evaluations may be applicable (or transferable) to their own setting.
PICOs
Plain language summary
Traditional suburethral sling operations for urinary incontinence in women
Review question
How do traditional slings compare with other surgical or conservative treatments for women with stress urinary incontinence (SUI)?
Background
A traditional suburethral sling operation is one of the surgical options for treating women with SUI. Stress urinary incontinence is loss (leakage) of urine when coughing, laughing, sneezing, or exercising. It may be due to damage to the muscles that hold up the bladder neck or damage to their nerves, which often occurs during childbirth. When stress urinary incontinence occurs together with an urge to empty the bladder that is difficult to defer (urgency urinary incontinence (UUI)), this is known as mixed urinary incontinence (MUI). The traditional suburethral sling operation aims to hold up the bladder neck with a strip of material that may be biological (made from human or animal tissue) or made of non‐absorbable synthetic plastic (mesh/tape).
How up‐to‐date is this review?
The evidence is current to 27 February 2017. A further search on 23 January 2019 was not fully incorporated into the review.
Study characteristics
We found 34 randomised controlled trials (RCTs) involving 3244 women that compared traditional slings with drugs or other types of surgery (colposuspension, mid‐urethral slings, bladder neck needle suspension, single‐incision slings (mini‐slings); one type of traditional sling with another; and traditional slings with injectables. All trials included women with SUI, but some also involved women with UUI, who are said to have MUI.
We did not find any studies comparing suburethral slings with no treatment or sham treatment, conservative management such as pelvic floor exercises, anterior repair, or laparoscopic colposuspension.
Study funding sources
Few trialists reported who had funded their work.
Key results
Surgery appears to work better than drugs for treating urinary incontinence. Some evidence suggests that women had less leakage with traditional slings in the medium term (one to five years) compared with those undergoing colposuspension (a major abdominal operation), and fewer needed repeat surgery in one trial. However, information about adverse effects is lacking. It is not clear whether traditional slings were better or worse than mid‐urethral slings (synthetic tape) in the medium term, but one small trial showed that women who had a traditional sling might have less leakage 10 years later. It is not clear whether traditional slings were better or worse than injectable treatment, bladder neck needle suspension, or mini‐slings. We found insufficient information about different types of slings compared with each other, except that slings made of porcine dermis (Pelvicol) were more likely to fail than other materials. Slings made of non‐absorbable synthetic Goretex involved more complications.
Quality of the evidence
Many trials were small and used different ways of measuring success, which made combining information difficult. The quality of evidence for most outcomes was judged to be low or very low. This means that most of our conclusions about traditional slings are uncertain.
Authors' conclusions
Some evidence suggests that women had less leakage with traditional slings in the medium term (one to five years) compared with those undergoing colposuspension (a major abdominal operation), and fewer needed repeat surgery in one trial. Evidence on comparison of traditional suburethral slings with other treatments is insufficient. Three eligible economic evaluations reported similar results, but they are not directly comparable because of differences in their methods. This review is confined to randomised controlled trials (RCTs) and therefore may not identify all of the adverse effects that may be associated with these procedures.
Authors' conclusions
Summary of findings
| Traditional suburethral sling operation versus no treatment or sham operation | ||||||
| Patient or population: women with urinary incontinence | ||||||
| Outcomes | Illustrative comparative risks* (95% CI) | Relative effect | Number of participants | Quality of the evidence | Comments | |
| Assumed risk | Corresponding risk | |||||
| No treatment or sham treatment | Sling | |||||
| Number of continent (dry) women (any definition) in the medium term (1 to 5 years) | Not reported | |||||
| Repeat surgery for urinary incontinence | Not reported | |||||
| Perioperative surgical complications | Not reported | |||||
| Long‐term adverse effects | Not reported | |||||
| Condition‐specific quality of life | Not reported | |||||
| *The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). | ||||||
| GRADE Working Group grades of evidence. | ||||||
| Traditional suburethral sling operation versus conservative management | ||||||
| Patient or population: women with urinary incontinence | ||||||
| Outcomes | Illustrative comparative risks* (95% CI) | Relative effect | Number of participants | Quality of the evidence | Comments | |
| Assumed risk | Corresponding risk | |||||
| Conservative treatment | Sling | |||||
| Number of continent (dry) women (any definition) in the medium term (1 to 5 years) | Not reported | |||||
| Repeat surgery for urinary incontinence | Not reported | |||||
| Perioperative surgical complications | Not reported | |||||
| Long‐term adverse effects | Not reported | |||||
| Condition‐specific quality of life | Not reported | |||||
| *The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). | ||||||
| GRADE Working Group grades of evidence. | ||||||
| Traditional suburethral sling operation versus drugs | ||||||
| Patient or population: women with urinary incontinence | ||||||
| Outcomes | Illustrative comparative risks* (95% CI) | Relative effect | Number of participants | Quality of the evidence | Comments | |
| Assumed risk | Corresponding risk | |||||
| Drugs | Sling | |||||
| Number of continent (dry) women (any definition) in the medium term (1 to 5 years) | Not reported | |||||
| Repeat surgery for urinary incontinence | Not reported | |||||
| Perioperative surgical complications | Not reported | |||||
| Long‐term adverse effects | Not reported | |||||
| Condition‐specific quality of life | Not reported | |||||
| *The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). | ||||||
| GRADE Working Group grades of evidence. | ||||||
| Traditional suburethral sling operation versus injectables | ||||||
| Patient or population: women with urinary incontinence | ||||||
| Outcomes | Illustrative comparative risks* (95% CI) | Relative effect | Number of participants | Quality of the evidence | Comments | |
| Assumed risk | Corresponding risk | |||||
| Injectable | Sling | |||||
| Number of continent (dry) women (any definition) in the medium term (1 to 5 years) | 714 per 1000 | 967 per 1000 (583 to 998) | OR 11.57 (0.56 to 239.7) | 43 | ⊕⊝⊝⊝ | 252 more women, per 1000, with traditional sling (131 fewer to 284 more) |
| Repeat surgery for urinary incontinence ‐ urodynamic stress incontinence (only) | 91 per 1000 | 47 per 1000 (5 to 487) | RR 0.52 (0.05 to 5.36) | 43 | ⊕⊝⊝⊝ | 44 fewer women, per 1000, with traditional sling (86 fewer to 396 more) |
| Perioperative surgical complications | 91 per 1000 | 143 per 1000 | RR 1.57 | 43 | ⊕⊝⊝⊝ | 52 more women, per 1000, with traditional sling (65 fewer to 681 more) |
| Long‐term adverse effects | Not reported | |||||
| Condition‐specific quality of life | Not reported | |||||
| *The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). | ||||||
| GRADE Working Group grades of evidence. | ||||||
| aDowngraded one level due to serious risk of bias (unclear for sequence generation, allocation concealment, and blinding) and two levels for imprecision (95% CI very wide, 0.56 to 239.74; crosses line of no effect). bDowngraded two levels due to very serious imprecision: single trial with small sample size. | ||||||
| Traditional suburethral sling operation versus anterior repair | ||||||
| Patient or population: women with urinary incontinence | ||||||
| Outcomes | Illustrative comparative risks* (95% CI) | Relative effect | Number of participants | Quality of the evidence | Comments | |
| Assumed risk | Corresponding risk | |||||
| Anterior repair | Sling | |||||
| Number of continent (dry) women (any definition) in the medium term (1 to 5 years) | Not reported | |||||
| Repeat surgery for urinary incontinence | Not reported | |||||
| Perioperative surgical complications | Not reported | |||||
| Long‐term adverse effects | Not reported | |||||
| Condition‐specific quality of life | Not reported | |||||
| *The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). | ||||||
| GRADE Working Group grades of evidence. | ||||||
| Traditional suburethral sling operation versus bladder neck needle suspension (abdominal and vaginal) | ||||||
| Patient or population: women with urinary incontinence | ||||||
| Outcomes | Illustrative comparative risks* (95% CI) | Relative effect | Number of participants | Quality of the evidence | Comments | |
| Assumed risk | Corresponding risk | |||||
| Bladder neck needle suspension | Sling | |||||
| Number of continent (dry) women (any definition) in the medium term (1 to 5 years) | 700 per 1000 | 900 per 1000 (435 to 991) | OR 3.86 0.33 to 45.57 | 20 | ⊕⊝⊝⊝ | 200 more women, per 1000, with traditional sling (265 fewer to 291 more) |
| Repeat surgery for urinary incontinence | Not reported | |||||
| Perioperative surgical complications ‐ urodynamic stress incontinence (only) | 200 per 1000 | 900 per 1000 | RR 4.5 | 20 | ⊕⊝⊝⊝ | 700 more women, per 1000, with traditional sling (56 fewer to 2962 more) |
| Long‐term adverse effects | Not reported | |||||
| Condition‐specific quality of life | Not reported | |||||
| *The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). | ||||||
| GRADE Working Group grades of evidence. | ||||||
| aDowngraded two levels for risk of bias (evidence comes from a single trial that was judged to be unclear for allocation concealment and blinding) and two levels for imprecision (95% CI very wide). | ||||||
| Traditional suburethral sling operation versus open abdominal retropubic suspension | ||||||
| Patient or population: women with urinary incontinence | ||||||
| Outcomes | Illustrative comparative risks* (95% CI) | Relative effect | Number of participants | Quality of the evidence | Comments | |
| Assumed risk | Corresponding risk | |||||
| Open abdominal retropubic suspension | Sling | |||||
| Number of continent (dry) women (any definition) in the medium term (1 to 5 years) | 589 per 1000 | 711 per 1000 (638 to 774) | OR 1.70 (1.22 to 2.37) | 687 (4 RCTs) | ⊕⊕⊕⊝ | 120 more dry women, per 1000, with traditional sling (47 more to 186 more) |
| Repeat surgery for urinary incontinence‐stress urinary incontinence (symptoms only) | 119 per 1000 | 18 per 1000 | RR 0.15 (0.05 to 0.42) | 450 | ⊕⊕⊕⊕ | 101 fewer women having repeat continence surgery, per 1000, with traditional sling (113 fewer to 69 fewer) |
| Perioperative surgical complications | 95 per 1000 | 118 per 1000 | RR 1.24 | 792 | ⊕⊝⊝⊝ | 23 more women, per 1000, with traditional sling (16 fewer to 82 more) |
| Long‐term adverse effects | 92 per 1000 | 94 per 1000 | RR 1.02 (0.57 to 1.82) | 453 | ⊕⊕⊝⊝ | 2 more women, per 1000, with traditional sling (39 fewer to 75 more) |
| Condition‐specific quality of life | Mean IIQ score in the control group was 44.8 | Mean condition‐specific quality of life in the intervention groups was | 453 | ⊕⊝⊝⊝ | Another trial reported no evidence of a difference between colposuspension groups and sling groups in IIQ and UDI scores but reported no actual numbers | |
| *The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). | ||||||
| GRADE Working Group grades of evidence. | ||||||
| aDowngraded one level due to serious risk of bias (unclear randomisation and allocation concealment in two of the smaller trials), but the trial carrying 90% of weight in the meta‐analysis was judged to have low risk of selection bias. bDowngraded one level for risk of bias (sequence generation was unclear in one‐fourth of trials and allocation concealment was unclear in three‐quarters of trials taking part in the meta‐analysis; participants were not blinded) and one level for imprecision (95% confidence interval was very wide). cDowngraded two levels for imprecision (95% confidence interval was very wide; 0.57 to 1.82). dDowngraded two levels for risk of bias (sequence generation and allocation concealment were judged to be "low risk"; blinding of participants was judged to be "high risk") and two levels for imprecision (95% confidence interval was very wide; ‐11.96 to 15.36). | ||||||
| Traditional suburethral sling operation versus laparoscopic colposuspension | ||||||
| Patient or population: women with urinary incontinence | ||||||
| Outcomes | Illustrative comparative risks* (95% CI) | Relative effect | Number of participants | Quality of the evidence | Comments | |
| Assumed risk | Corresponding risk | |||||
| Laparoscopic procedures | Sling | |||||
| Number of continent (dry) women (any definition) in the medium term (1 to 5 years) | Not reported | |||||
| Repeat surgery for urinary incontinence | Not reported | |||||
| Perioperative surgical complications | Not reported | |||||
| Voiding dysfunction | Not reported | |||||
| Long‐term adverse effects | Not reported | |||||
| Condition‐specific quality of life | Not reported | |||||
| *The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). | ||||||
| GRADE Working Group grades of evidence. | ||||||
| Traditional suburethral sling operation versus a mid‐urethral sling or tape | ||||||
| Patient or population: women with urinary incontinence | ||||||
| Outcomes | Illustrative comparative risks* (95% CI) | Relative effect | Number of participants | Quality of the evidence | Comments | |
| Assumed risk | Corresponding risk | |||||
| Minimally invasive sling operation | Traditional sling | |||||
| Number of continent (dry) women (any definition) in the medium term (1 to 5 years) | 737 per 1000 | 652 per 1000 (552 to 741) | OR 0.67 (0.44 to 1.02) | 445 (6 RCTs) | ⊕⊕⊕⊝ | 85 fewer women, per 1000, with traditional sling (185 fewer to 4 more) |
| Repeat surgery for urinary incontinence ‐ urodynamic stress incontinence (only) | One trial reported the numbers of women having repeat continence surgery at 10‐year follow‐up: traditional sling: 0/67; mid‐urethral sling: 2/69 | 136 | ⊕⊕⊝⊝ | |||
| Perioperative surgical complications | 193 per 1000 | 336 per 1000 | RR 1.74 | 293 | ⊕⊕⊝⊝ | 143 more women, per 1000, with traditional sling (31 more to 309 more) |
| Long‐term adverse effects | 25 per 1000 | 62 per 1000 | RR 2.53 | 326 | ⊕⊝⊝⊝ | 38 more women, per 1000, with traditional sling (3 fewer to 157 more) |
| Condition‐specific quality of life | Mean IIQ‐7 score in the control group was 24.4 | Mean condition‐specific quality of life score in the intervention groups was | 63 | ⊕⊝⊝⊝ | Eight other trials reported some measure of QoL but the data were unsuitable for met‐analysis. Overall, there was no evidence of a difference between groups in QoL scores | |
| *The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). | ||||||
| GRADE Working Group grades of evidence. | ||||||
| 1Downgraded one level due to serious risk of bias: 2/6 trials had high risk of selection bias. 2Downgraded two levels due to very serious imprecision: single study with small sample size. 3Downgraded two levels for risk of bias (sequence generation and allocation concealment were high or unclear risk in all four trials taking part in the meta‐analysis). 4Downgraded two levels for risk of bias (sequence generation and allocation concealment were high or unclear risk in two of three trials taking part in the meta‐analysis) and two levels for imprecision (95% confidence interval was very wide: 0.87 to 7.35). 5Downgraded two levels for risk of bias (sequence generation was judged to be high risk, and allocation concealment was judged to be low risk; outcome data were incomplete) and two levels for imprecision (95% confidence interval was very wide: ‐10.17 to 11.37). | ||||||
| Traditional suburethral sling operation versus a single‐incision sling (mini‐sling) | ||||||
| Patient or population: women with urinary incontinence | ||||||
| Outcomes | Illustrative comparative risks* (95% CI) | Relative effect | Number of participants | Quality of the evidence | Comments | |
| Assumed risk | Corresponding risk | |||||
| Number of continent (dry) women (any definition) in the medium term (1 to 5 years) | 886 per 1000 | 886 per 1000 (641 to 971) | OR 1.00 (0.23 to 4.36) | 70 | ⊕⊝⊝⊝ | 0 fewer women, per 1000, with traditional sling (245 fewer to 86 more) |
| Repeat surgery for urinary incontinence | not reported | |||||
| Perioperative surgical complications ‐ bladder perforation | 0 per 1000 | 0 per 1000 (0 to 0) | RR 3 (0.13 to 71.22) | 70 | ⊕⊝⊝⊝ | |
| Long‐term adverse effects | not reported | |||||
| Condition‐specific quality of life IIQ | Mean IIQ score in the control group was 42.7 | Mean condition‐specific quality of life score in the intervention groups was 50.2 higher (2.23 higher to 12.77 higher) | 70 | ⊕⊝⊝⊝ | Based on mean IIQ score, quality of life was worse in the traditional sling group compared with the mini‐sling group | |
| *The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). | ||||||
| GRADE Working Group grades of evidence. | ||||||
| aDowngraded two levels due to very serious risk of bias: unclear randomisation and inadequate blinding. bDowngraded two levels due to very serious imprecision: single trial, small sample size, wide 95% confidence intervals. | ||||||
| One type of traditional sling operation versus another type of traditional sling operation | ||||||
| Patient or population: women with urinary incontinence | ||||||
| Outcomes | Illustrative comparative risks* (95% CI) | Relative effect | Number of participants | Quality of the evidence | Comments | |
| Assumed risk | Corresponding risk | |||||
| Another type of traditional sling | One type of traditional sling | |||||
| Number of continent (dry) women (any definition) in the medium term (1 to 5 years) | Not estimable | 749 | ⊕⊝⊝⊝ | Results not pooled (Analysis 11.2) | ||
| Repeat surgery for urinary incontinence at first year Fascial sling vs Pelvicol sling | 196 per 1000 | 8 per 1000 (0 to 119) | RR 0.04 (0.00 to 0.61) | 113 | ⊕⊕⊝⊝2 | 188 fewer women, per 1000, with fascial sling (0 fewer to 76 fewer) (Analysis 11.4 |
| Perioperative surgical complications | Not estimable | 239 | ⊕⊝⊝⊝ | Results not pooled (Analysis 11.14) | ||
| Long‐term adverse effects | Not estimable | 421 | ⊕⊝⊝⊝ | Results not pooled (Analysis 11.23) | ||
| Condition‐specific quality of life | Not estimable | 282 | ⊕⊝⊝⊝ | Results not pooled* (Analysis 11.25) | ||
| *The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). | ||||||
| GRADE Working Group grades of evidence. | ||||||
| 1Downgraded two levels for imprecision (Analysis 11.2) and two levels for heterogeneity, as the trials used different materials for the traditional sling procedure. 2Downgraded two levels for imprecision (Analysis 11.4) 3Downgraded one level for risk of bias (sequence generation was judged to be at low risk of bias in two of three trials and unclear in the third trial; allocation concealment was unclear in two of three trials). Blinding (performance bias and detection bias) was judged to be unclear (two of three) or high risk (one of three). Downgraded two levels for heterogeneity, as the trials used three different materials for the traditional sling procedure, and one level for inconsistency, as 95% CIs did not overlap (Analysis 11.14). 4Downgraded two levels for heterogeneity, as the trials used four different materials for the traditional sling procedure, and one level for imprecision, as the 95% CIs were very wide (Analysis 11.23). 5Downgraded two levels for heterogeneity, as the trials used three different materials for the traditional sling procedure, and one level for inconsistency, as 95% CIs did not overlap (Analysis 11.25). * Data from two other trials were identified and are reported narratively in the text. These two trials did not report their data in a form suitable for meta‐analysis | ||||||
Background
Description of the condition
Urinary incontinence (UI) in women is a distressing condition that influences the physical, psychological, and social well‐being of affected individuals with considerable impact on women, carers, and health services (NICE 2013). Prevalence of urinary incontinence varies widely in different studies due to differences in definition and population but ranges from 8% to 45%, with stress urinary incontinence the most common type (Agarwal 2017). The prevalence of urinary incontinence increases with age, parity, smoking, and body mass index (BMI) (Amaral 2015; Lasserre 2009).
The International Continence Society defines urinary incontinence as involuntary loss of urine (Haylen 2010). Stress (urinary) incontinence (SUI) refers to involuntary loss of urine on effort or physical exertion (e.g. sporting activities), or on sneezing or coughing (Haylen 2010). Two mechanisms for stress incontinence are recognised: hypermobility or significant displacement of the urethra and bladder neck during exertion, and intrinsic urethral sphincter deficiency (Blaivas 1988). Among women, these mechanisms may co‐exist (O'Donnell 1994). Few clinical trials have distinguished between the two conditions, probably because no standardised and validated test is available to date (Abrams 2006; Blaivas 1988; McGuire 1993; McGuire 2004), and they are not defined by recognised terminology (Haylen 2010). Women whose incontinence may be due to either of these two mechanisms will be considered together in this review.
The diagnosis of urodynamic stress incontinence (USI) requires urodynamic investigation to exclude detrusor overactivity, in addition to history‐taking, physical examination, use of frequency/volume charts, and urine analysis. Some study authors have described women with only symptoms of stress incontinence (diagnosis made on clinical evaluation without urodynamics). Women with stress incontinence, both with and without urodynamic investigation, will be included in this review.
Urgency urinary incontinence (UUI) is the symptom of involuntary leakage of urine accompanied or immediately preceded by a sudden strong desire (urgency) to void that is difficult to delay. The woman has a sensation of urgency because the bladder is contracting too strongly. Detrusor overactivity (DO) is a urodynamic diagnosis characterised by occurrence of involuntary detrusor (bladder muscle) contractions. When a neurological cause is known, the term neurogenic detrusor overactivity is used. Idiopathic detrusor overactivity denotes absence of any identified cause (Haylen 2010). Women with both these symptoms and the urodynamic diagnosis of detrusor overactivity will be included in the review only if they have co‐existing and predominant stress urinary incontinence (mixed urinary incontinence (MUI)).
Women with mixed incontinence included in this review will have symptoms of stress and urgency urinary incontinence (diagnosed clinically), or urodynamic stress incontinence and detrusor overactivity (diagnosed via urodynamics).
Stress urinary incontinence is associated with various direct and indirect economic costs. For example, one USA‐based study found that women about to undergo Burch or fascial sling surgery for SUI had mean out‐of‐pocket costs (for supplies, laundry, and dry cleaning) equivalent to $19 USD (SD = 30) per week in today’s terms (2019 USD; converted from 2012 USD ‐ Shemilt 2010 ‐ at baseline) (Subak 2014). The women who participated in this study had an average (mean) age of 53 years (SD = 10) and an average (mean) baseline frequency of urinary UI episodes of 23 per week (SD = 21); 48% had undergone prior non‐surgical treatment for UI, and 16% had undergone prior surgery for UI. Another study estimated that in a single year (2012) in Spain alone, a national total of over 350,000 quality‐adjusted life‐years were lost due to UI among women 60 years of age and older (Villoro 2016).
Description of the intervention
Treatments for SUI include conservative, mechanical, pharmacological, and surgical interventions.
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Conservative treatment centres on physical methods, including pelvic floor muscle training, electrical stimulation, biofeedback, and use of weighted cones.
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Mechanical devices that prevent or reduce urinary leakage are available, such as metal plugs/patches and urethral and vaginal inserts.
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Drug therapies, principally oestrogens and less often alpha‐adrenergic agents, can be used. A trial of conservative therapy is generally undertaken before surgery is undertaken.
These interventions are the topic of separate Cochrane Reviews.
Surgical procedures to remedy stress incontinence generally aim to lift and support the outlet of the bladder neck (urethrovesical junction). There is disagreement, however, regarding the precise mechanism by which continence is achieved. The choice of procedure is often influenced by co‐existent problems, surgeons' and/or women's preferences, and physical features of the person affected.
Numerous surgical methods have been described, but essentially they fall into nine categories.
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Open abdominal retropubic suspension (e.g. colposuspension (Burch), Marshall‐Marchetti‐Krantz (MMK)) (Lapitan 2017).
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Laparoscopic retropubic suspension (Dean 2017).
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Vaginal anterior repair (anterior colporrhaphy) (Glazener 2017a).
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Traditional suburethral slings (current review).
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Mid‐urethral slings (retropubic or transobturator tapes) (Ford 2017).
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Single‐incision slings (mini‐slings) (Nambiar 2017).
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Bladder neck needle suspensions (Glazener 2017b).
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Periurethral injections (Kirchin 2017).
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Artificial sphincters.
This review will concentrate on traditional suburethral sling operations.
How the intervention might work
The aim of the suburethral sling operation is to restore or enhance the patient’s urethral support during sudden movement, such as that associated with coughing or sneezing. This is a achieved by lifting and supporting the urethrovesical junction with autologous or synthetic material. A traditional suburethral sling operation requires a combined abdominal and vaginal approach. Strips of material are tunnelled under the urethra and are attached to the rectus muscle or to the ileopectineal ligaments. The materials used for slings may be biological or synthetic.
Autologous biological materials include rectus fascia, fascia lata, pubococcygeal muscle, vaginal wall, aponeurosis, and pyramidalis fascia. Exogenous biological materials include ox fascia and porcine dermis (Pelvicol). Synthetic materials include Teflon, Mersilene tape in a silicon tube, lyodura, polytetrafluoroethylene (Goretex), Marlex mesh, and Silastic.
A modification of the suburethral sling procedure is the 'minimally invasive' mid‐urethral synthetic polypropylene mesh (sling/tape) applied via the retropubic or transobturator route. In this operation, a tape is inserted under the mid‐urethra with trocars but without fixation of free ends of the tape. This can be done with the patient under general or local anaesthesia (Smith 2002). These procedures have been considered in a separate Cochrane Review (Ford 2017). Only traditional sling operations using an open abdominal approach and suture fixation are included in this review.
Why it is important to do this review
The wide variety of surgical treatments for urinary incontinence suggests lack of consensus as to which procedure is best. The most robust evidence is likely to come from consideration of all well‐designed randomised controlled trials (RCTs). Hence, an easily accessible, periodically updated, comprehensive systematic review of such trials is needed to identify optimal practice and to highlight gaps in the evidence base. The findings of this review, taken in context with the findings of other continence surgery reviews, will provide women and their caregivers with the most robust evidence available to enable them to make an informed decision about whether to have surgery and, if so, what type.
Objectives
To assess the effectiveness of traditional suburethral sling procedures for treating stress urinary incontinence in women; and summarise the principal findings of relevant economic evaluations.
Methods
Criteria for considering studies for this review
Types of studies
Randomised or quasi‐randomised controlled trials of women with stress incontinence (urodynamic diagnosis) or symptoms of stress or mixed urinary incontinence (clinical diagnosis), in which at least one trial arm involves traditional suburethral sling procedures.
Types of participants
Adult women with SUI due to hypermobility and/or intrinsic sphincter deficiency, diagnosed clinically or with urodynamics, or with mixed urinary incontinence. Classification of diagnoses will be accepted as defined by the trialists.
Types of interventions
At least one arm of a study must involve traditional suburethral sling procedures to treat stress or mixed urinary incontinence. Comparison interventions may include other surgical techniques and non‐surgical interventions. The following comparisons were made for traditional suburethral sling procedures (abdominal and vaginal).
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Traditional suburethral sling operation versus no treatment or sham operation.
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Traditional suburethral sling operation versus conservative management (e.g. pelvic floor muscle training, electrical stimulation, cones, biofeedback).
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Traditional suburethral sling operation versus drugs.
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Traditional suburethral sling operation versus injectables.
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Traditional suburethral sling operation versus anterior repair.
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Traditional suburethral sling operation versus bladder neck needle suspension (abdominal and vaginal).
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Traditional suburethral sling operation versus open abdominal retropubic colposuspension.
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Traditional suburethral sling operation versus laparoscopic colposuspension.
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Traditional suburethral sling operation versus a mid‐urethral sling or tape.
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Traditional suburethral sling operation versus a single‐incision sling (mini‐sling).
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One type of traditional sling operation versus another type of traditional sling operation.
Types of outcome measures
Outcome measures used in this review were selected on the basis of their relevance to clinical cure or improvement in incontinence. We regard the principal measures of effectiveness as the proportion of women whose incontinence was cured following surgery and the proportion of women whose incontinence was improved.
Primary outcomes
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Urinary incontinence
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Number of continent (dry) women in the short term (less than 12 months), medium term (one to five years), and long term (longer than five years) as defined by women's report, quantified measures, clinician's observations, or combined measures (as defined by trialists; Table 1)
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Number of women who have had repeat continence surgery
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| Trial ID | Definition of outcome | Notes |
| WOMAN‐REPORTED | ||
| Overall success defined as no self‐reported symptoms of UI, no incontinence on 3‐day diary, negative stress test, no re‐treatment (combined outcome). Failure (self‐reported UI) at 5 years only (woman‐reported) | Also combined outcome before 5 years | |
| Cure defined as complete dryness with no usage of pads (woman‐reported) | ||
| Cure of incontinence defined as a quality of life (QoL) improvement of 90% and/or patient‐determined continent status as dry (woman‐reported) | Questionnaire‐based | |
| Dry (symptom‐free) patients (woman‐reported) | ||
| Assessment of cure not defined. Data abstracted from this trial therefore assumed to be woman‐reported | ||
| Cure stated as subjective (woman‐reported) at 24 months' follow‐up Objective (urodynamic diagnosis, pad test (clinician‐reported)) at 3 months | Also clinician‐reported outcome at 3 months | |
| Subjective cure consistent with complete dryness or a few drops of water with strong exercises (assumed to be woman‐reported) | Also separate clinician‐reported outcome | |
| Success rate measured by recurrence of stress leakage as reported in patient questionnaire (woman‐reported) | ||
| Subjective success: no or occasional (less than once a week) stress incontinence (woman‐reported) | Also separate clinician‐reported outcome | |
| Cure defined as subjective (history: woman‐reported) | Also separate clinician‐reported outcome | |
| Cure defined as of some degree of SUI at 1 year after surgery (woman‐reported) | ||
| Success rate (dry) (method unspecified: assumed woman‐reported) | ||
| Cure rate (method unspecified: assumed woman‐reported) | ||
| Stress urinary incontinence (method unspecified: assumed woman‐reported) | ||
| QUANTITATIVE | ||
| Cure = dry pads, improvement = 1 wet pad, failure ≥ 1 wet pad per day (quantitative) | Satisfaction separately measured by questionnaire | |
| Subjective cure assessed via comparison between pre‐operative and postoperative Incontinence Impact Questionnaire (IIQ), Urinary Distress Inventory (UDI) (quantitative) | Also separate clinician‐reported outcome | |
| Cure defined as no pad use (quantitative) | ||
| Subjective improvement only; subjective patient evaluations included QoL questionnaire, incontinence diary, pain and global outcome assessments (quantitative) | Also separate clinician‐reported outcome | |
| Objective cure defined as 1‐hour pad test ≤ 2 grams (quantitative) | Also separate clinician‐reported outcome | |
| Women declared objectively cured when they had a postoperative pad test < 8 grams (quantitative) | ||
| Objective assessment via 48‐hour frequency volume chart, 48‐hour pad test, and standardised stress test. Surgery was considered successful when there was no postoperative SUI (patient was dry (quantitative)) | Also separate clinician‐reported outcome | |
| CLINICIAN‐REPORTED | ||
| No leakage of urine during stress test and urodynamic testing (clinician‐reported) | ||
| Cure defined as complete freedom from SUI (clinician‐reported) | ||
| Urine loss during cough‐stress test defined as persistent stress incontinence (clinician‐assessed) | ||
| Objective cure by stress test, voiding dysfunction by urodynamic assessment if incontinence seen (clinician‐reported) | Also separate quantitative outcome | |
| Cure stated as objective (urodynamic diagnosis, pad test (clinician‐reported)) at 3 months | Also woman‐reported outcome at 24 months | |
| Objective cure defined as complete absence of leakage during cough‐stress test with 250 or 300 mL of water in the bladder (clinician‐reported) | Also separate woman‐reported outcome | |
| Objective success: no leakage due to SUI on repeat urodynamic study (clinician‐reported) | Also separate woman‐reported outcome | |
| Objective outcome assessment: urine loss via a provocative pad test (clinician‐reported) | Also separate quantitative outcome (improvement only) | |
| Cure defined as objective (urodynamic: clinician‐reported) | Also separate woman‐reported outcome | |
| Objective cure defined as negative cough‐induced stress test with full bladder (≥ 250 mL filled) in lithotomy and standing positions (clinician‐reported) | Also separate quantitative outcome | |
| Objective assessment via 48‐hour frequency volume chart, 48‐hour pad test, and standardised stress test. Surgery considered successful when stress test was negative (clinician‐reported) and postoperative cystocoele was < grade 2 | Also separate quantitative outcome | |
| COMBINED WOMAN‐ AND CLINICIAN‐REPORTED | ||
| Overall success defined as no self‐reported symptoms of UI, no incontinence on 3‐day diary, negative stress test, no re‐treatment (combined outcome). Failure (self‐reported UI) at 5 years only (woman‐reported) | Also woman‐reported outcome at 5 years | |
| Cure of SUI defined as significant dryness as perceived by the patient, no more use of pads, negative stress test, and acceptable voiding stream (combined primary outcome) | However, no data after first week, so not useable | |
| Cure defined as absence of subjective complaints of leakage and absence of urinary leakage on stress test (combined outcome) | ||
| Cure defined as dry, symptom‐free without objective urine loss during stress with bladder filled to 300 mL or positive urethral‐closure pressure during stress provocation (combined outcome) | ||
| Continence defined as no urinary leakage on a 3‐day voiding diary, no self‐reported stress incontinence symptoms, and no stress incontinence surgical treatment (combined outcome) | ||
| Cure defined as complete freedom from SUI (subjective and objective demonstrations) (combined outcome) | ||
| Patients evaluated by SEAPI score (subjective and objective) after urodynamic examination before and after treatment (combined outcome) | ||
| Cure defined as reported absence of SUI with no urinary loss during effort manoeuvres (combined outcome) | ||
| Cure defined as no leakage reported by the patient or noticed at examination (combined outcome) | ||
| Cure defined as complete dryness with no usage of pad and negative cough‐stress test (combined outcome) | ||
Trials that did not report cure rates.
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Teixeira 2008: this trial did not address efficacy because it was a trial of tissue (histological) reaction to different sling materials.
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Al‐Azzawi 2014: this trial followed up women to one year and beyond but did not provide any outcome data after the first week.
Secondary outcomes
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Women's observations
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Number of women cured at one year or later (women's observations)
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Number of women improved (cured or improved) in the short term (less than 12 months), medium term (one to five years), and long term (longer than five years)
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Number of women satisfied
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Quantification of symptoms
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Pad changes over 24 hours (from self‐reported number of pads used)
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Incontinent episodes over 24 hours (from self‐completed bladder chart)
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Pad test of quantified leakage (mean weight of urine loss)
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Clinician's observations
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Numbers of women with urinary incontinence (clinician's observation) in the short term (less than 12 months), medium term (one to five years), and long term (longer than five years)
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Surgical outcome measures
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Duration of operation
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Length of hospital stay
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Time to return to normal activity level
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Blood loss
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Further treatment
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Number of women requiring treatment for pelvic organ prolapse
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Adverse events
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Perioperative surgical complications
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Bladder perforation
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Urinary tract infection
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Urinary urgency symptoms, urgency urinary incontinence
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Detrusor overactivity (urodynamic overactivity)
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Voiding dysfunction (with or without urodynamic confirmation)
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Long‐term adverse effects such as mesh exposure, pelvic pain, dyspareunia, or release of sling
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Quality of life
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Condition‐specific measures to assess quality of life (e.g. Bristol Female Lower Urinary Tract Symptoms questionnaire (BFLUTS)) (Jackson 1996)
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General health status measures (e.g. Short Form 36) (Ware 1993)
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Main outcomes for ‘Summary of findings’ tables
We adopted the GRADE method for assessing the quality of evidence for the following five outcomes.
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Number of continent (dry) women (any definition) in the medium term (1 to 5 years)
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Repeat surgery for urinary incontinence.
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Perioperative surgical complications.
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Long‐term adverse effects such as mesh exposure, pain, and dyspareunia.
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Condition‐specific quality of life.
Definition of cure and urinary incontinence
After discussion, the review authors agreed to add another outcome: women's report of cure of urinary incontinence. We identified the definitions of cure and incontinence used in each individual included trial (Table 1). However, only 14 trials used women's report of cure or incontinence to determine cure. The remainder used quantitative methods (such as whether pads were wet or dry, questionnaire scores, or diaries) (seven trials), clinician‐observed or ‐reported urine leakage (11 trials), or a combined definition without reporting the elements separately (10 trials). Some trials did report incontinence in more than one way. We therefore decided to use as our primary outcome the number of continent (dry) women, with any method used to measure or report urinary incontinence, but we added a further outcome of 'cure' as reported by women at 12 months or later.
Search methods for identification of studies
We did not impose language or other restrictions on any of these searches.
Electronic searches
Search for clinical effectiveness studies
We drew on the search strategy developed for Cochrane Incontinence. We identified relevant trials from the Cochrane Incontinence Specialised Register. For more details of the search methods used to build the Specialised Register, please see the Group's webpages, where details of the Register's development (from inception) and of the most recent searches performed to populate the Register can be found. To summarise, the Register contains trials identified by searching the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In‐Process, MEDLINE Epub Ahead of Print, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), ClinicalTrials.gov, and WHO ICTRP, and by handsearching journals and conference proceedings. Many of the trials in the Cochrane Incontinence Specialised Register are also contained in CENTRAL.
The date of the last fully incorporated search was 27 February 2017.
A further updated search was conducted on 23 January 2019, the results of which were not fully incorporated into the review.
The terms used to search the Cochrane Incontinence Specialised Register are given in Appendix 1.
For previous versions of this review, one of the review authors performed extra literature searches. These are described in Appendix 2.
Search for economic evaluations
We performed additional searches of the following databases for the brief economic commentary (BEC).
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MEDLINE on Ovid SP (1 January 1946 to week 5 July 2018), searched on 10 August 2018.
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Embase on Ovid SP (1 January 1980 to week 32 2018), searched on 10 August 2018.
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National Health Service Economic Evaluation Database (NHS EED) on Ovid SP (first quarter 2016), searched on 6 April 2017 (this database is no longer updated by the producer).
Search strategies used for the BEC are given in Appendix 3.
Searching other resources
We searched the reference lists of relevant articles for other possibly relevant trials.
Data collection and analysis
Selection of studies
At least two review authors evaluated the appropriateness of including reports of all possibly eligible studies without prior consideration of the results. We retrieved the reports of potentially eligible trials in full. We resolved any differences of opinion by discussion between the review authors.
Data extraction and management
At least three review authors undertook data extraction independently using a standard form containing pre‐specified outcomes. When data may have been collected but not reported, we sought clarification from the trialists.
Any differences of opinion related to study inclusion, data extraction, or risk of bias assessment were resolved by discussion among the review authors and, when necessary, were referred to a fourth review author for arbitration. We conducted the review using the standard Cochrane RevMan software.
Assessment of risk of bias in included studies
Each review author independently assessed risk of bias using Cochrane's 'Risk of bias' tool as described in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). The following questions were assessed and reported in the 'Risk of bias' tables.
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Was the random sequence adequately generated (selection bias)?
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Was allocation adequately concealed (selection bias)?
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Were the participants or caregivers (performance bias) or outcome assessors (detection bias) blinded?
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Were incomplete outcome data adequately addressed (attrition bias)?
We judged studies to be at low risk of bias if the method of blinding was adequate, or if lack of blinding could not have affected the results or could not be avoided. Each element was assessed as having low risk, high risk, or unclear risk of bias (the latter usually when no information was supplied).
Measures of treatment effect
When appropriate, we calculated a combined estimate of treatment effect across similar studies for each pre‐specified outcome, using risk ratios (RRs) for dichotomous data and mean differences (MDs) for continuous outcomes, along with 95% confidence intervals (CIs) when possible. For categorical (dichotomous) outcomes, the numbers reporting an outcome were related to the numbers at risk in each group to derive a risk ratio (RR). We have, however, used the odds ratio (OR) when reporting the number of continent or cured women, as event rates were expected to be high. For continuous variables, we used means and standard deviations to derive a mean difference (MD). We undertook a fixed‐effect approach to the analysis unless we noted evidence of heterogeneity across studies.
Unit of analysis issues
We analysed studies with multiple treatment groups by treating each pair of arms as a separate comparison, as appropriate. Studies based on a non‐standard design, such as cross‐over trials and cluster‐randomised trials, would have been analysed as described in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011).
Dealing with missing data
We included data as they were reported. If women's subjective reporting of (cure of) urinary incontinence was not provided, we used the objective clinician's observations or other measures of urine leakage as surrogate data to maximise information available for the primary outcome ‐ the number of continent (dry) women (Table 1 shows data used). We did not contact authors of trials for missing data or further details for this version of the review.
Assessment of heterogeneity
We investigated differences between trials when apparent from visual inspection of the results, or when statistically significant heterogeneity was demonstrated, by using the Chi² test at the 10% probability level or assessment of the I² statistic (Higgins 2003). If we found no obvious reason for the heterogeneity (after consideration of populations, interventions, outcomes, and settings of individual trials), or if heterogeneity persisted despite removal of outlying trials, we used a random‐effects model.
Assessment of reporting biases
We would have examined publication bias through a funnel plot if 10 or more studies had been included in a meta‐analysis.
Data synthesis
We sought data on the number of participants with each outcome event by allocated treated group, irrespective of compliance and whether or not the participant was later thought to be ineligible or otherwise excluded from treatment or follow‐up, to allow an intention‐to‐treat (ITT) analysis when possible. We defined an ITT analysis to mean that all participants were analysed in their randomised groups whether or not they received the allocated intervention. We used the Mantel‐Haenszel statistical method for meta‐analysis. We used a fixed‐effect approach to the analysis, unless we found evidence of heterogeneity across studies, in which case we adopted a random‐effects model. We used a narrative review of eligible studies when statistical synthesis of data from than one study was not possible or was considered not appropriate.
Subgroup analysis and investigation of heterogeneity
We grouped trial data by type of incontinence: urodynamic stress incontinence based on a urodynamic diagnosis, or stress or mixed urinary incontinence based on symptom classification. It is unclear whether there is a clinical difference between women who had SUI alone (diagnosed by urodynamics to exclude concomitant detrusor contractions, which might be indicative of overactive bladder or urgency urinary incontinence) and women whose diagnosis of SUI was based on their report of symptoms alone. Women who have MUI (stress plus urgency) may have a worse outcome than those with SUI alone. We wished to explore whether different interventions had a differential effect among women with different types of incontinence. Quantitative synthesis was done when more than one eligible study was identified.
We also planned to examine whether findings would vary among women with primary versus recurrent SUI, or with presence or absence of prolapse, but this was not possible due to lack of information provided by the included trials.
In addition, we examined whether biological materials were associated with different outcomes compared with synthetic materials used for traditional sling arms in a separate comparison (comparison 11). It is biologically feasible that biological materials might be reabsorbed by the body tissues and thus might not be as long‐lasting as non‐absorbable synthetic materials.
Sensitivity analysis
We would have carried out sensitivity analysis based on eligibility criteria, such as by including and excluding results from abstract‐only publications or quasi‐randomised trials, if we had identified enough trials.
'Summary of findings' tables and assessing the quality of evidence
The GRADE Working Group strongly recommends including up to seven outcomes in 'Summary of findings' tables in a systematic review (Guyatt 2011a; Guyatt 2011b; Guyatt 2013a; Guyatt 2013b). We classified the primary and secondary outcomes in the Types of outcome measures as 'critical', 'important', or 'not important' for decision‐making from the patient's perspective, and we used this hierarchy to decide which outcomes should be included in the 'Summary of findings' tables. We also made judgements about which adverse events may be important to patients.
We implemented the GRADE method for assessing the quality of evidence.
Incorporating economics evidence
Following the search outlined under Search methods for identification of studies, we developed a brief economic commentary (BEC) to summarise the availability and principal findings of full economic evaluations that compare traditional sling operations for urinary incontinence in women (Shemilt 2019). This BEC encompasses full economic evaluations (i.e. cost‐effectiveness analyses, cost‐utility analyses, and cost‐benefit analyses), conducted alongside or based upon one or more RCTs included in the main review of intervention effects. This commentary focuses on the extent to which principal findings of eligible economic evaluations indicate that an intervention might be judged favourably or unfavourably from an economic perspective when implemented in different settings.
Results
Description of studies
Results of the search
We screened a total of 582 records produced by the literature search for this fourth update and retrieved 167 full‐text articles that appeared to meet the eligibility criteria for this review. After assessing the full‐text articles, we identified 115 reports of 34 included studies and 50 reports of 38 excluded studies. Additionally, we found reports of two ongoing studies (Hilton 2000; Zhu 2014). The flow of literature through the assessment process can be seen in Figure 1.
PRISMA study flow diagram ‐ search for clinical effectiveness studies.
For this update, eight new trials were included (Abouhashem 2014; Al‐Azzawi 2014; Choe 2000; Helmy 2012; Okulu 2013; Sharifiaghdas 2015; Teleb 2011; Zargham 2013). A further four have been updated with new information (Albo 2007; Amaro 2007; Guerrero 2008; Wadie 2005). In total, the review now contains 34 included trials, 38 excluded trials, and two ongoing studies.
A further updated search of the Cochrane Incontinence Specialised Register was conducted on 23 January 2019. This search was not fully incorporated into the review. A total of 28 records retrieved by the search were screened. Four reports of trials were eligible for inclusion in the review ‐ for transparency, all four eligible reports have been added to Studies awaiting classification, and details can be found under Characteristics of studies awaiting classification. In brief, the authors of Sharifiaghdas 2008 published a 10‐year update in 2017, but the data have not yet been added to the review (Sharifiaghdas 2017). Abou Hashem 2017 served as another report of the already included study (Abouhashem 2014); however, this appears to be exactly the same conference abstract as the one included study report (also a conference abstract); no new details or data are available in this additional report. Two new ongoing studies were also identified (Hassan 2018; Kajbafzadeh 2017), but their data have not yet been added to the review.
Our search for economic evaluations produced a total of 465 titles and abstracts to be screened, from which we selected four reports of three economic evaluations for further assessment (Berman 1997; Kilonzo 2004; Kumar 2017). The flow of literature through the assessment process is shown in Figure 2.
PRISMA study flow diagram ‐ search for economic evaluations for the BEC.
Included studies
We included a total of 34 RCTs, reporting data on outcomes of 3244 women, with sample sizes ranging from 20 to 655 participants. Three trials are quasi‐randomised (Choe 2000; Kondo 2006; Zargham 2013), and two are multi‐arm trials (Bai 2005; Guerrero 2008). With the exception of Albo 2007 and Sand 2000, the included trials were small and had short follow‐up.
Participants
Inclusion criteria were not always clearly defined. Ten trials included women (some or all) with stress‐predominant MUI, both stress and urgency (Al‐Azzawi 2014; Barbalias 1997; Basok 2008; Kondo 2006; Okulu 2013; Osman 2003; Sand 2000; Song 2004; Teleb 2011; Zargham 2013). Two trials involved women with self‐reported or predominant SUI (Albo 2007; Wadie 2005). All others were restricted to women with a urodynamic diagnosis of stress incontinence (USI, previously known as genuine stress incontinence). Data from two trials were insufficient, with only abstracts available (Abouhashem 2014; Helmy 2012). All trials included both pre‐menopausal and postmenopausal women, but none included women who were treated with hormone replacement therapy. One study was restricted to women with vaginal narrowing due to atrophic vaginitis or previous surgical scars (Hilton 1989).
Previous continence surgery status
Two trials included only women without previous interventions for incontinence (Henriksson 1978; Silva Filho 2006), and another included only women who had recurrent incontinence after a previous vaginal hysterectomy and at least one anterior repair (Enzelsberger 1996). The others included women with both primary and recurrent SUI but did not report outcome data separately according to previous continence surgery.
Presence or absence of pelvic organ prolapse
This information was not routinely reported in the included trials, and when it was, data were not reported separately.
Interventions
Fifteen materials were used for the traditional sling procedure across 34 studies.
Autologous biological materials
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Autologous dermal graft patch (Shin 2001)
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Autologous fascia lata (Song 2004)
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Autologous rectus fascia (Abouhashem 2014; Al‐Azzawi 2014; Albo 2007; Amaro 2007; Bai 2005; Barbalias 1997; Demirci 2001; Guerrero 2008; Helmy 2012; Kondo 2006; Lucas 2000; Maher 2005; Osman 2003; Pacetta 2005; Sharifiaghdas 2008; Sharifiaghdas 2015; Silva Filho 2006; Tcherniakovsky 2009; Teleb 2011; Viseshsindh 2003; Wadie 2005)
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Autologous vaginal wall sling (Choe 2000; Teleb 2011; Viseshsindh 2003; Zargham 2013)
Other biological materials
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Cadaveric fascia lata (Basok 2008; Shin 2001)
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Fortaperm (Pacetta 2005)
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Lyphohilised dura matter (Enzelsberger 1996)
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Porcine dermis, also known as Pelvicol (Arunkalaivanan 2003; Guerrero 2008; Hilton 1989, Teixeira 2008)
Synthetic non‐absorbable materials
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Goretex sling operation (Barbalias 1997)
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Polytetrafluoroethylene ‐ PTFE (Sand 2000)
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Polytetrafluoroethylene impregnated with silver diacetate and chlorhexidine; Antimicrobial Mycromesh (Choe 2000)
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Teflon sling (Henriksson 1978)
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Ultrapro mesh: synthetic monofilament combined mesh, non‐absorbable with absorbable coating (Okulu 2013)
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Prolene or prolene light mesh (Okulu 2013; Teleb 2011)
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Vypro mesh: semi‐absorbable multi‐filament mesh (Okulu 2013)
One trial, reported in abstract form, did not mention the type of material used for the suburethral sling (Fischer 2001).
Comparators
The 34 included trials reported the following comparisons.
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One compared traditional suburethral sling operations with oxybutynin for treating women with mixed urinary incontinence (Osman 2003).
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One compared traditional suburethral sling operations with suburethral injectable treatment (Maher 2005).
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One compared traditional suburethral sling operations with bladder neck needle suspension (Hilton 1989).
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Eight compared traditional suburethral sling operations with open abdominal retropubic colposuspension (Albo 2007; Bai 2005; Demirci 2001; Enzelsberger 1996; Fischer 2001; Helmy 2012; Henriksson 1978; Sand 2000). There were no useable data in one of the trials identified in the updated search (Helmy 2012), and one trial was updated with new information (Albo 2007).
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Fifteen trials compared traditional suburethral sling operations with mid‐urethral sling operations (Abouhashem 2014; Al‐Azzawi 2014; Amaro 2007; Arunkalaivanan 2003; Bai 2005; Basok 2008; Guerrero 2008; Kondo 2006; Sharifiaghdas 2008; Silva Filho 2006; Song 2004; Tcherniakovsky 2009; Teixeira 2008; Wadie 2005; Zargham 2013). Of these, three were added to this comparison in this version of the review (Abouhashem 2014; Al‐Azzawi 2014; Zargham 2013), but one did not provide any useable data (Abouhashem 2014). One trial did not provide data after the first week (Al‐Azzawi 2014), and further data were identified for three trials (Amaro 2007; Guerrero 2008; Wadie 2005).
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One compared a traditional suburethral sling with a single‐incision sling (mini‐sling) (Sharifiaghdas 2015).
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Nine trials compared one type of traditional suburethral sling with another (Barbalias 1997; Choe 2000; Guerrero 2008; Lucas 2000; Okulu 2013; Pacetta 2005; Shin 2001; Teleb 2011; Viseshsindh 2003). Of these, three are new to this comparison for this version of the review (Choe 2000; Okulu 2013; Teleb 2011), and one trial was updated with further data (Guerrero 2008).
No trials compared suburethral slings with anterior repair, laparoscopic retropubic colposuspension, or artificial sphincters.
There were seven non‐traditional sling comparators across 25 studies.
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Anticholinergic (Osman 2003).
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Intravaginal slingplasty (Basok 2008).
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Mid‐urethral sling (Abouhashem 2014; Al‐Azzawi 2014; Amaro 2007; Arunkalaivanan 2003; Bai 2005, Guerrero 2008; Kondo 2006; Sharifiaghdas 2008; Silva Filho 2006; Song 2004; Tcherniakovsky 2009; Teixeira 2008; Wadie 2005; Zargham 2013).
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Retropubic colposuspension: Burch colposuspension (Albo 2007; Bai 2005; Demirci 2001; Enzelsberger 1996; Fischer 2001; Helmy 2012; Osman 2003; Sand 2000); Marshall‐Marchetti‐Krantz (Henriksson 1978).
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Stamey bladder neck (needle) suspension (Hilton 1989).
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Transurethral Macroplastique (injectable material) (Maher 2005).
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Single‐incision sling (mini‐sling) (Sharifiaghdas 2015).
One trial was designed to study an anticholinergic agent (oxybutynin) in comparison with surgery (Burch or sling) for women with MUI (Osman 2003). It was possible to extract only the data from sling surgery in comparison with medical treatment for inclusion in the analysis.
Outcome measures (definition of incontinence)
Outcome measures were not reported in a standardised fashion (Table 1).
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Fourteen trials used women's self‐report of cure or absence of incontinence to define urinary incontinence.
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Seven trials used quantitative methods (such as based on wet or dry pads, questionnaire scores, or diaries).
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Eleven trials used clinician‐observed or ‐reported urine leakage (such as the stress test, or at urodynamics).
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Ten trials used a combined definition without reporting the elements separately.
The primary outcome was the number of continent (dry) women using at least one of these definitions of urine leakage (32/34 trials). If woman‐reported leakage alone or clinician‐observed leakage was reported separately, those were also reported in separate outcomes. Only two trials did not report any measure of urine leakage (Al‐Azzawi 2014; Teixeira 2008).
Follow‐up
Trials varied in their reports of initial and long‐term follow‐up, reporting data on outcomes of 3244 women at last follow‐up.
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Ten trialists presented their results at three‐ and/or six‐ and/or nine‐month assessment (Bai 2005; Choe 2000; Fischer 2001; Henriksson 1978; Osman 2003; Silva Filho 2006; Sand 2000; Song 2004; Teleb 2011; Viseshsindh 2003).
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One trial followed up women to one year and beyond but did not provide any outcome data after the first week, such that cure data were not useable (Al‐Azzawi 2014).
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Eleven trials presented follow‐up at around one year (Arunkalaivanan 2003; Basok 2008; Demirci 2001; Guerrero 2008; Lucas 2000; Maher 2005; Pacetta 2005; Sharifiaghdas 2008; Sharifiaghdas 2015; Shin 2001; Tcherniakovsky 2009).
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Eleven trials described follow‐up between one and five years (Albo 2007; Amaro 2007; Arunkalaivanan 2003; Barbalias 1997; Enzelsberger 1996; Hilton 1989; Kondo 2006; Okulu 2013; Teixeira 2008; Wadie 2005; Zargham 2013).
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Three trials have now reported data on the outcomes of 892 women at the last follow‐up at five years or later (Albo 2007; Guerrero 2008; Sand 2000).
For more details about the characteristics of these trials, please see Characteristics of included studies.
Excluded studies
In total, 38 studies were excluded. For further details, please see Characteristics of excluded studies.
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Seventeen trials compared mid‐urethral or variant sling procedures with each other or with other operations (Amat 2007; Chong 2003; Corcos 2001; Darai 2007; Gamble 2010; Halaska 2001; Han 2001; Kocjancic 2008; Liapis 2002; Lim 2005; Naumann 2006; Oremus 2010; O'Sullivan 2000; Palomba 2008; Seo 2007; Ward 2002a; Yoo 2007). Mid‐urethral sling and open colposuspension procedures are considered in other Cochrane Reviews (Ford 2017; Lapitan 2017).
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Eleven studies were not randomised (Atherton 2000; Brandt 2009; Bruschini 2005; Debodinance 1994; Giri 2004; Giri 2006; Hung 2001; Ishenko 1999; Kuo 2001; Obrink 1978; Schostak 2001).
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There was uncertainty regarding the population included in two trials (Aurunkalaivanan 2001; Barrington 2003).
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Five trials included some participants who did not have SUI (Debodinance 1993; Goldberg 2001; Kwon 2002; Meschia 2001; Trezza 2001).
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Three trials were excluded for other reasons: Choe 2001 randomised women to having urodynamic evaluation or not; Wang 1999 randomised women to different types of anaesthetic; Lemieux 1991 compared clamping and non‐clamping of catheters after incontinence surgery.
Risk of bias in included studies
Risk of bias findings for the included trials are summarised in Figure 3 and Figure 4.
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
Allocation
Adequate sequence generation
Eight trials used an adequate method of sequence generation (Al‐Azzawi 2014; Albo 2007; Amaro 2007; Barbalias 1997; Guerrero 2008; Okulu 2013; Osman 2003; Sand 2000). Two trials used randomisation charts to generate the randomisation sequence without providing further information about the process (Enzelsberger 1996; Hilton 1989). Nevertheless, these were judged to be adequate. In one of these trials, one woman was randomised to one arm of the study and was compared with two women randomised to the other intervention (Barbalias 1997).
Sequence generation was inadequate in three trials, which were therefore categorised as quasi‐randomised trials. Kondo 2006 used date of birth with even dates assigned to one group and odd dates to the other. In two trials, women were randomised in alternate fashion (Choe 2000; Zargham 2013).
In the remainder, women were stated to be randomised but no other details of the process were provided.
Allocation concealment
The reported method of concealment of randomisation was secure in seven trials (Albo 2007; Amaro 2007; Guerrero 2008; Lucas 2000; Okulu 2013; Sharifiaghdas 2015; Wadie 2005). Allocation concealment was unknown for most of the remaining trials, as study authors did not record it. Another trial used sealed opaque envelopes but made no mention of numbering and thus was judged as unclear for allocation concealment (Sharifiaghdas 2008).
Inadequate allocation concealment was noted in three quasi‐randomised trials (Kondo 2006; Choe 2000; Zargham 2013).
Blinding
Masking of women or surgeons was not reported in most trials, but this is difficult to achieve in surgical trials. Only two trials attempted or reported blinding of participants or care providers (Guerrero 2008; Wadie 2005). Third party outcome assessment was not performed in any of the trials.
Incomplete outcome data
Most trials had complete outcome data at follow‐up, or losses were evenly distributed between randomised groups, and this was unlikely to have a significant effect on the final analysis. Two trials did not account for losses at follow‐up, which might potentially have been a source of bias (Demirci 2001; Fischer 2001). One trial had a differential dropout at two years' follow‐up (Wadie 2005).
Other potential sources of bias
Comparability of groups at baseline
Baseline comparisons between groups were provided in 19 trials (Albo 2007; Arunkalaivanan 2003; Bai 2005; Basok 2008; Choe 2000; Demirci 2001; Enzelsberger 1996; Hilton 1989; Kondo 2006; Lucas 2000; Maher 2005; Okulu 2013; Sand 2000; Sharifiaghdas 2008; Song 2004; Tcherniakovsky 2009; Teleb 2011; Wadie 2005; Zargham 2013). Henriksson 1978 stated that the two groups were comparable without supplying data, and the remainder did not mention baseline comparisons between groups.
Although we did not formally assess 'selective reporting' or 'other bias' (other than comparability of groups at baseline, as above), we had no concerns for these two domains across studies.
Effects of interventions
See: Summary of findings for the main comparison Traditional suburethral sling operation versus no treatment or sham operation; Summary of findings 2 Traditional suburethral sling operation versus conservative management; Summary of findings 3 Traditional suburethral sling operation versus drugs; Summary of findings 4 Traditional suburethral sling operation versus injectables; Summary of findings 5 Traditional suburethral sling operation versus anterior repair; Summary of findings 6 Traditional suburethral sling operation versus bladder neck needle suspension (abdominal and vaginal); Summary of findings 7 Traditional suburethral sling operation versus open abdominal retropubic colposuspension; Summary of findings 8 Traditional suburethral sling operation versus laparoscopic colposuspension; Summary of findings 9 Traditional suburethral sling operation versus a mid‐urethral sling or tape; Summary of findings 10 Traditional suburethral sling operation versus a single‐incision sling (mini‐sling); Summary of findings 11 One type of traditional sling operation versus another traditional sling operation
Comparison 1. Traditional suburethral sling operation versus no treatment or sham operation
No trials were identified.
Comparison 2. Traditional suburethral sling operation versus conservative management
No trials were identified.
Comparison 3. Traditional suburethral sling operation versus drugs
One trial included 75 women with MUI treated with surgery (either Burch colposuspension (n = 24) or rectus fascia sling (n = 26)) or oxybutynin (an anticholinergic drug treatment for urinary incontinence, overactive bladder, and detrusor overactivity ‐ not for stress incontinence; n = 25)) (Osman 2003). The type of surgery was selected according to Valsalva leak point pressure (VLPP) ‐ those with VLPP of less than 90 cm of water had rectus fascia sling, and those with VLPP of more than 90 cm of water had Burch colposuspension.
Results for the surgically managed group were similar to those for the subgroup having slings. Due to small sample sizes, the data were too few to be reliable, and we therefore compared only data from oxybutynin versus sling patients in tables (Table 2).
| Comparison 3. Traditional suburethral sling operation versus drugs | |
| Osman 2003 included 75 women with mixed urinary incontinence treated with surgery (either Burch colposuspension (n = 24) or rectus fascia sling (n = 26)) or oxybutynin (an anticholinergic drug treatment for urinary incontinence, overactive bladder, and detrusor overactivity ‐ not for stress incontinence; n = 25) (Osman 2003). The type of surgery was selected according to Valsalva leak point pressure (VLPP) ‐ those with VLPP < 90 cm of water had rectus fascia sling, and those with VLPP > 90 cm of water had Burch colposuspension) Results for the surgically managed group were similar to those of the subgroup having slings. Due to small sample sizes, data were too few to be reliable; we therefore compared only data from oxybutynin versus sling patients provided in tables Primary outcomes Number of continent (dry) women Data suggest that, within the first year, women were significantly more likely to be continent after undergoing surgery with slings than after treatment with oxybutynin (20/24; 83% vs 0/21; OR 195.89, 95% CI 9.91 to 3871.03; n = 45; Analysis 3.1) Number of women who have repeat continence surgery Not reported Secondary outcomes Fewer women had persistent urgency urinary incontinence after traditional sling surgery (3/24; 13% vs 9/21; 43% with oxybutynin; RR 0.29, 95% CI 0.09 to 0.94; n = 45; Analysis 3.2) | |
| Comparison 4. Traditional suburethral sling operation vs injectables | |
| Maher 2005 compared slings (21) vs injectable Macroplastique (22) in 45 women. Due to the small size of the trial, the data were too few to be reliable Primary outcomes Number of continent (dry) women Short‐term: data from 1 small trial were too few to reliably identify evidence of a difference between traditional sling and injectables in the number of continent women within the first year (OR 2.79, 95% CI 0.48 to 16.33; n = 43; Maher 2005; Analysis 4.1) Medium‐term: Maher 2005 found no evidence of a difference between groups in the number of continent women after the first year (13/13; 100% continent with a traditional sling vs 10/14, 71% with the injectable; OR 11.57, 95% CI 0.56 to 239.74; n = 27; very low‐quality evidence; Analysis 4.2;summary of findings Table 4) Number of women who have repeat continence surgery We found no evidence of a difference between groups in the numbers of women having repeat surgery for urinary incontinence (1 after traditional sling vs 2 after injectable: RR 0.52, 95% CI 0.05 to 5.36; n = 43; very low‐quality evidence; Maher 2005; Analysis 4.3;summary of findings Table 4) Secondary outcomes Number of women cured at 1 year or later (women's observations) The trial was too small to reliably identify evidence of a difference between groups in the number of women cured after the first year (OR 11.57, 95% CI 0.56 to 239.74; n = 27; Analysis 4.4) Number of women improved Not reported Number of women satisfied Data from Maher 2005 were too few to identify a difference between groups in satisfaction rates at 6 months (P = 0.41) or at 5 years (RR 2.42, 95% CI 0.98 to 5.98; n = 27; Analysis 4.5) Quantification of symptoms Not reported Clinician's observations Data suggest there were more women with incontinence (clinician‐observed) within the first year with injectables compared with the traditional sling: 4/21 vs 20/22 (RR 0.21, 95% 0.09 to 0.21; n = 43; Maher 2005; Analysis 4.6) Surgical outcome measures Injectables were quicker to perform, involved shorter hospital stay and time to catheter removal, and led to quicker return to normal activity than after traditional sling surgery, but the data were not suitable for meta‐analysis (Maher 2005) Further treatment Not reported Adverse events Perioperative surgical complications Not reported Bladder perforation Not reported Urinary tract infection Maher 2005 reported no evidence of a difference between traditional slings and injectables in the numbers of women with urinary tract infection (RR 1.57, 95% CI 0.29 to 8.49; very low‐quality evidence; Analysis 4.7;summary of findings Table 4) Urinary urgency symptoms, urgency urinary incontinence Not reported Detrusor overactivity (urodynamic overactivity) Maher 2005 reported no evidence of a difference between traditional slings and injectables in the numbers of women with de novo detrusor overactivity (RR 3.14, 95% CI 0.13 to 72.96; Analysis 4.8) Voiding dysfunction (with or without urodynamic confirmation) Maher 2005 reported no evidence of a difference between traditional slings and injectables in the numbers of women with voiding dysfunction (RR 4.19, 95% CI 0.51 to 34.50; Analysis 4.9) Long‐term adverse effects Not reported Quality of life Maher 2005 reported a significant reduction in Incontinence Impact Questionnaire (IIQ) scores compared with baseline (P < 0.01) in both groups, although he provided no data | |
| Comparison 6. Traditional suburethral sling operation vs bladder neck needle suspension (abdominal and vaginal) | |
| Only 1 trial compared porcine dermis sling vs Stamey needle suspension (Hilton 1989). This was a small trial with only 10 women in each arm. The women were unsuitable for abdominal colposuspension (the study author's preferred procedure) because they had vaginal narrowing secondary to previous interventions or atrophic vaginitis. Thus they constitute a population of women with SUI who are not typical of the majority. All women had urodynamic stress incontinence. Groups were comparable for age, parity, previous interventions, and hormonal status. Follow‐up was reported at 3 months and 24 months. Due to the small size of the trial, the data were too few to be reliable Primary outcomes Number of continent (dry) women Short‐term: within the first year after surgery, 1 small trial reported 9/10 and 8/10 continent women in the traditional sling and needle suspension groups, respectively (OR 2.25, 95% CI 0.17 to 29.77; n = 20; Hilton 1989; Analysis 6.1) Medium‐term: very low‐quality evidence from 1 trial comparing slings vs bladder neck needle suspension suggested no evidence of a difference between groups in the likelihood of being continent at 2 years after surgery (OR 3.86, 95% CI 0.33 to 45.57; n = 20; Hilton 1989; Analysis 6.2;summary of findings Table 6) Long‐term: not reported Number of women who have repeat continence surgery Not reported Secondary outcomes Women's observations Number of women cured at 1 year or later (women's observations) Evidence from 1 small trial comparing slings vs bladder neck needle suspension suggests no difference between groups in cure rates at 2 years after surgery (OR 3.86, 95% CI 0.33 to 45.57; n = 20; Hilton 1989) Quantification of symptoms Pad test at 12 months and 24 months stated but not reported (Hilton 1989) Clinician's observations Not reported Surgical outcome measures Duration of operation Not reported Length of hospital stay Sling group needed an indwelling catheter for longer and more adjuvant therapy, resulting in a longer stay in hospital than those with bladder neck needle suspension (MD 13 days longer, 95% CI 5 to 21; n = 20; Hilton 1989; Analysis 6.4) Time to return to normal activity level Not reported Blood loss Not reported Further treatment Not reported Adverse events Perioperative surgical complications Nine of the 10 women who had sling operations had complications, compared with 2/10 who had needle suspension. These included pyrexia, blood loss, wound infection, and pulmonary embolus (RR 4.50, 95% CI 1.28 to 15.81; n = 20; very low‐quality evidence; Hilton 1989; Analysis 6.5;summary of findings Table 6) Bladder perforation Not reported Urinary tract infection Not reported Urinary urgency symptoms, urgency urinary incontinence At 3 months: sling: 5/10, needle suspension: 3/10 (Hilton 1989; Analysis 6.6) Detrusor overactivity (urodynamic overactivity) At 3 months: sling: 2/10, needle suspension: 1/10 (Hilton 1989; Analysis 6.7) Voiding dysfunction (with or without urodynamic confirmation) At 3 months: sling: 4/10, needle suspension: 2/10 (Hilton 1989; Analysis 6.8) Long‐term adverse effects Not reported Quality of life Not reported | |
| Comparison 10. Traditional suburethral sling operation vs a single‐incision sling (mini‐sling) | |
| One small trial compared a rectus fascia pubovaginal traditional sling vs a single‐incision sling (mini‐sling; Ophira) and included women with urodynamically diagnosed stress urinary incontinence (USI) (Sharifiaghdas 2015) Due to the small size of the trial, the data were too few to be reliable Primary outcomes Number of continent (dry) women Short‐term: not reported Medium‐term: exactly the same proportion of women were continent at 1 year after surgery (traditional sling: 31/35; mini‐sling: 31/35; very low‐quality evidence; Sharifiaghdas 2015; Analysis 10.1;summary of findings Table 10) Long‐term: not reported Number of women who have repeat continence surgery Not reported Secondary outcomes Women's observations Cure For self‐report of cure at 1 year after surgery, exactly the same proportion of women were cured (traditional sling: 31/35; mini‐sling: 31/35; Sharifiaghdas 2015; Analysis 10.2) Number of women improved Not reported Number of women satisfied 10/35 women in the traditional sling group and 7/35 in the mini‐sling group reported that they were satisfied with their treatment at 1 year (RR 0.89, 95% CI 0.68 to 1.17; n = 70; Sharifiaghdas 2015; Analysis 10.3) Quantification of symptoms Not reported Clinician's observations The clinician's report of observed stress incontinence concurred with that reported by women ‐ 4 in each group (RR 1.00, 95% CI 0.27 to 3.69; n = 70; Sharifiaghdas 2015) Surgical outcome measures Not reported Further treatment Not reported Adverse effects Perioperative complications Not reported Bladder perforation One woman (of 35) had a bladder perforation in the traditional sling group compared with none (of 35) in the mini‐sling group (very low‐quality evidence; Sharifiaghdas 2008; Analysis 10.5;summary of findings Table 10) Urinary tract infection Not reported Urinary urgency symptoms, urgency urinary incontinence More women in the traditional sling group reported urinary urgency incontinence (5/35) compared with the mini‐sling group (1/35) (RR 5.00, 95% CI 0.62 to 40.64; n = 70; Sharifiaghdas 2015; Analysis 10.6) Detrusor overactivity (urodynamic overactivity) Not reported Voiding dysfunction (with or without urodynamic confirmation) Not reported Long‐term adverse effects Dyspareunia: 3/35 and 4/35 in traditional sling and mini‐sling groups, respectively, reported pain with intercourse (RR 0.75, 95% CI 0.18 to 3.11; n = 70; Sharifiaghdas 2008; Analysis 10.7) Tape or mesh exposure: 1 woman in the traditional sling group and 2 in the mini‐sling group were found to have tape or mesh exposure (RR 0.50, 95% CI 0.05 to 5.27; n = 70; Sharifiaghdas 2008; Analysis 10.8) Quality of life Based on mean IIQ score, quality of life was lower in the traditional sling group compared with the mini‐sling group (MD 7.50, 95% CI 2.23 to 12.77; very low‐quality evidence; Analysis 10.9;summary of findings Table 10) | |
USI: urodynamically diagnosed stress urinary incontinence
VLPP: Valsalva leak point pressure
Comparison 4. Traditional suburethral sling operation versus injectables
Maher 2005 compared slings (n = 21) with injectable Macroplastique (n = 22). Based on very low‐quality evidence, we are uncertain about the impact of surgery versus injectables in terms of the number of continent women (100% were dry with a traditional sling vs 71% with the injectable after the first year; odds ratio (OR) 11.57, 95% confidence interval (CI) 0.56 to 239.74; Analysis 4.2), the need for repeat surgery for urinary incontinence (risk ratio (RR) 0.52, 95% CI 0.05 to 5.36; Analysis 4.3), or perioperative complications such as urinary tract infection (RR 1.57, 95% CI 0.29 to 8.49; Analysis 4.7).
Due to the small size of the trial, the data were too few to be reliable (summary of findings Table 4; Table 2).
Comparison 5. Traditional suburethral sling operation versus anterior repair
No trials were identified.
Comparison 6. Traditional suburethral sling operation versus bladder neck needle suspension (abdominal and vaginal)
Only one trial compared porcine dermis sling with Stamey needle suspension (Hilton 1989). This was a small trial with only 10 women in each arm. The women were unsuitable for abdominal colposuspension (the study author's preferred procedure) because they had vaginal narrowing secondary to previous interventions or atrophic vaginitis. Thus they constitute a population of women with SUI who are not typical of the majority. All women had USI. Groups were comparable for age, parity, previous interventions, and hormonal status. Follow‐up was reported at 3 months and at 24 months.
Due to the small size of the trial, the data were too few to be reliable (summary of findings Table 6; Table 2).
Comparison 7. Traditional suburethral sling operation versus open abdominal retropubic colposuspension
Eight trials compared slings with open abdominal retropubic colposuspension (Albo 2007; Bai 2005; Demirci 2001; Enzelsberger 1996; Fischer 2001; Helmy 2012; Henriksson 1978; Sand 2000). One of these trials provided no data (Helmy 2012). The extent to which the trials could be considered together was limited because of differences in procedures compared, populations studied, outcomes assessed, and length of follow‐up. Two trials involved a pubovaginal sling technique using autologous rectus fascia (Albo 2007; Demirci 2001). One trial used a lyodura sling (Enzelsberger 1996). Another trial used the Zoedler sling made of Teflon (Henriksson 1978). Still another trial used the Gortex type (Sand 2000). These were all biological materials except in two trials (Henriksson 1978; Sand 2000). Fischer 2001 did not specify the sling material used.
Only two of these trials reported follow‐up for longer than five years and presented both short‐term and long‐term data in two full reports (Albo 2007; Sand 2000).
Primary outcomes
Number of continent (dry) women
Short term
Data from four trials suggested no evidence of a difference in the likelihood of being continent within a year after treatment when comparing slings to open abdominal colposuspension (OR 2.70, 95% CI 0.69 to 10.55; n = 147; Analysis 7.1) (Bai 2005; Fischer 2001; Henriksson 1978; Sand 2000).
Medium term
Moderate‐quality evidence from four trials show that women were more likely to be continent between one and five years after surgery with slings compared with open abdominal colposuspension (OR 1.70, 95% CI 1.22 to 2.37; n = 687; Analysis 7.2;summary of findings Table 7) (Albo 2007; Bai 2005; Demirci 2001; Enzelsberger 1996).
Long term
At five years post surgery and beyond, evidence from two trials suggests that women were more likely to be continent after surgery with slings than after open abdominal colposuspension (OR 1.55, 95% CI 1.06 to 2.27; n = 190; Analysis 7.3) (Albo 2007; Sand 2000).
Number of women who had repeat continence surgery
High‐quality evidence from one trial shows that the risk of required repeat continence surgery was lower after traditional slings compared to after open abdominal colposuspension (RR 0.15, 95% CI 0.05, 0.42; n = 450; Analysis 7.4; summary of findings Table 7) (Albo 2007).
Secondary outcomes
Women's observations
Number of women cured at one year or later (women's observations)
Data from three trials suggest that women undergoing surgery with slings were more likely to report subjective cure than women having open abdominal colposuspension (OR 1.56, 95% CI 1.07 to 2.28; n = 221; Analysis 7.5) (Albo 2007; Demirci 2001; Sand 2000).
Number of women improved
This was not reported.
Number of women satisfied
Data from one trial indicate that more women were likely to be satisfied with surgery with slings than with open abdominal colposuspension (RR 1.14, 95% CI 1.02 to 1.27; n = 352; Analysis 7.6) (Albo 2007).
Quantification of symptoms
This was not reported.
Clinician's observations
Number of women with urinary incontinence (clinician's observations)
Short term
This was not reported.
Medium term and long term
Researchers found no evidence of a difference between slings and open abdominal colposuspension in the numbers of women with urinary incontinence at one to five years (RR 0.88, 95% CI 0.59 to 1.31; n = 626; Analysis 7.8) (Albo 2007; Demirci 2001; Enzelsberger 1996). Depending on judgements about what constitutes a clinically important difference between interventions with regard to continence, traditional suburethral slings are probably no worse, and may be slightly more effective, than colposuspension beyond five years (RR 0.90, 95% CI 0.80 to 1.01, n = 461; Analysis 7.9) (Albo 2007; Sand 2000).
Surgical outcome measures
Duration of operation
One trial was too small to reliably detect a difference in operating times between slings (61 minutes) and open abdominal colposuspension (55 minutes) (mean difference (MD) 6.02, 95% CI ‐0.52 to 12.56; Analysis 7.10) (Demirci 2001). Moreover, the difference in the duration of operation time observed was too small to be of clinical importance.
Length of hospital stay/time to catheter removal
Data from three trials suggest that women undergoing surgery with slings had longer hospital stays than women having open abdominal colposuspension (MD 2.03 days, 95% CI 1.47 to 2.59; n = 137; Analysis 7.11) (Demirci 2001; Enzelsberger 1996; Sand 2000). This may have been due in part to a difference in the time of catheter use after surgery (women in the sling group used a sling for eight days longer (MD) after sling than after colposuspension; 95% CI 6.84 to 9.18, n = 108; Analysis 7.12). However, it is unclear if this was due to the procedures themselves or to differences in hospital policies.
Time to return to normal activity level
This was not reported.
Blood loss
This was not reported.
Further treatment
Three trials reported that significantly more women required treatment for a new or recurrent prolapse after open colposuspension (12/282; 4.3%) compared to after a sling procedure (2/277; 0.7%; RR 0.20, 95% CI 0.05 to 0.77; n = 559; Analysis 7.14) (Albo 2007; Demirci 2001; Enzelsberger 1996). However, trial authors provided no information about subsequent surgery for prolapse in any trial.
Adverse events
Perioperative surgical complications
Four trials reported similar numbers of perioperative complications in the groups (47/394; 12% vs 38/398; 10%; RR 1.24, 95% CI 0.83 to 1.86; n = 792; low‐quality evidence; Analysis 7.15;summary of findings Table 7) (Albo 2007; Demirci 2001; Enzelsberger 1996; Sand 2000).
Bladder perforation
One large trial reported significantly lower risk of bladder perforation with the sling procedure (RR 0.20, 95% CI 0.04 to 0.91; Analysis 7.16) (Albo 2007).
Urinary tract infection
Researchers reported significantly more urinary tract infections with the sling procedure soon after surgery compared with colposuspension (RR 1.50, 95% CI 1.33 to 1.70; n = 655; Analysis 7.17). However, the risk of recurrent urinary tract infection (UTI) was not statistically different at five years or later (RR 1.02, 95% CI 0.57 to 1.82; n = 453; low‐quality evidence; Analysis 7.18;summary of findings Table 7) (Albo 2007).
Urinary urgency symptoms; urgency urinary incontinence
Two trials reported data on de novo urgency symptoms or incontinence: the evidence was insufficient to identify whether there was a difference between sling and colposuspension groups (RR 1.10, 95% CI 0.74 to 1.64; Analysis 7.19) (Albo 2007; Enzelsberger 1996).
Detrusor overactivity (urodynamic overactivity)
Evidence from four small trials was insufficient to show whether there was a difference in detrusor overactivity between sling and colposuspension groups (RR 1.42, 95% CI 0.52 to 3.87; Analysis 7.20) (Bai 2005; Demirci 2001; Enzelsberger 1996; Sand 2000).
Voiding dysfunction (with or without urodynamic confirmation)
Pooled data from five trials show that significantly more women had voiding dysfunction after sling (13% vs 2% after open colposuspension; RR 6.08, 95% CI 3.10 to 11.95; moderate‐quality evidence; Analysis 7.21) (Albo 2007; Bai 2005; Demirci 2001; Enzelsberger 1996; Sand 2000). One trial reported long‐term voiding dysfunction at five years or later (Albo 2007). Very few women still reported this complication (seven after sling vs one after colposuspension).
Long‐term adverse effects
This was not reported.
Quality of life
Data were reported in different formats; thus meta‐analysis was not possible.
One trial reported quality of life scores at over five years (Albo 2007). Women reported better quality of life after the sling surgery on one scale (Urogenital Distress Inventory (UDI)) (MD ‐10, 95% CI ‐18.91 to ‐1.09) but no difference on another scale (Incontinence Impact Questionnaire (IIQ)) (MD 1.70, 95% CI ‐11.96 to 15.36; very low‐quality evidence; summary of findings Table 7).
One trial reported no significant difference in IIQ and UDI scores between the colposuspension group and the sling group, although actual numbers were not reported (Fischer 2001).
Comparison 8. Traditional suburethral sling operation versus laparoscopic colposuspension
No trials were identified.
Comparison 9. Traditional suburethral sling operation versus mid‐urethral sling or tape
Fifteen trials addressed this comparison (Abouhashem 2014; Al‐Azzawi 2014; Amaro 2007; Arunkalaivanan 2003; Bai 2005; Basok 2008; Guerrero 2008; Kondo 2006; Sharifiaghdas 2008; Silva Filho 2006; Song 2004; Tcherniakovsky 2009; Teixeira 2008; Wadie 2005; Zargham 2013). Two new trials were added in this update (Abouhashem 2014; Zargham 2013). However, one of the new trials did not provide any useable data (Abouhashem 2014). Three trials were updated (Amaro 2007; Guerrero 2008; Wadie 2005).
Primary outcomes
Number of continent (dry) women
Short term
Data from 11 trials suggest there was no evidence of a difference between traditional slings and mid‐urethral slings in the likelihood of being continent within one year (73% vs 75%; OR 0.94, 95% CI 0.67 to 1.32; n = 841; Analysis 9.1) (Amaro 2007; Arunkalaivanan 2003; Bai 2005; Basok 2008; Guerrero 2008; Kondo 2006; Sharifiaghdas 2008; Song 2004; Tcherniakovsky 2009; Wadie 2005; Zargham 2013).
Medium term
Depending on judgements about what constitutes a clinically important difference between interventions with regard to continence, traditional suburethral slings are probably no better, and may be less effective, than mid‐urethral slings in terms of number of women continent in the medium term (one to five years). However, the results were not statistically significant (67% vs 74%, OR 0.67, 95% CI 0.44 to 1.02; n = 458; moderate‐quality evidence); Analysis 9.2;summary of findings Table 9) (Amaro 2007; Arunkalaivanan 2003; Bai 2005; Guerrero 2008; Kondo 2006; Zargham 2013).
Long term
Data from one small trial suggest that women undergoing traditional sling operations were nearly twice as likely to be continent at five years after traditional sling surgery as women who had received a mid‐urethral sling (51% vs 32%; OR 2.22, 95% CI 1.07 to 4.61; n = 124; Analysis 9.3) (Guerrero 2008).
Number of women who had repeat continence surgery
Low‐quality evidence from one trial reported the numbers of women having repeat continence surgery; no women in either arm required repeat surgery (traditional sling: 0/67; mid‐urethral sling: 0/69; Analysis 7.4;summary of findings Table 9) (Guerrero 2008). By 10 years, 2 of 63 women still being followed‐up after a mid‐urethral sling had required repeat continence surgery compared to none in the traditional sling group.
Secondary outcomes
Women's observations
Number of women cured after the first year (women's observations)
Four trials provided no evidence of a difference between traditional slings and mid‐urethral slings in the likelihood of cure at one year or later (OR 1.06, 95% CI 0.65 to 1.72; n = 337; Analysis 9.5) (Amaro 2007; Arunkalaivanan 2003; Guerrero 2008; Kondo 2006).
Number of women improved or cured
Trials provided no evidence of a difference between traditional slings and mid‐urethral slings in the likelihood of improvement or cure:
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within one year (OR 1.33, 95% CI 0.74 to 2.39; n = 425; Analysis 9.6) (Arunkalaivanan 2003; Basok 2008; Guerrero 2008);
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at one to five years (OR 0.76, 95% CI 0.31 to 1.87; n = 264; (Analysis 9.7) (Arunkalaivanan 2003; Guerrero 2008); or
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after five years (OR 1.13, 95% CI 0.51 to 2.54; n = 124; Analysis 9.8) (Guerrero 2008).
Number of women satisfied
No evidence suggests a difference between traditional slings and mid‐urethral slings in the likelihood of women being satisfied (RR 1.09, 95% CI 0.89 to 1.33; n = 163; Analysis 9.9) (Amaro 2007; Guerrero 2008).
Quantification of symptoms
Pad changes over 24 hours (from self‐reported number of pads used)
This was not reported.
Incontinent episodes over 24 hours (from self‐completed bladder chart)
This was not reported.
Pad test of quantified leakage (mean weight of urine loss)
One small trial reported the mean weight of urine on a pad test (Silva Filho 2006). Data show less incontinence in the traditional sling group compared with the mid‐urethral sling group (MD ‐31.00 grams, 95% CI ‐57.53 to ‐4.47; n = 20; Analysis 9.10).
Clinician's observations
Number of women with urinary incontinence
Short term
Clinician‐reported incontinence within one year, defined as complete absence of urinary leakage during a cough‐stress test, was assessed in two small trials (Kondo 2006; Sharifiaghdas 2008), which provided no evidence of a difference between the two groups (RR 1.29, 95% CI 0.45 to 3.71; Analysis 9.11).
One trial further addressed objective cure after the first year, but again the evidence was insufficient to reveal whether there was a difference between groups, as the confidence interval was wide (RR 1.72, 95% CI 0.82 to 3.61; n = 44; Analysis 9.12) (Kondo 2006).
Surgical outcome measures
Duration of operation
Traditional suburethral sling operations took significantly longer to complete (MD 57.08 minutes, 95% CI 54.67 to 59.49; Analysis 9.13). There was statistically significant heterogeneity that could not be explained by differences in populations, interventions, or settings of the individual trials. This heterogeneity persisted even after sensitivity analysis was performed. This excludes the largest trial, which showed a much longer operating time for the traditional sling operation than was seen in the other trials (Song 2004). It also excludes another trial in which women also had concomitant prolapse surgery in both arms, and in the mid‐urethral sling arm, an additional mesh kit was used to repair the prolapse (Zargham 2013). Because of heterogeneity in trials that included women with MUI, some of whom also had concomitant prolapse surgery, a sensitivity analysis was performed excluding the four trials (Al‐Azzawi 2014; Kondo 2006; Song 2004; Zargham 2013). The mean difference in operative time was 44 minutes longer for traditional sling surgery (95% CI 40 to 48; analysis not shown).
Length of hospital stay and duration of catheterisation
In four small trials, the length of hospital stay was longer after traditional sling operations (RR 0.74 days, 95% CI 0.55 to 0.93; Analysis 9.14) (Al‐Azzawi 2014; Kondo 2006; Silva Filho 2006; Zargham 2013). Two trials reported no evidence of a difference between groups in length of time to catheter removal (MD 0.11 days, 95% ‐0.07 to 0.30; Analysis 9.15) (Kondo 2006; Wadie 2005).
Time to return to normal activity level
This was not reported.
Blood loss
This was not reported.
Further treatment
This was not reported.
Adverse events
Perioperative complications
Low‐quality evidence from four trials was insufficient to identify whether risk of perioperative complications was higher after traditional sling operations (49/148; 33.1% vs 28/145; 19.3% after a mid‐urethral sling; RR 1.74, 95% CI 1.16 to 2.60; n = 293; Analysis 9.16;summary of findings Table 9) (Arunkalaivanan 2003; Kondo 2006; Tcherniakovsky 2009; Zargham 2013).
Bladder perforation
Evidence from 10 RCTs shows that traditional slings may have fewer bladder perforations compared with mid‐urethral slings. However, whilst there is no evidence of a statistical difference in the number of bladder perforations, the confidence interval may rule out clinically important reductions for mid‐urethral slings (17/414; 4.1% vs 30/430; 6.9%; RR 0.59, 95% CI 0.34 to 1.01; n = 844; Analysis 9.17) (Al‐Azzawi 2014; Arunkalaivanan 2003; Bai 2005; Guerrero 2008; Kondo 2006; Sharifiaghdas 2008; Song 2004; Tcherniakovsky 2009; Wadie 2005; Zargham 2013).
Urinary tract infection
Trials provided no evidence of a difference between traditional slings and mid‐urethral slings in the number of women with urinary tract infections (RR 1.00, 95% CI 0.22 to 4.49; n = 50; Analysis 9.20) (Zargham 2013).
Urinary urgency symptoms; urgency urinary incontinence
Combined results from four trials were insufficient to show whether there was a difference between traditional slings and mid‐urethral slings in the number of women with urinary urgency symptoms (RR 1.50, 95% CI 0.58 to 3.88; Analysis 9.22) (Guerrero 2008; Kondo 2006; Sharifiaghdas 2008; Zargham 2013).
Detrusor overactivity (urodynamic overactivity)
Data from four trials suggest higher risk of detrusor overactivity after traditional sling operations than after mid‐urethral sling operations (RR 2.61, 95% CI 1.17 to 5.84; n = 325; Analysis 9.23) (Al‐Azzawi 2014; Bai 2005; Basok 2008; Wadie 2005). This was principally due to the higher weighting given to the largest trial (Basok 2008).
Voiding dysfunction
Very low‐quality evidence from eight trials suggests no difference between traditional slings and mid‐urethral slings in the number of women with voiding dysfunction (RR 1.34, 95% CI 0.85 to 2.12; n = 629; summary of findings Table 9) (Al‐Azzawi 2014; Arunkalaivanan 2003; Bai 2005; Guerrero 2008; Kondo 2006; Sharifiaghdas 2008; Wadie 2005; Zargham 2013).
Long‐term adverse effects
Wound pain
Three trials reported that more women had long‐term wound pain in the traditional sling groups (17/126 vs 2/131; RR 6.40, 95% CI 1.94 to 21.12; n = 257; Analysis 9.25) (Al‐Azzawi 2014; Guerrero 2008; Wadie 2005).
Mesh exposure
Evidence from five trials was insufficient to reveal whether there was a difference in vaginal exposure (RR 0.28, 95% CI 0.05 to 1.65; n = 348; Analysis 9.26) (Al‐Azzawi 2014; Guerrero 2008; Tcherniakovsky 2009; Wadie 2005; Zargham 2013). Only four cases of mesh exposure (from 177 women) were reported in the mid‐urethral sling group compared with none among 171 women in the traditional sling arms. The five trials all used a biological graft as traditional sling material.
Release of sling
Very low‐quality evidence from three trials suggests no difference between traditional slings and mid‐urethral slings in the numbers of women requiring release of sling (11/164; 6.7% vs 4/162; 2.5%: RR 2.53, 95% CI 0.87 to 7.35; n = 326; Analysis 9.24;summary of findings Table 9) (Arunkalaivanan 2003; Guerrero 2008; Kondo 2006).
Other adverse effects
One trial further reported urethral injury alone, which suggests no evidence of a difference between groups (RR 0.36, 95% CI 0.02 to 8.39) (Kondo 2006).
Finally, one small trial reported vaginal bleeding and UTI (Analysis 9.19;Analysis 9.20) (Zargham 2013). Results show no significant difference in the risk of vaginal bleeding (RR 1.67, 95% CI 0.45 to 6.24).
Quality of life
Quality of life (QoL) was assessed in nine trials (Amaro 2007; Arunkalaivanan 2003; Basok 2008; Guerrero 2008; Kondo 2006; Okulu 2013; Sharifiaghdas 2008; Silva Filho 2006; Wadie 2005). Data were reported in different ways; thus meta‐analysis was not possible and individual results are reported below. In this section, results are reported qualitatively according to how trialists reported their findings. Therefore, use of 'statistically significant' is as reported in the trials ‐ not as interpreted by the review authors ‐ and we have not changed this.
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Amaro 2007 used the Portuguese version of King's Health Questionnaire (KHQ), reporting no statistically significant differences between groups in general health condition; impact of incontinence; role, physical, and social limitations; personal relationships; emotions; sleep; and severity perception of urinary incontinence at 36 months.
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A 10‐point questionnaire‐based assessment was used by Arunkalaivanan 2003. The mean score was 8.03 for mid‐urethral synthetic suburethral slings and 8.05 for traditional slings, with a median score of 9 for both groups.
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A subjective 10‐point patient satisfaction questionnaire was used by Basok 2008, which provided no evidence of a difference between groups, with satisfaction rates of 82% and 87.5% with the traditional sling and the mid‐urethral sling, respectively.
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Trialists found no significant difference in any domain of the Bristol Female Lower Urinary Tract Symptom (BFLUTS) score, as assessed in Guerrero 2008.
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Statistically significant improvement was noted postoperatively on the IIQ Short Form (IIQ‐7) and the UDI Short Form (UDI‐6) within both groups, but no significant difference in the degree of improvement was evident between groups (Kondo 2006).
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One study assessed quality of life using the ICIQ‐Short form score. While there was improvement from baseline in all groups, there were no significant differences between randomised groups (Okulu 2013).
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IIQ score was also used by Sharifiaghdas 2008 to determine subjective cure. Means were reported as 44.3 (range 35.2 to 61.5) for the mid‐urethral procedure and 48.5 (range 38.5 to 69.7) for the sling operation (P = 0.46). A score less than 50 represents good quality of life, between 50 and 70 moderate quality of life, and greater than 70 poor quality of life. There was no significant difference in QoL between groups; 15 (72%) in the mid‐urethral group and 20 (55%) in the sling group were satisfied with the operation (P = 0.3, as reported by trialists).
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The KHQ was used in Silva Filho 2006 to show significantly greater improvement in those who underwent the traditional suburethral sling operation in the following domains: general health perception; physical, social, and role limitations; emotions and severity measures. There were no significant differences in incontinence impact, personal relationships, sleep, and energy domains.
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In one small trial (Wadie 2005), researchers reported UDI‐6 and IIQ‐7 scores, which show no statistically significant differences between trial arms (Analysis 9.27;Analysis 9.28
Comparison 10. Traditional suburethral sling operation versus single‐incision sling (mini‐sling)
One small trial compared a rectus fascia pubovaginal traditional sling with a single‐incision sling (mini‐sling; Ophira) and included women with urodynamically diagnosed stress urinary incontinence (USI) (Sharifiaghdas 2015).
Due to the small size of the trial, the data were too few to be reliable (Table 2).
Comparison 11. One type of traditional sling operation versus another type of traditional sling operation
Nine trials addressed this comparison (Barbalias 1997; Choe 2000; Guerrero 2008; Lucas 2000; Okulu 2013; Pacetta 2005; Shin 2001; Teleb 2011; Viseshsindh 2003). Three of these were newly added in this update (Choe 2000; Okulu 2013; Teleb 2011). One was updated (Guerrero 2008).
The traditional slings in this comparison used the following materials to suspend the urethra.
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Autologous biological materials: rectus fascial sling (Barbalias 1997; Guerrero 2008; Lucas 2000; Teleb 2011); dermal graft patch (Shin 2001); tissue removed from the vaginal wall (Choe 2000; Teleb 2011; Viseshsindh 2003).
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Other biological materials: cadaveric fascia lata (Shin 2001); Fortaperm porcine collagen matrix (Pacetta 2005); Pelvicol (Guerrero 2008).
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Synthetic materials: Goretex (Barbalias 1997); antimicrobial MycroMesh (Choe 2000); Vypro, Ultrapro, and Prolene (Okulu 2013); Prolene (Teleb 2011).
Some trials compared three different materials: these have been presented as pair‐wise comparisons. One trial compared the same material (autologous rectus fascia) but with different lengths of the material used (Lucas 2000). It is not possible to pool data from any of these trials because different materials were compared, and each individual trial was too small for findings to be conclusive.
Primary outcomes
Number of continent (dry) women
Short term
Five trials reported the number of continent women within the first year after surgery (Guerrero 2008; Lucas 2000; Okulu 2013; Pacetta 2005; Viseshsindh 2003). A total of 437 women studied within the first 12 months after surgery showed similar incontinence rates between traditional sling operations using biological or synthetic materials. However, the confidence intervals were wide (Analysis 11.1).
Medium term
Seven trials reported the number of continent women from one to five years after surgery (Barbalias 1997; Choe 2000; Guerrero 2008; Lucas 2000; Okulu 2013; Shin 2001; Teleb 2011). Again, it is not possible to pool any of these trials because different materials were compared. With one exception, none of the comparisons suggest any evidence of a difference between different materials. One small trial suggests that women were more likely to be continent with autologous fascial sling operations than with Pelvicol graft (OR 3.29, 95% 1.41 to 7.69; n = 113; Analysis 11.2.1; summary of findings Table 11) (Guerrero 2008). This effect was evident early and led to premature closure of the Pelvicol arm.
Long term
One trial measured continence rates at six years after surgery and found no evidence of a difference between a standard (long) sling and a short sling (31/73 and 35/69 continent women, respectively) (OR 0.72, 95% CI 0.37 to 1.39, n = 142; Analysis 11.3) (Lucas 2000).
Number of women who had repeat continence surgery
One trial reported the number of women requiring repeat continence surgery at 1 year and at 10 years (Guerrero 2008). Only women who received the biological material Pelvicol required any repeat surgery (9/46; 20%; RR 0.04, 95% CI 0.00 to 0.61; Analysis 11.4; summary of findings Table 11) compared to 0 of 67 women in the rectus fascia group requiring repeat surgery 10 years later. This was statistically significant in favour of the traditional sling with rectus fascia; as a result, Pelvicol is no longer used in traditional sling surgery.
Secondary outcomes
Women's observations
Number of women cured at one year or later (women's observations)
Three trials reported women's perception of cure of incontinence (Guerrero 2008; Lucas 2000; Shin 2001). Only one reported any evidence of a difference between groups; fascial slings were significantly better than Pelvicol slings (OR 3.29, 95% CI 1.41 to 7.69; Analysis 11.5.1) (Guerrero 2008).
Number of women improved
Short term
Three trials reported women’s perception of improvement within one year (Barbalias 1997; Guerrero 2008; Pacetta 2005). Only one reported a difference between groups; women having fascial slings were more likely to perceive themselves as improved compared to women having Pelvicol slings (69/73 vs 33/34; OR 6.27, 95% CI 1.88 to 20.94; Analysis 11.6.1) (Guerrero 2008).
Medium term
Four trials reported women’s perception of improvement after one year (Barbalias 1997; Guerrero 2008; Shin 2001; Teleb 2011). Only one reported a difference between groups; women having fascial slings were more likely to perceive themselves as improved compared to women having Pelvicol slings (60/67 vs 28/46; RR 1.47, 95% CI 1.15 to 1.88; Analysis 11.7.1) (Guerrero 2008).
Long term
This was not reported.
Number of women satisfied
Three trials reported satisfaction, but results could not be combined and individually, numbers were too small to be conclusive (Analysis 11.8) (Choe 2000; Guerrero 2008; Okulu 2013). Study authors provided no evidence of a difference between groups in any comparison.
Quantification of symptoms
Two trials reported data on mean weight of urine on a pad test (Analysis 11.9) (Lucas 2000; Okulu 2013).
In the short term, trials provided no reliable evidence of a difference between groups (Analysis 11.9), but after one year, one trial showed that Ultrapro was better than both Vypro and Prolene light for this outcome (Analysis 11.10) (Okulu 2013).
Clinician's observations
This was not reported.
Surgical outcome measures
Duration of operation
The duration of operation for the traditional long length sling procedure was significantly longer in one trial, which compared long and short lengths of autologous fascia (MD 8 minutes, 95% CI 3 to 13; Analysis 11.7) (Lucas 2000). In another trial comparing three materials, duration of operation was shortest for Prolene (36 minutes), intermediate for anterior vaginal wall patch (42 minutes), and longest when rectus sheath was used as a sling (52 minutes) (Analysis 11.11) (Teleb 2011). However, it is unclear whether these differences in operating time would be enough to be clinically important.
Length of hospital stay
Length of hospital stay was reported in one trial (Teleb 2011). Hospital stay was longest for women having the anterior rectus sheath sling compared to women with the other two materials (Analysis 11.13).
Time to return to normal activity level
This was not reported.
Blood loss
Blood loss was significantly less with Prolene compared to the other two materials (Analysis 11.12) (Teleb 2011).
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Anterior rectus sheath sling versus prolene strip: MD 32.00 mL, 95% CI 7.14 to 56.86; n = 24.
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Anterior rectus sheath sling versus anterior vaginal wall patch: ‐20.00 mL, 95% CI ‐46.93 to 6.93; n = 20.
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Prolene strip versus anterior vaginal wall patch: MD ‐52.00 mL, 95% CI ‐77.41 to ‐26.59; n = 20.
However, total differences in volumes of blood lost were small, and their clinical importance is uncertain.
Further treatment
This was not reported.
Adverse events
Perioperative surgical complications
The three trials that reported any perioperative complications could not be combined because different materials were compared (Barbalias 1997; Lucas 2000; Viseshsindh 2003). More complications were reported with the use of synthetic non‐absorbable Goretex in one trial (RR 0.05, 95% CI 0.00 to 0.80; Analysis 11.14.2) (Barbalias 1997). In the other trial, evidence was insufficient to show whether there was a difference between two biological slings (RR 1.14, 95% CI 0.78 to 1.66; Analysis 11.14.1; summary of findings Table 11) (Lucas 2000). There were no perioperative complications in the third trial between the two groups (Viseshsindh 2003).
Bladder perforation
Three trials reported the number of bladder perforations (Guerrero 2008; Lucas 2000; Teleb 2011), showing no evidence of a difference between groups in any comparison (Analysis 11.15).
Urinary tract infection
Two trials reported the number of women with urinary tract infection (Choe 2000; Lucas 2000), providing no evidence of a difference between groups in any comparison (Analysis 11.16).
Urinary urgency symptoms; urgency urinary incontinence
Three trials reported the number of women with urgency symptoms (Barbalias 1997; Lucas 2000; Okulu 2013), revealing no evidence of a difference between groups in any comparison (Analysis 11.20).
Detrusor overactivity (urodynamic overactivity)
One trial reported 4 of 33 women in the autologous dermal graft patch group with de novo detrusor overactivity compared with 5 of 20 in the cadaveric fascia lata group (RR 0.48, 95% CI 0.15 to 1.60; n = 53; Analysis 11.21) (Shin 2001).
Voiding dysfunction (with or without urodynamic confirmation)
Six trials reported the number of women with voiding dysfunction (Choe 2000; Guerrero 2008; Lucas 2000; Okulu 2013; Teleb 2011; Viseshsindh 2003), showing no evidence of a difference between groups in any comparison (Analysis 11.19).
Long‐term adverse effects
One trial reported the number of women with wound pain: 2 of 61 and 0 of 38 in the fascial sling and Pelvicol groups, respectively (RR 3.15, 95% CI 0.16 to 63.80; n = 99; Guerrero 2008). The same trial also reported 2 of 61 and 1 of 38 women requiring release of sling (RR 1.25, 95% CI 0.12 to 13.28; n = 99).
Two women in one trial reported long‐term scar pain after a rectus fascial sling compared to none in the Pelvicol group; there were no graft exposures in either group (Guerrero 2008). In another trial, when participants all received a different type of synthetic mesh, five instances of mesh exposure were reported among 141 women in the three mesh groups (Okulu 2013). One trial of a synthetic versus a biological material reported no mesh exposures (Analysis 11.23; summary of findings Table 11) (Choe 2000).
Other adverse effects
One trial reported 1 of 20 women with vaginal bleeding after anterior wall vaginal sling compared with 0 of 20 in the biosynthetic mesh group (RR 3.00, 95% CI 0.13 to 69.52; n = 40) (Choe 2000).
Quality of life
Data were reported in different ways; thus meta‐analysis was not possible (summary of findings Table 11).
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Lucas 2000 showed significant improvement in average scores for the UDI‐6 (reported P = 0.007) and the IIQ‐7 (P = 0.002) when compared with baseline. Scores between groups were similar.
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Pacetta 2005 evaluated women using the Incontinence Quality of Life questionnaire (I‐QOL), reporting improvement from 45 at baseline to 97 at one year in the autologous fascia group, and from 39 to 92 in the Fortaperm group.
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Okulu 2013 used the International Consultation on Incontinence Questionnaire (ICIQ) Short Form urinary incontinence scale to compare three synthetic meshes. Ultrapro was better than Prolene light, which was better than Vypro, in the short term and in the medium term (Analysis 11.24; Analysis 11.25).
Discussion
The main systematic review of effects is discussed below but we sought to supplement this review by identifying economic evaluations that compared traditional suburethral sling operations with any of the other main categories of surgical methods listed in the background section. Identifed economic evaluations have been summarised in a brief economic commentary. A supplementary search in Ovid NHS EED, MEDLINE, and Embase identified two such economic evaluations. Details of the search strategies are given in Appendix 3.
Summary of main results
We included 34 trials involving 3244 women. Traditional slings were compared with 10 other treatments and with each other; but we did not identify any trial comparing suburethral slings with no treatment or sham treatment, conservative management, anterior repair, or laparoscopic retropubic colposuspension. One trial compared traditional slings with bladder neck needle suspension (summary of findings Table 6), and another trial compared traditional slings with single‐incision slings (summary of findings Table 10). Both trials were too small to be informative.
Traditional suburethral sling operation versus drugs
One small trial comparing traditional slings with oxybutynin for women with mixed urinary incontinence did not report any of the outcomes used in the 'Summary of findings' tables. However, it is uncertain whether surgery compared with oxybutynin leads to more women being dry (83% vs 0%; odds ratio (OR) 195.89, 95% confidence interval (CI) 9.91 to 3871.03) or having less urgency urinary incontinence (13% vs 43%; risk ratio (RR) 0.29, 95% CI 0.09 to 0.94) (summary of findings Table 3).
Traditional suburethral sling operation versus injectables
Based on very low‐quality evidence from one small trial, we are uncertain about the impact of surgery versus injectables in terms of the numbers of continent women (100% were dry with a traditional sling vs 71% with the injectable after the first year; OR 11.57, 95% CI 0.56 to 239.74) or the need for repeat surgery for urinary incontinence (RR 0.52, 95% CI 0.05 to 5.36) or the occurrence of perioperative complications (RR 1.57, 95% CI 0.29 to 8.49) (summary of findings Table 4).
Traditional suburethral sling operation versus open abdominal retropubic colposuspension
Eight trials compared slings with open abdominal retropubic colposuspension. Moderate‐quality evidence shows that traditional suburethral sling probably leads to more continent women in the medium term (one to five years) (69% vs 59% after colposuspension: OR 1.70, 95% CI 1.22 to 2.37). High‐quality evidence indicates that women were less likely to need repeat continence surgery after a traditional sling than after colposuspension (RR 0.15, 95% CI 0.05 to 0.42). We found no evidence of a difference in perioperative complications between the two groups, but the CI was very wide and the quality of evidence was very low (RR 1.24, 95% CI 0.83 to 1.86; summary of findings Table 7).
Traditional suburethral sling operation versus mid‐urethral sling operation
Fourteen trials addressed the comparison between traditional sling operations and mid‐urethral sling operations. Depending on judgements about what constitutes a clinically important difference between interventions with regard to continence, traditional suburethral slings are probably no better, and may be less effective, than mid‐urethral slings in terms of number of women continent in the medium term (one to five years) (67% vs 74%; OR 0.67, 95% CI 0.44 to 1.02; n = 458; moderate‐quality evidence). One trial reported more continent women with the traditional sling after 10 years (51% vs 32%; OR 2.22, 95% CI 1.07 to 4.61), but this finding needs to be replicated in other trials. Mid‐urethral slings may be associated with fewer perioperative complications (RR 1.74, 95% CI 1.16 to 2.60; low‐quality evidence; summary of findings Table 9).
One type of traditional sling operation versus another type of traditional sling operation
Nine trials compared one type of traditional sling with another. A number of different materials were used such as porcine dermis, lyophilised dura mater, fascia lata, vaginal wall, autologous dermis, and rectus fascia. Study results could not be pooled due to clinical heterogeneity, as different materials or types of traditional slings were used. Complications were reported by two trials ‐ one comparing non‐absorbable Goretex with a rectus fascia sling, and the second comparing Pelvicol with a rectus fascial sling. The impact was uncertain due to the very low quality of evidence (summary of findings Table 11).
Overall completeness and applicability of evidence
Historically, traditional suburethral sling procedures were used for women who had recurrent stress incontinence (after a previous failed continence operation). However, the current review includes both women with new and recurrent incontinence, without reporting the results separately. These operations are designed to restore normal urethrovesical junction support by mechanically compressing or kinking the proximal urethra.
Evidence related to the primary outcome ‐ urinary continence ‐ was available in one form or another for most trials to determine the effectiveness of traditional suburethral sling operations for treatment of urinary incontinence. However, study findings were consistent regardless of which method of ascertainment of continence was used (urine leakage using any definition, women's report, clinician's observation, combinations of these, or quantification methods such as pad test weights). More long‐term data are now available, suggesting that traditional slings may be equally as effective or more effective than other currently available surgical treatments (such as colposuspension and mid‐urethral slings). However, most trials did not provide sufficient information to adequately judge risk of bias; therefore most trials had to be judged to be at "unclear risk of bias" due to inadequate reporting.
None of the included trials contained all relevant patient‐reported outcomes. More data on pain after different procedures (both postoperative and long‐term) and time to return to 'normal' daily living following surgery would have been useful. In particular, reporting on medium‐ and long‐term adverse effects and the need for repeat continence surgery in the long term is not available but this information would be essential for informed decision‐making.
This Cochrane Review is limited to randomised controlled trials (RCTs) only. As adverse events were relatively rare and/or may not have been reported, it is not possible to infer accurate information about their frequency or type.
The importance of having a range of surgical options is that a woman can choose the procedure that she is most comfortable with, for example, trading off efficacy for the chance of having fewer adverse effects or a more minimally invasive procedure. Traditional slings appear to be as, if not more, effective than both colposuspension and mid‐urethral slings but without the risks perceived to be associated with synthetic mesh.
This Cochrane Review may not be applicable to clinicians everywhere. High‐income nations have been increasingly using mid‐urethral procedures with synthetic materials as first‐line treatment for stress urinary incontinence for about 20 years but because the safety of these operations has been called into question, this practice may decrease in the future. Use of traditional suburethral operations, which appear to be just as effective, might be reserved for countries where new technology is not available or is too expensive. For women who wish to avoid the possible complications of synthetic materials, biological materials such as rectus fascia (but not porcine dermis) seem as effective as synthetic mid‐urethral slings.
When possible, data were analysed in subgroups according to clinical characteristics of the type of incontinence (urodynamic stress incontinence, stress incontinence symptoms, or mixed urinary incontinence). Study findings were similar regardless of how incontinence was originally diagnosed. Because information was not available on this basis, it was not possible to determine if any type of surgery was more effective for women who had undergone previous failed continence surgery. Further analysis according to clinical characteristics of women, such as primary versus recurrent stress urinary incontinence and presence or absence of prolapse, was not possible due to lack of information. It might also be useful to look at possible differences according to intrinsic urethral sphincter deficiency versus urethral hypermobility (although there is no current clinical support for the use of these terms; Abrams 2006), obesity, ethnicity, vaginal delivery versus C‐section, or experience of the surgeon. These might make the findings of this review more generalisable. However, most trials have not reported these characteristics.
Quality of life, emotional well‐being, and social implications were poorly reported, or they were assessed by a variety of instruments, thus precluding meta‐analysis. These outcomes are of great importance to women and to decision‐makers.
Two searches have been conducted since the last fully incorporated search (9 October 2017 and 23 January 2019). Four studies are awaiting classification: Abou Hashem 2017; Hassan 2018; Kajbafzadeh 2017; Sharifiaghdas 2017. Of these, two are ongoing trials (Hassan 2018; Kajbafzadeh 2017), one is a second but identical publication of an included trial with no useable data (Abou Hashem 2017; Abouhashem 2014, respectively), and one is a 10‐year update of an already included trial (Sharifiaghdas 2017; Sharifiaghdas 2008, respectively).
Quality of the evidence
Quality of evidence plays a crucial role in our confidence in the estimate of effect. Most GRADE‐specific outcomes were judged to be of "low" or "very low" quality. This indicates that when more evidence becomes available, the estimate of effect is likely to be changed, or that any estimate of effect is very uncertain. In this systematic review, we assessed the methodological flaws of the included trials using trial reports. Therefore, our judgement of risk of bias and quality of evidence was influenced by reporting.
Although trial authors stated that their trials were randomised, most reports did not give sufficient detail about the method of sequence generation or concealment of allocation. Ten trials used an adequate randomisation method. Blinding of surgeons or women was generally not possible, but only two trials reported that outcomes were assessed by a nurse who was blinded to allocation. The total number of women enrolled was 3244, but some trials recruited only 10 women per arm. In addition, several types of slings were compared with different interventions, meaning that different materials had to be grouped together for comparison. Thus the numbers in each comparison were small, and the confidence intervals were wide; therefore several outcomes were downgraded due to imprecision.
Study populations varied, including women with and without previous surgery, and one study included only women who were deemed not suitable for another procedure (Hilton 1989). Although most study participants had urodynamic stress incontinence, some trials included women with mixed urinary incontinence. Baseline comparability of groups was not reported in all trials. Several trials assessed different types of sling in comparison with autologous rectus fascia, suggesting that the latter was considered as the 'standard' comparator.
Although eight trials used open abdominal retropubic colposuspension as the comparator, each used a different type of sling, and three followed up on women for only six months. Fourteen trials used a mid‐urethral sling as the comparator as this has arguably become the gold standard procedure for continence surgery in many countries.
In general, most trials reported different outcome measures, often poorly. The principal measure of effectiveness used in most studies was the proportion of women with incontinence following surgery. Few researchers have considered other outcomes, such as activities of daily living and quality of life. Few have addressed general health status, repeat incontinence surgery, later prolapse surgery, or time to return to normal activity level. Satisfaction with and acceptability of the treatment were also seldom addressed but are important factors for choice of management.
Potential biases in the review process
All relevant databases were searched and no language restriction was imposed during the search process, which enabled as many potentially eligible trials as possible to be included. Some reports of trials may not be published; therefore the full extent of the data may not have been captured. To account for any potential bias in the review process, data extraction and risk of bias assessment were performed by at least two independent review authors.
Although most trials reported the outcomes that they mentioned in their methods sections, none reported all outcomes of interest for this review, including, in many cases, the primary outcomes of urinary incontinence and repeat continence surgery (Figure 4).
The review sought to use rigorous methods of synthesis throughout and has sought to identify statistical evidence of differences between interventions. For some comparisons, no statistical evidence of a difference was identified but examination of the confidence intervals produced indicate that clinically important differences may be unlikely. Such conclusions require judgements about the magnitude of the minimum (clinically) important difference. Such judgements might be contested.
Agreements and disagreements with other studies or reviews
No other comparable systematic reviews of RCTs have addressed the specific use of traditional slings for treating women with stress urinary incontinence.
Brief economic commentary
To supplement the main systematic review, we looked for economic evaluations that compared traditional suburethral slings with a variety of surgical interventions for treating women with stress urinary incontinence.
Three studies, selected from a search carried out on 10 August 2018, provided a cost analysis (Berman 1997), a cost‐utility analysis (Kilonzo 2004), and another cost‐utility analysis (Kumar 2017).
The comparative cost analysis by Berman 1997 used data from a retrospective observational study carried out in the United States, which compared traditional suburethral retropubic sling procedures with transurethral collagen injections in women with stress urinary incontinence. This study included a total of 14 women across both arms, each of whom had had stress urinary incontinence and had undergone an average of 1.1 procedures between December 1993 and October 1995. The retrospective analysis found that the traditional sling had an average operating room time of 186 minutes and required an average hospital stay of 2.9 days. The total cost per patient was on average $16,229 (in 2019 International Dollars; $10,381 in 1995 USD). The collagen treatment was on average less costly (P < 0.001) with an average cost in 2019 International Dollars of $7810 (or $4996 in 1995 USD). Average procedure time for the collagen injections was 57 minutes, and no time was spent as a hospital inpatient. A high percentage of costs for the traditional sling study arm involved those for the physician (33%) and operating room (36%), and costs for the collagen arm included collagen (40%) and physician fees (22%). Postoperative care for the traditional sling cost $1927 2019 International Dollars ($1,233 1995 USD), which was almost twice the cost of the collagen injection ‐ $980 in 2019 International Dollars ($627 in 1995 USD).
Before the procedure, there was no evidence of a difference in the occurrence of incontinence between groups. However, the average number of pads decreased after the procedure from 4.7 to 1.4 and from 5.2 to 2.3 for traditional sling and collagen injection, respectively (P = 0.049).
Women were followed up for 15 months post surgery, and 71.4% of those in the traditional sling arm were symptom‐free compared with 26.7% in the collagen injection arm (P = 0.05), with 85% from the traditional sling arm having minimal or no incontinence (using one pad or no pads daily).
Despite lower costs associated with the collagen injection, the traditional sling arm showed better overall improvement and had lower reoperation rates. The study author concluded that the traditional sling might be more cost‐effective when compared with collagen injection.
A cost‐utility analysis using a Markov model compared the mid‐urethral sling with open abdominal retropubic colposuspension, laparoscopic colposuspension, the traditional suburethral retropubic sling, and injectables (Kilonzo 2004). This study provides a summary of work presented in the technology assessment review conducted for the UK’s National Institute for Clinical Excellence (NICE) (Cody 2003). Study authors utilised clinical data from a systematic review of RCTs conducted up to mid‐2003 (Lapitan 2003; Moehrer 2002; Ward 2002b), and these results were based on economic modelling for a time horizon of up to 10 years; all costs were originally reported in UK pounds for 2001 and were adjusted to international dollars for 2019.
This study assumed, based upon the findings of Cody 2003, that the traditional sling and open abdominal retropubic colposuspension had equivalent effectiveness. This contrasts with evidence from the current review showing that traditional slings are more effective (summary of findings Table 7).
The cost for traditional slings was $2756 per woman (2019 International Dollars; £1340 2001 GBP), with operation time of 46 minutes and average hospital stay of 7.2 days. Mid‐urethral slings cost $2176 (2019 International Dollars; £1058 2001 GBP) per woman, with an average hospital stay of 2.9 days and operation time of 30 minutes, but these costs were excluded. Open colposuspension cost $2676 per woman (2019 International Dollars; £1301 2001 GBP), with an operation time of 52 minutes and average hospital stay of 7.1 days, and laparoscopic colposuspension cost $2709 (2019 International Dollars; £1317 2001 GBP), with an operation time of 60 minutes and an average hospital stay of 4.6 days. A formal comparison of the cost‐effectiveness of traditional slings versus any of the other interventions was not performed. However, Kilonzo 2004 estimated that there was an 86% probability that mid‐urethral slings were cost‐effective compared to open colposuspension, if society was willing to pay approximately $62,000 (2019 International Dollars; £30,000 2001 GBP) per quality‐adjusted life‐year (QALY) gained. Given the model assumptions (traditional slings being more costly and as effective as open colposuspension), by implication traditional slings would not in this evaluation be considered cost‐effective compared with mid‐urethral slings or open colposuspension.
A cost‐utility analysis (Markov model) by Kumar 2017 compared the effectiveness of the traditional sling with Burch colposuspension. This study utilised data from published RCTs that included women 60 years of age and older with stress urinary incontinence, which compared the two procedures (Albo 2007; Bai 2005; Culligan 2003; Sand 2000). Follow‐up from these studies varied from three months to 73 months. However, the model extrapolated follow‐up of women for a time horizon of 16 years. The cost perspective was not explicitly stated but appears to be that of the US patient and healthcare provider based on captured costs (procedure costs and costs of caring for the patient with treatment failure for a year). These costs were originally reported in USD for 2015 and were converted to 2019 International Dollars.
Literature describing this cost‐utility analysis shows that the cure rate for Burch colposuspension at 3 months, 12 months, 36 months, and 73 months was 90%, 87%, 49%, and 84.6%, respectively, and that for the traditional sling was 100% at 3 months and 73 months, 87.8% at 12 months, and 66% at 36 months. Studies reported that the overall cost of the traditional sling per woman was $8186 (2019 International Dollars; $7619 2015 USD) less than the overall cost of Burch colposuspension. The cost‐utility analysis concluded that the traditional sling was more effective than Burch colposuspension based on the QALY gained. Women in the traditional sling arm (11.18 QALYs) had 0.99 QALYs more compared with those in the Burch colposuspension arm (10.19 QALYs), with an incremental cost per QALY of $8251 (2019 International Dollars; $7696 2015 USD). Kumar 2017 stated that it would be important to have published data from large‐scale trials before a definitive recommendation could be provided.
Eligible economic evaluations were not directly comparable due to differences in methods, time horizons, and settings. We have not sought to determine the potential reasons why results differ between studies, nor have we conducted any critical appraisal. Consequently, we do not attempt to draw any firm or general conclusions regarding the relative costs or efficiency of traditional suburethral retropubic slings for surgical management of stress urinary incontinence compared with current alternatives.
PRISMA study flow diagram ‐ search for clinical effectiveness studies.
PRISMA study flow diagram ‐ search for economic evaluations for the BEC.
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
Comparison 3 Traditional suburethral sling operation versus drugs, Outcome 1 Number of continent women within 1 year (any definition).
Comparison 3 Traditional suburethral sling operation versus drugs, Outcome 2 Urge urinary symptoms, urgency urinary incontinence.
Comparison 4 Traditional suburethral sling operation versus injectables, Outcome 1 Number of continent women within 1 year (any definition).
Comparison 4 Traditional suburethral sling operation versus injectables, Outcome 2 Number of continent women at 1 to 5 years (any definition).
Comparison 4 Traditional suburethral sling operation versus injectables, Outcome 3 Repeat surgery for urinary incontinence.
Comparison 4 Traditional suburethral sling operation versus injectables, Outcome 4 Number of women cured after first year (women's observations).
Comparison 4 Traditional suburethral sling operation versus injectables, Outcome 5 Number of women satisfied (women's observations).
Comparison 4 Traditional suburethral sling operation versus injectables, Outcome 6 Number of women with urinary incontinence within first year (clinician's observations).
Comparison 4 Traditional suburethral sling operation versus injectables, Outcome 7 Urinary tract infection.
Comparison 4 Traditional suburethral sling operation versus injectables, Outcome 8 De novo detrusor overactivity (urodynamic diagnosis).
Comparison 4 Traditional suburethral sling operation versus injectables, Outcome 9 Voiding dysfunction.
Comparison 6 Traditional suburethral sling operation versus bladder neck needle suspension (abdominal and vaginal), Outcome 1 Number of continent women within 1 year (any definition).
Comparison 6 Traditional suburethral sling operation versus bladder neck needle suspension (abdominal and vaginal), Outcome 2 Number of continent women at 1 to 5 years (any definition).
Comparison 6 Traditional suburethral sling operation versus bladder neck needle suspension (abdominal and vaginal), Outcome 3 CURE: number of women cured after first year (women's observations).
Comparison 6 Traditional suburethral sling operation versus bladder neck needle suspension (abdominal and vaginal), Outcome 4 Length of hospital stay (hours).
Comparison 6 Traditional suburethral sling operation versus bladder neck needle suspension (abdominal and vaginal), Outcome 5 Perioperative surgical complications.
Comparison 6 Traditional suburethral sling operation versus bladder neck needle suspension (abdominal and vaginal), Outcome 6 Urinary urgency symptoms, urgency urinary incontinence.
Comparison 6 Traditional suburethral sling operation versus bladder neck needle suspension (abdominal and vaginal), Outcome 7 Detrusor overactivity (urodynamic diagnosis).
Comparison 6 Traditional suburethral sling operation versus bladder neck needle suspension (abdominal and vaginal), Outcome 8 Voiding dysfunction after 3 months.
Comparison 7 Traditional suburethral sling operation versus open abdominal retropubic colposuspension, Outcome 1 Number of continent women within 1 year (any definition).
Comparison 7 Traditional suburethral sling operation versus open abdominal retropubic colposuspension, Outcome 2 Number of continent women at 1 to 5 years (any definition).
Comparison 7 Traditional suburethral sling operation versus open abdominal retropubic colposuspension, Outcome 3 Number of continent women after 5 years (any definition).
Comparison 7 Traditional suburethral sling operation versus open abdominal retropubic colposuspension, Outcome 4 Repeat surgery for urinary incontinence.
Comparison 7 Traditional suburethral sling operation versus open abdominal retropubic colposuspension, Outcome 5 Number of women cured after first year (women's observations).
Comparison 7 Traditional suburethral sling operation versus open abdominal retropubic colposuspension, Outcome 6 Number of women satisfied (women's observations).
Comparison 7 Traditional suburethral sling operation versus open abdominal retropubic colposuspension, Outcome 8 Number of women with urinary incontinence at 1 to 5 years (clinician's observations).
Comparison 7 Traditional suburethral sling operation versus open abdominal retropubic colposuspension, Outcome 9 Number of women with urinary incontinence after 5 years (clinician's observations).
Comparison 7 Traditional suburethral sling operation versus open abdominal retropubic colposuspension, Outcome 10 Duration of operation (minutes).
Comparison 7 Traditional suburethral sling operation versus open abdominal retropubic colposuspension, Outcome 11 Length of hospital stay (days).
Comparison 7 Traditional suburethral sling operation versus open abdominal retropubic colposuspension, Outcome 12 Time to catheter removal (days).
Comparison 7 Traditional suburethral sling operation versus open abdominal retropubic colposuspension, Outcome 14 Number of women requiring treatment for pelvic organ prolapse.
Comparison 7 Traditional suburethral sling operation versus open abdominal retropubic colposuspension, Outcome 15 Perioperative surgical complications.
Comparison 7 Traditional suburethral sling operation versus open abdominal retropubic colposuspension, Outcome 16 Bladder perforation.
Comparison 7 Traditional suburethral sling operation versus open abdominal retropubic colposuspension, Outcome 17 Urinary tract infection.
Comparison 7 Traditional suburethral sling operation versus open abdominal retropubic colposuspension, Outcome 18 Number of women with recurrent UTIs at > 5 years.
Comparison 7 Traditional suburethral sling operation versus open abdominal retropubic colposuspension, Outcome 19 Urinary urgency symptoms, urgency urinary incontinence.
Comparison 7 Traditional suburethral sling operation versus open abdominal retropubic colposuspension, Outcome 20 Detrusor overactivity (urodynamic diagnosis).
Comparison 7 Traditional suburethral sling operation versus open abdominal retropubic colposuspension, Outcome 21 Voiding dysfunction after 3 months.
Comparison 7 Traditional suburethral sling operation versus open abdominal retropubic colposuspension, Outcome 22 Long‐term voiding dysfunction > 5 years.
Comparison 7 Traditional suburethral sling operation versus open abdominal retropubic colposuspension, Outcome 23 Condition‐specific measures to assess quality of life.
Comparison 9 Traditional suburethral sling operation versus mid‐urethral sling or tape, Outcome 1 Number of continent women within 1 year (any definition).
Comparison 9 Traditional suburethral sling operation versus mid‐urethral sling or tape, Outcome 2 Number of continent women at 1 to 5 years (any definition).
Comparison 9 Traditional suburethral sling operation versus mid‐urethral sling or tape, Outcome 3 Number of continent women after 5 years (any definition).
Comparison 9 Traditional suburethral sling operation versus mid‐urethral sling or tape, Outcome 4 Repeat surgery for urinary incontinence.
Comparison 9 Traditional suburethral sling operation versus mid‐urethral sling or tape, Outcome 5 Number of women cured after first year (women's observations).
Comparison 9 Traditional suburethral sling operation versus mid‐urethral sling or tape, Outcome 6 Number of women improved or cured within 1 year (women's observations).
Comparison 9 Traditional suburethral sling operation versus mid‐urethral sling or tape, Outcome 7 Number of women improved or cured at 1 to 5 years (women's observations).
Comparison 9 Traditional suburethral sling operation versus mid‐urethral sling or tape, Outcome 8 Number of women improved or cured after 5 years (women's observations).
Comparison 9 Traditional suburethral sling operation versus mid‐urethral sling or tape, Outcome 9 Number of women satisfied (women's observations).
Comparison 9 Traditional suburethral sling operation versus mid‐urethral sling or tape, Outcome 10 Pad test of quantified leakage (mean weight of urine lost).
Comparison 9 Traditional suburethral sling operation versus mid‐urethral sling or tape, Outcome 11 Number of women with urinary incontinence within first year (clinician's observations).
Comparison 9 Traditional suburethral sling operation versus mid‐urethral sling or tape, Outcome 12 Number of women with urinary incontinence at 1 to 5 years (any definition) (clinician's observations).
Comparison 9 Traditional suburethral sling operation versus mid‐urethral sling or tape, Outcome 13 Duration of operation (minutes).
Comparison 9 Traditional suburethral sling operation versus mid‐urethral sling or tape, Outcome 14 Length of hospital stay (days).
Comparison 9 Traditional suburethral sling operation versus mid‐urethral sling or tape, Outcome 15 Time to catheter removal (days).
Comparison 9 Traditional suburethral sling operation versus mid‐urethral sling or tape, Outcome 16 Perioperative surgical complications.
Comparison 9 Traditional suburethral sling operation versus mid‐urethral sling or tape, Outcome 17 Bladder perforations.
Comparison 9 Traditional suburethral sling operation versus mid‐urethral sling or tape, Outcome 18 Urethral injury.
Comparison 9 Traditional suburethral sling operation versus mid‐urethral sling or tape, Outcome 19 Vaginal bleeding.
Comparison 9 Traditional suburethral sling operation versus mid‐urethral sling or tape, Outcome 20 Urinary tract infection.
Comparison 9 Traditional suburethral sling operation versus mid‐urethral sling or tape, Outcome 21 Voiding dysfunction.
Comparison 9 Traditional suburethral sling operation versus mid‐urethral sling or tape, Outcome 22 Urinary urgency symptoms, urgency urinary incontinence.
Comparison 9 Traditional suburethral sling operation versus mid‐urethral sling or tape, Outcome 23 De novo detrusor overactivity (urodynamic diagnosis).
Comparison 9 Traditional suburethral sling operation versus mid‐urethral sling or tape, Outcome 24 Long‐term adverse effects (release of sling required).
Comparison 9 Traditional suburethral sling operation versus mid‐urethral sling or tape, Outcome 25 Long‐term adverse effects (wound pain at 6 months).
Comparison 9 Traditional suburethral sling operation versus mid‐urethral sling or tape, Outcome 26 Long‐term adverse effects (vaginal mesh or graft exposure).
Comparison 9 Traditional suburethral sling operation versus mid‐urethral sling or tape, Outcome 27 Condition‐specific measures to assess quality of life: UDI‐6.
Comparison 9 Traditional suburethral sling operation versus mid‐urethral sling or tape, Outcome 28 Condition‐specific measures to assess quality of life: IIQ‐7.
Comparison 10 Traditional suburethral sling operation versus a single‐incision sling (mini‐sling), Outcome 1 Number of continent women at 1 to 5 years (any definition).
Comparison 10 Traditional suburethral sling operation versus a single‐incision sling (mini‐sling), Outcome 2 Number of women cured after first year (women's observations).
Comparison 10 Traditional suburethral sling operation versus a single‐incision sling (mini‐sling), Outcome 3 Number of women satisfied (women's observations).
Comparison 10 Traditional suburethral sling operation versus a single‐incision sling (mini‐sling), Outcome 4 Number of women with urinary incontinence (clinician's observations) within first year.
Comparison 10 Traditional suburethral sling operation versus a single‐incision sling (mini‐sling), Outcome 5 Bladder perforation.
Comparison 10 Traditional suburethral sling operation versus a single‐incision sling (mini‐sling), Outcome 6 Urinary urgency symptoms, urgency urinary incontinence.
Comparison 10 Traditional suburethral sling operation versus a single‐incision sling (mini‐sling), Outcome 7 Pain with intercourse (dyspareunia).
Comparison 10 Traditional suburethral sling operation versus a single‐incision sling (mini‐sling), Outcome 8 Long‐term adverse effects (vaginal mesh or graft exposure).
Comparison 10 Traditional suburethral sling operation versus a single‐incision sling (mini‐sling), Outcome 9 Condition‐specific measures to assess quality of life: IIQ score.
Comparison 11 One type of traditional sling operation versus another type of traditional sling operation, Outcome 1 Number of continent women within 1 year (any definition).
Comparison 11 One type of traditional sling operation versus another type of traditional sling operation, Outcome 2 Number of continent women at 1 to 5 years (any definition).
Comparison 11 One type of traditional sling operation versus another type of traditional sling operation, Outcome 3 Number of continent women after 5 years (any definition).
Comparison 11 One type of traditional sling operation versus another type of traditional sling operation, Outcome 4 Repeat surgery for urinary incontinence.
Comparison 11 One type of traditional sling operation versus another type of traditional sling operation, Outcome 5 Number of women cured after first year (women's observations).
Comparison 11 One type of traditional sling operation versus another type of traditional sling operation, Outcome 6 Number of women improved or cured within first year (women's observations).
Comparison 11 One type of traditional sling operation versus another type of traditional sling operation, Outcome 7 Number of women improved or cured at 1 to 5 years (women's observations).
Comparison 11 One type of traditional sling operation versus another type of traditional sling operation, Outcome 8 Number of women satisfied (women's observations).
Comparison 11 One type of traditional sling operation versus another type of traditional sling operation, Outcome 9 Pad test of quantified leakage (mean weight of urine lost) within 1 year.
Comparison 11 One type of traditional sling operation versus another type of traditional sling operation, Outcome 10 Pad test of quantified leakage (mean weight of urine lost) at 1 to 5 years.
Comparison 11 One type of traditional sling operation versus another type of traditional sling operation, Outcome 11 Duration of operation (minutes).
Comparison 11 One type of traditional sling operation versus another type of traditional sling operation, Outcome 12 Blood loss (mL).
Comparison 11 One type of traditional sling operation versus another type of traditional sling operation, Outcome 13 Length of hospital stay (days).
Comparison 11 One type of traditional sling operation versus another type of traditional sling operation, Outcome 14 Perioperative surgical complications.
Comparison 11 One type of traditional sling operation versus another type of traditional sling operation, Outcome 15 Bladder perforation.
Comparison 11 One type of traditional sling operation versus another type of traditional sling operation, Outcome 16 Urinary tract infection.
Comparison 11 One type of traditional sling operation versus another type of traditional sling operation, Outcome 17 Vaginal bleeding.
Comparison 11 One type of traditional sling operation versus another type of traditional sling operation, Outcome 18 Long‐term adverse effects (wound pain).
Comparison 11 One type of traditional sling operation versus another type of traditional sling operation, Outcome 19 Voiding dysfunction.
Comparison 11 One type of traditional sling operation versus another type of traditional sling operation, Outcome 20 Urinary urgency symptoms, urgency urinary incontinence.
Comparison 11 One type of traditional sling operation versus another type of traditional sling operation, Outcome 21 Detrusor overactivity (urodynamic overactivity).
Comparison 11 One type of traditional sling operation versus another type of traditional sling operation, Outcome 22 Long‐term adverse effects (release of sling required).
Comparison 11 One type of traditional sling operation versus another type of traditional sling operation, Outcome 23 Long‐term adverse effects (vaginal mesh or graft exposure).
Comparison 11 One type of traditional sling operation versus another type of traditional sling operation, Outcome 24 Condition‐specific measures to assess quality of life (ICI‐Q short form UI score at 1 year).
Comparison 11 One type of traditional sling operation versus another type of traditional sling operation, Outcome 25 Condition‐specific measures to assess quality of life (ICI‐Q short form UI score at 1 to 5 years).
Comparison 12 Traditional suburethral sling operation versus drugs, Outcome 1 Number of women with urinary incontinence (worse, unchanged, or improved) within first year (women's observations).
Comparison 12 Traditional suburethral sling operation versus drugs, Outcome 2 Urge urinary symptoms, urgency urinary incontinence.
Comparison 13 Traditional suburethral sling operation versus injectables, Outcome 1 Number of women with urinary incontinence (worse, unchanged, or improved) within first year (women's observations).
Comparison 13 Traditional suburethral sling operation versus injectables, Outcome 2 Number of women with urinary incontinence (worse, unchanged, or improved) after first year (women's observations).
Comparison 13 Traditional suburethral sling operation versus injectables, Outcome 3 Number of women with urinary incontinence (clinician's observations) within first year.
Comparison 13 Traditional suburethral sling operation versus injectables, Outcome 4 CURE: number of women cured after first year (women's observations).
Comparison 13 Traditional suburethral sling operation versus injectables, Outcome 5 Voiding dysfunction.
Comparison 13 Traditional suburethral sling operation versus injectables, Outcome 6 De novo detrusor overactivity (urodynamic diagnosis).
Comparison 13 Traditional suburethral sling operation versus injectables, Outcome 7 Urinary tract infection.
Comparison 13 Traditional suburethral sling operation versus injectables, Outcome 8 Repeat surgery for urinary incontinence.
Comparison 14 Traditional suburethral sling operation versus bladder neck needle suspension (abdominal and vaginal), Outcome 1 Number with incontinence (worse, unchanged, or improved) within first year (women's observations).
Comparison 14 Traditional suburethral sling operation versus bladder neck needle suspension (abdominal and vaginal), Outcome 2 Number with incontinence (worse, unchanged, or improved) after first year (women's observations).
Comparison 14 Traditional suburethral sling operation versus bladder neck needle suspension (abdominal and vaginal), Outcome 3 CURE: number of women cured after first year (women's observations).
Comparison 14 Traditional suburethral sling operation versus bladder neck needle suspension (abdominal and vaginal), Outcome 4 Length of hospital stay (hours).
Comparison 14 Traditional suburethral sling operation versus bladder neck needle suspension (abdominal and vaginal), Outcome 5 Perioperative surgical complications.
Comparison 14 Traditional suburethral sling operation versus bladder neck needle suspension (abdominal and vaginal), Outcome 6 Urge urinary symptoms, urgency urinary incontinence.
Comparison 14 Traditional suburethral sling operation versus bladder neck needle suspension (abdominal and vaginal), Outcome 7 Voiding dysfunction after 3 months.
Comparison 14 Traditional suburethral sling operation versus bladder neck needle suspension (abdominal and vaginal), Outcome 8 Detrusor overactivity (urodynamic diagnosis).
Comparison 15 Traditional suburethral sling operation versus open abdominal retropubic colposuspension, Outcome 1 Number of women with urinary incontinence (worse, unchanged, or improved) within first year (women's observations).
Comparison 15 Traditional suburethral sling operation versus open abdominal retropubic colposuspension, Outcome 3 Number of women with urinary incontinence (worse, unchanged, or improved) at 1 to 5 years (women's observations).
Comparison 15 Traditional suburethral sling operation versus open abdominal retropubic colposuspension, Outcome 5 Number of women with urinary incontinence (worse, unchanged, or improved) at > 5 years (women's observations).
Comparison 15 Traditional suburethral sling operation versus open abdominal retropubic colposuspension, Outcome 6 CURE: number of women cured at > 1 year (women's observations).
Comparison 15 Traditional suburethral sling operation versus open abdominal retropubic colposuspension, Outcome 7 Number of women not satisfied at > 5 years.
Comparison 15 Traditional suburethral sling operation versus open abdominal retropubic colposuspension, Outcome 10 Number of women with urinary incontinence (clinician's observations) at 1 to 5 years.
Comparison 15 Traditional suburethral sling operation versus open abdominal retropubic colposuspension, Outcome 11 Number of women with urinary incontinence (clinician's observations) at > 5 years.
Comparison 15 Traditional suburethral sling operation versus open abdominal retropubic colposuspension, Outcome 12 Duration of operation (minutes).
Comparison 15 Traditional suburethral sling operation versus open abdominal retropubic colposuspension, Outcome 13 Time to catheter removal (days).
Comparison 15 Traditional suburethral sling operation versus open abdominal retropubic colposuspension, Outcome 14 Length of hospital stay (days).
Comparison 15 Traditional suburethral sling operation versus open abdominal retropubic colposuspension, Outcome 16 Perioperative surgical complications.
Comparison 15 Traditional suburethral sling operation versus open abdominal retropubic colposuspension, Outcome 17 Bladder perforation.
Comparison 15 Traditional suburethral sling operation versus open abdominal retropubic colposuspension, Outcome 18 Urinary tract infection.
Comparison 15 Traditional suburethral sling operation versus open abdominal retropubic colposuspension, Outcome 19 Number of women with recurrent UTIs at > 5 years.
Comparison 15 Traditional suburethral sling operation versus open abdominal retropubic colposuspension, Outcome 20 Urge urinary symptoms, urgency urinary incontinence.
Comparison 15 Traditional suburethral sling operation versus open abdominal retropubic colposuspension, Outcome 21 Detrusor overactivity (urodynamic diagnosis).
Comparison 15 Traditional suburethral sling operation versus open abdominal retropubic colposuspension, Outcome 22 Voiding dysfunction after 3 months.
Comparison 15 Traditional suburethral sling operation versus open abdominal retropubic colposuspension, Outcome 23 Long‐term voiding dysfunction > 5 years.
Comparison 15 Traditional suburethral sling operation versus open abdominal retropubic colposuspension, Outcome 24 Number of women requiring treatment for pelvic organ prolapse.
Comparison 15 Traditional suburethral sling operation versus open abdominal retropubic colposuspension, Outcome 25 Repeat surgery for urinary incontinence.
Comparison 15 Traditional suburethral sling operation versus open abdominal retropubic colposuspension, Outcome 26 Condition‐specific measures to assess quality of life.
Comparison 16 Traditional suburethral sling operation versus a mid‐urethral sling or tape, Outcome 1 Number of women with urinary incontinence (worse, unchanged, or improved) within first year (women's observations).
Comparison 16 Traditional suburethral sling operation versus a mid‐urethral sling or tape, Outcome 2 Number not improved (worse or unchanged) within first year (women's observations).
Comparison 16 Traditional suburethral sling operation versus a mid‐urethral sling or tape, Outcome 3 Number of women with urinary incontinence (worse, unchanged, or improved) at 1 to 5 years (women's observations).
Comparison 16 Traditional suburethral sling operation versus a mid‐urethral sling or tape, Outcome 4 Number not improved (worse or unchanged) after first year (women's observations).
Comparison 16 Traditional suburethral sling operation versus a mid‐urethral sling or tape, Outcome 5 Number of women with urinary incontinence after 5 years (women's observations).
Comparison 16 Traditional suburethral sling operation versus a mid‐urethral sling or tape, Outcome 6 Number with incontinence not improved after 5 years (women's observations).
Comparison 16 Traditional suburethral sling operation versus a mid‐urethral sling or tape, Outcome 7 CURE: number of women cured at > 1 year (women's observations).
Comparison 16 Traditional suburethral sling operation versus a mid‐urethral sling or tape, Outcome 8 Repeat surgery for urinary incontinence.
Comparison 16 Traditional suburethral sling operation versus a mid‐urethral sling or tape, Outcome 9 Number of women not satisfied.
Comparison 16 Traditional suburethral sling operation versus a mid‐urethral sling or tape, Outcome 10 Pad test of quantified leakage (mean weight of urine loss).
Comparison 16 Traditional suburethral sling operation versus a mid‐urethral sling or tape, Outcome 11 Number of women with urinary incontinence (clinician's observations) within first year.
Comparison 16 Traditional suburethral sling operation versus a mid‐urethral sling or tape, Outcome 12 Number of women with urinary incontinence (clinician's observations) after first year.
Comparison 16 Traditional suburethral sling operation versus a mid‐urethral sling or tape, Outcome 13 Duration of operation (minutes).
Comparison 16 Traditional suburethral sling operation versus a mid‐urethral sling or tape, Outcome 14 Length of hospital stay (days).
Comparison 16 Traditional suburethral sling operation versus a mid‐urethral sling or tape, Outcome 15 Time to catheter removal (days).
Comparison 16 Traditional suburethral sling operation versus a mid‐urethral sling or tape, Outcome 16 Perioperative surgical complications.
Comparison 16 Traditional suburethral sling operation versus a mid‐urethral sling or tape, Outcome 17 Bladder perforations.
Comparison 16 Traditional suburethral sling operation versus a mid‐urethral sling or tape, Outcome 18 Urethral injury.
Comparison 16 Traditional suburethral sling operation versus a mid‐urethral sling or tape, Outcome 19 Vaginal bleeding.
Comparison 16 Traditional suburethral sling operation versus a mid‐urethral sling or tape, Outcome 20 Urinary tract infection.
Comparison 16 Traditional suburethral sling operation versus a mid‐urethral sling or tape, Outcome 21 Voiding dysfunction.
Comparison 16 Traditional suburethral sling operation versus a mid‐urethral sling or tape, Outcome 22 De novo detrusor urgency or urge symptoms.
Comparison 16 Traditional suburethral sling operation versus a mid‐urethral sling or tape, Outcome 23 De novo detrusor overactivity (urodynamic diagnosis).
Comparison 16 Traditional suburethral sling operation versus a mid‐urethral sling or tape, Outcome 24 Long‐term adverse effects (release of sling required).
Comparison 16 Traditional suburethral sling operation versus a mid‐urethral sling or tape, Outcome 25 Long‐term adverse effects (wound pain at 6 months).
Comparison 16 Traditional suburethral sling operation versus a mid‐urethral sling or tape, Outcome 26 Long‐term adverse effects (vaginal mesh or graft exposure).
Comparison 16 Traditional suburethral sling operation versus a mid‐urethral sling or tape, Outcome 27 Condition‐specific measures to assess quality of life: UDI‐6.
Comparison 16 Traditional suburethral sling operation versus a mid‐urethral sling or tape, Outcome 28 Condition‐specific measures to assess quality of life: IIQ‐7.
Comparison 17 Traditional suburethral sling operation versus a single‐incision sling (mini‐sling), Outcome 1 Number of women with urinary incontinence in the medium term (1 to 5 years).
Comparison 17 Traditional suburethral sling operation versus a single‐incision sling (mini‐sling), Outcome 2 Number of women not satisfied within first year.
Comparison 17 Traditional suburethral sling operation versus a single‐incision sling (mini‐sling), Outcome 3 Number of women with urinary incontinence (clinician's observations) within first year.
Comparison 17 Traditional suburethral sling operation versus a single‐incision sling (mini‐sling), Outcome 4 CURE: number of women cured at > 1 year (women's observations).
Comparison 17 Traditional suburethral sling operation versus a single‐incision sling (mini‐sling), Outcome 5 Bladder perforation.
Comparison 17 Traditional suburethral sling operation versus a single‐incision sling (mini‐sling), Outcome 6 Urge urinary symptoms, urgency urinary incontinence.
Comparison 17 Traditional suburethral sling operation versus a single‐incision sling (mini‐sling), Outcome 7 Pain with intercourse (dyspareunia).
Comparison 17 Traditional suburethral sling operation versus a single‐incision sling (mini‐sling), Outcome 8 Long‐term adverse effects (vaginal mesh or graft exposure).
Comparison 17 Traditional suburethral sling operation versus a single‐incision sling (mini‐sling), Outcome 9 Condition‐specific measures to assess quality of life: IIQ score.
Comparison 18 One type of traditional sling operation versus another type of traditional sling operation, Outcome 1 Number of women with urinary incontinence (worse, unchanged, or improved) within first year (women's observations).
Comparison 18 One type of traditional sling operation versus another type of traditional sling operation, Outcome 2 Number not improved (worse or unchanged) within first year (women's observations).
Comparison 18 One type of traditional sling operation versus another type of traditional sling operation, Outcome 3 Number of women with urinary incontinence (worse, unchanged, or improved) at 1 to 5 years (women's observations).
Comparison 18 One type of traditional sling operation versus another type of traditional sling operation, Outcome 4 Number not improved (worse or unchanged) after first year (women's observations).
Comparison 18 One type of traditional sling operation versus another type of traditional sling operation, Outcome 5 Number of women with urinary incontinence (worse, unchanged, or improved) after 5 years (women's observations).
Comparison 18 One type of traditional sling operation versus another type of traditional sling operation, Outcome 6 CURE: number of women with urinary incontinence > 1 year (women's observations).
Comparison 18 One type of traditional sling operation versus another type of traditional sling operation, Outcome 7 Number of women not satisfied.
Comparison 18 One type of traditional sling operation versus another type of traditional sling operation, Outcome 8 Pad test of quantified leakage (mean weight of urine loss) at 1 year.
Comparison 18 One type of traditional sling operation versus another type of traditional sling operation, Outcome 9 Pad test of quantified leakage (mean weight of urine loss) at 1 to 5 years.
Comparison 18 One type of traditional sling operation versus another type of traditional sling operation, Outcome 10 Duration of operation (minutes).
Comparison 18 One type of traditional sling operation versus another type of traditional sling operation, Outcome 11 Blood loss (mL).
Comparison 18 One type of traditional sling operation versus another type of traditional sling operation, Outcome 12 Length of hospital stay (days).
Comparison 18 One type of traditional sling operation versus another type of traditional sling operation, Outcome 13 Perioperative surgical complications.
Comparison 18 One type of traditional sling operation versus another type of traditional sling operation, Outcome 14 Bladder perforation.
Comparison 18 One type of traditional sling operation versus another type of traditional sling operation, Outcome 15 Urinary tract infection.
Comparison 18 One type of traditional sling operation versus another type of traditional sling operation, Outcome 16 Vaginal bleeding.
Comparison 18 One type of traditional sling operation versus another type of traditional sling operation, Outcome 17 Long‐term adverse effects (wound pain).
Comparison 18 One type of traditional sling operation versus another type of traditional sling operation, Outcome 18 Voiding dysfunction.
Comparison 18 One type of traditional sling operation versus another type of traditional sling operation, Outcome 19 Long‐term adverse effects (release of sling required).
Comparison 18 One type of traditional sling operation versus another type of traditional sling operation, Outcome 20 De novo detrusor urgency or urge symptoms or detrusor overactivity.
Comparison 18 One type of traditional sling operation versus another type of traditional sling operation, Outcome 21 Repeat surgery for urinary incontinence at first year.
Comparison 18 One type of traditional sling operation versus another type of traditional sling operation, Outcome 22 Long‐term adverse effects (vaginal mesh or graft exposure).
Comparison 18 One type of traditional sling operation versus another type of traditional sling operation, Outcome 23 Condition‐specific measures to assess quality of life (ICI‐Q short form UI score at 1 year).
Comparison 18 One type of traditional sling operation versus another type of traditional sling operation, Outcome 24 Condition‐specific measures to assess quality of life (ICI‐Q short form UI score at 1 to 5 years).
| Traditional suburethral sling operation versus no treatment or sham operation | ||||||
| Patient or population: women with urinary incontinence | ||||||
| Outcomes | Illustrative comparative risks* (95% CI) | Relative effect | Number of participants | Quality of the evidence | Comments | |
| Assumed risk | Corresponding risk | |||||
| No treatment or sham treatment | Sling | |||||
| Number of continent (dry) women (any definition) in the medium term (1 to 5 years) | Not reported | |||||
| Repeat surgery for urinary incontinence | Not reported | |||||
| Perioperative surgical complications | Not reported | |||||
| Long‐term adverse effects | Not reported | |||||
| Condition‐specific quality of life | Not reported | |||||
| *The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). | ||||||
| GRADE Working Group grades of evidence. | ||||||
| Traditional suburethral sling operation versus conservative management | ||||||
| Patient or population: women with urinary incontinence | ||||||
| Outcomes | Illustrative comparative risks* (95% CI) | Relative effect | Number of participants | Quality of the evidence | Comments | |
| Assumed risk | Corresponding risk | |||||
| Conservative treatment | Sling | |||||
| Number of continent (dry) women (any definition) in the medium term (1 to 5 years) | Not reported | |||||
| Repeat surgery for urinary incontinence | Not reported | |||||
| Perioperative surgical complications | Not reported | |||||
| Long‐term adverse effects | Not reported | |||||
| Condition‐specific quality of life | Not reported | |||||
| *The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). | ||||||
| GRADE Working Group grades of evidence. | ||||||
| Traditional suburethral sling operation versus drugs | ||||||
| Patient or population: women with urinary incontinence | ||||||
| Outcomes | Illustrative comparative risks* (95% CI) | Relative effect | Number of participants | Quality of the evidence | Comments | |
| Assumed risk | Corresponding risk | |||||
| Drugs | Sling | |||||
| Number of continent (dry) women (any definition) in the medium term (1 to 5 years) | Not reported | |||||
| Repeat surgery for urinary incontinence | Not reported | |||||
| Perioperative surgical complications | Not reported | |||||
| Long‐term adverse effects | Not reported | |||||
| Condition‐specific quality of life | Not reported | |||||
| *The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). | ||||||
| GRADE Working Group grades of evidence. | ||||||
| Traditional suburethral sling operation versus injectables | ||||||
| Patient or population: women with urinary incontinence | ||||||
| Outcomes | Illustrative comparative risks* (95% CI) | Relative effect | Number of participants | Quality of the evidence | Comments | |
| Assumed risk | Corresponding risk | |||||
| Injectable | Sling | |||||
| Number of continent (dry) women (any definition) in the medium term (1 to 5 years) | 714 per 1000 | 967 per 1000 (583 to 998) | OR 11.57 (0.56 to 239.7) | 43 | ⊕⊝⊝⊝ | 252 more women, per 1000, with traditional sling (131 fewer to 284 more) |
| Repeat surgery for urinary incontinence ‐ urodynamic stress incontinence (only) | 91 per 1000 | 47 per 1000 (5 to 487) | RR 0.52 (0.05 to 5.36) | 43 | ⊕⊝⊝⊝ | 44 fewer women, per 1000, with traditional sling (86 fewer to 396 more) |
| Perioperative surgical complications | 91 per 1000 | 143 per 1000 | RR 1.57 | 43 | ⊕⊝⊝⊝ | 52 more women, per 1000, with traditional sling (65 fewer to 681 more) |
| Long‐term adverse effects | Not reported | |||||
| Condition‐specific quality of life | Not reported | |||||
| *The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). | ||||||
| GRADE Working Group grades of evidence. | ||||||
| aDowngraded one level due to serious risk of bias (unclear for sequence generation, allocation concealment, and blinding) and two levels for imprecision (95% CI very wide, 0.56 to 239.74; crosses line of no effect). bDowngraded two levels due to very serious imprecision: single trial with small sample size. | ||||||
| Traditional suburethral sling operation versus anterior repair | ||||||
| Patient or population: women with urinary incontinence | ||||||
| Outcomes | Illustrative comparative risks* (95% CI) | Relative effect | Number of participants | Quality of the evidence | Comments | |
| Assumed risk | Corresponding risk | |||||
| Anterior repair | Sling | |||||
| Number of continent (dry) women (any definition) in the medium term (1 to 5 years) | Not reported | |||||
| Repeat surgery for urinary incontinence | Not reported | |||||
| Perioperative surgical complications | Not reported | |||||
| Long‐term adverse effects | Not reported | |||||
| Condition‐specific quality of life | Not reported | |||||
| *The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). | ||||||
| GRADE Working Group grades of evidence. | ||||||
| Traditional suburethral sling operation versus bladder neck needle suspension (abdominal and vaginal) | ||||||
| Patient or population: women with urinary incontinence | ||||||
| Outcomes | Illustrative comparative risks* (95% CI) | Relative effect | Number of participants | Quality of the evidence | Comments | |
| Assumed risk | Corresponding risk | |||||
| Bladder neck needle suspension | Sling | |||||
| Number of continent (dry) women (any definition) in the medium term (1 to 5 years) | 700 per 1000 | 900 per 1000 (435 to 991) | OR 3.86 0.33 to 45.57 | 20 | ⊕⊝⊝⊝ | 200 more women, per 1000, with traditional sling (265 fewer to 291 more) |
| Repeat surgery for urinary incontinence | Not reported | |||||
| Perioperative surgical complications ‐ urodynamic stress incontinence (only) | 200 per 1000 | 900 per 1000 | RR 4.5 | 20 | ⊕⊝⊝⊝ | 700 more women, per 1000, with traditional sling (56 fewer to 2962 more) |
| Long‐term adverse effects | Not reported | |||||
| Condition‐specific quality of life | Not reported | |||||
| *The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). | ||||||
| GRADE Working Group grades of evidence. | ||||||
| aDowngraded two levels for risk of bias (evidence comes from a single trial that was judged to be unclear for allocation concealment and blinding) and two levels for imprecision (95% CI very wide). | ||||||
| Traditional suburethral sling operation versus open abdominal retropubic suspension | ||||||
| Patient or population: women with urinary incontinence | ||||||
| Outcomes | Illustrative comparative risks* (95% CI) | Relative effect | Number of participants | Quality of the evidence | Comments | |
| Assumed risk | Corresponding risk | |||||
| Open abdominal retropubic suspension | Sling | |||||
| Number of continent (dry) women (any definition) in the medium term (1 to 5 years) | 589 per 1000 | 711 per 1000 (638 to 774) | OR 1.70 (1.22 to 2.37) | 687 (4 RCTs) | ⊕⊕⊕⊝ | 120 more dry women, per 1000, with traditional sling (47 more to 186 more) |
| Repeat surgery for urinary incontinence‐stress urinary incontinence (symptoms only) | 119 per 1000 | 18 per 1000 | RR 0.15 (0.05 to 0.42) | 450 | ⊕⊕⊕⊕ | 101 fewer women having repeat continence surgery, per 1000, with traditional sling (113 fewer to 69 fewer) |
| Perioperative surgical complications | 95 per 1000 | 118 per 1000 | RR 1.24 | 792 | ⊕⊝⊝⊝ | 23 more women, per 1000, with traditional sling (16 fewer to 82 more) |
| Long‐term adverse effects | 92 per 1000 | 94 per 1000 | RR 1.02 (0.57 to 1.82) | 453 | ⊕⊕⊝⊝ | 2 more women, per 1000, with traditional sling (39 fewer to 75 more) |
| Condition‐specific quality of life | Mean IIQ score in the control group was 44.8 | Mean condition‐specific quality of life in the intervention groups was | 453 | ⊕⊝⊝⊝ | Another trial reported no evidence of a difference between colposuspension groups and sling groups in IIQ and UDI scores but reported no actual numbers | |
| *The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). | ||||||
| GRADE Working Group grades of evidence. | ||||||
| aDowngraded one level due to serious risk of bias (unclear randomisation and allocation concealment in two of the smaller trials), but the trial carrying 90% of weight in the meta‐analysis was judged to have low risk of selection bias. bDowngraded one level for risk of bias (sequence generation was unclear in one‐fourth of trials and allocation concealment was unclear in three‐quarters of trials taking part in the meta‐analysis; participants were not blinded) and one level for imprecision (95% confidence interval was very wide). cDowngraded two levels for imprecision (95% confidence interval was very wide; 0.57 to 1.82). dDowngraded two levels for risk of bias (sequence generation and allocation concealment were judged to be "low risk"; blinding of participants was judged to be "high risk") and two levels for imprecision (95% confidence interval was very wide; ‐11.96 to 15.36). | ||||||
| Traditional suburethral sling operation versus laparoscopic colposuspension | ||||||
| Patient or population: women with urinary incontinence | ||||||
| Outcomes | Illustrative comparative risks* (95% CI) | Relative effect | Number of participants | Quality of the evidence | Comments | |
| Assumed risk | Corresponding risk | |||||
| Laparoscopic procedures | Sling | |||||
| Number of continent (dry) women (any definition) in the medium term (1 to 5 years) | Not reported | |||||
| Repeat surgery for urinary incontinence | Not reported | |||||
| Perioperative surgical complications | Not reported | |||||
| Voiding dysfunction | Not reported | |||||
| Long‐term adverse effects | Not reported | |||||
| Condition‐specific quality of life | Not reported | |||||
| *The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). | ||||||
| GRADE Working Group grades of evidence. | ||||||
| Traditional suburethral sling operation versus a mid‐urethral sling or tape | ||||||
| Patient or population: women with urinary incontinence | ||||||
| Outcomes | Illustrative comparative risks* (95% CI) | Relative effect | Number of participants | Quality of the evidence | Comments | |
| Assumed risk | Corresponding risk | |||||
| Minimally invasive sling operation | Traditional sling | |||||
| Number of continent (dry) women (any definition) in the medium term (1 to 5 years) | 737 per 1000 | 652 per 1000 (552 to 741) | OR 0.67 (0.44 to 1.02) | 445 (6 RCTs) | ⊕⊕⊕⊝ | 85 fewer women, per 1000, with traditional sling (185 fewer to 4 more) |
| Repeat surgery for urinary incontinence ‐ urodynamic stress incontinence (only) | One trial reported the numbers of women having repeat continence surgery at 10‐year follow‐up: traditional sling: 0/67; mid‐urethral sling: 2/69 | 136 | ⊕⊕⊝⊝ | |||
| Perioperative surgical complications | 193 per 1000 | 336 per 1000 | RR 1.74 | 293 | ⊕⊕⊝⊝ | 143 more women, per 1000, with traditional sling (31 more to 309 more) |
| Long‐term adverse effects | 25 per 1000 | 62 per 1000 | RR 2.53 | 326 | ⊕⊝⊝⊝ | 38 more women, per 1000, with traditional sling (3 fewer to 157 more) |
| Condition‐specific quality of life | Mean IIQ‐7 score in the control group was 24.4 | Mean condition‐specific quality of life score in the intervention groups was | 63 | ⊕⊝⊝⊝ | Eight other trials reported some measure of QoL but the data were unsuitable for met‐analysis. Overall, there was no evidence of a difference between groups in QoL scores | |
| *The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). | ||||||
| GRADE Working Group grades of evidence. | ||||||
| 1Downgraded one level due to serious risk of bias: 2/6 trials had high risk of selection bias. 2Downgraded two levels due to very serious imprecision: single study with small sample size. 3Downgraded two levels for risk of bias (sequence generation and allocation concealment were high or unclear risk in all four trials taking part in the meta‐analysis). 4Downgraded two levels for risk of bias (sequence generation and allocation concealment were high or unclear risk in two of three trials taking part in the meta‐analysis) and two levels for imprecision (95% confidence interval was very wide: 0.87 to 7.35). 5Downgraded two levels for risk of bias (sequence generation was judged to be high risk, and allocation concealment was judged to be low risk; outcome data were incomplete) and two levels for imprecision (95% confidence interval was very wide: ‐10.17 to 11.37). | ||||||
| Traditional suburethral sling operation versus a single‐incision sling (mini‐sling) | ||||||
| Patient or population: women with urinary incontinence | ||||||
| Outcomes | Illustrative comparative risks* (95% CI) | Relative effect | Number of participants | Quality of the evidence | Comments | |
| Assumed risk | Corresponding risk | |||||
| Number of continent (dry) women (any definition) in the medium term (1 to 5 years) | 886 per 1000 | 886 per 1000 (641 to 971) | OR 1.00 (0.23 to 4.36) | 70 | ⊕⊝⊝⊝ | 0 fewer women, per 1000, with traditional sling (245 fewer to 86 more) |
| Repeat surgery for urinary incontinence | not reported | |||||
| Perioperative surgical complications ‐ bladder perforation | 0 per 1000 | 0 per 1000 (0 to 0) | RR 3 (0.13 to 71.22) | 70 | ⊕⊝⊝⊝ | |
| Long‐term adverse effects | not reported | |||||
| Condition‐specific quality of life IIQ | Mean IIQ score in the control group was 42.7 | Mean condition‐specific quality of life score in the intervention groups was 50.2 higher (2.23 higher to 12.77 higher) | 70 | ⊕⊝⊝⊝ | Based on mean IIQ score, quality of life was worse in the traditional sling group compared with the mini‐sling group | |
| *The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). | ||||||
| GRADE Working Group grades of evidence. | ||||||
| aDowngraded two levels due to very serious risk of bias: unclear randomisation and inadequate blinding. bDowngraded two levels due to very serious imprecision: single trial, small sample size, wide 95% confidence intervals. | ||||||
| One type of traditional sling operation versus another type of traditional sling operation | ||||||
| Patient or population: women with urinary incontinence | ||||||
| Outcomes | Illustrative comparative risks* (95% CI) | Relative effect | Number of participants | Quality of the evidence | Comments | |
| Assumed risk | Corresponding risk | |||||
| Another type of traditional sling | One type of traditional sling | |||||
| Number of continent (dry) women (any definition) in the medium term (1 to 5 years) | Not estimable | 749 | ⊕⊝⊝⊝ | Results not pooled (Analysis 11.2) | ||
| Repeat surgery for urinary incontinence at first year Fascial sling vs Pelvicol sling | 196 per 1000 | 8 per 1000 (0 to 119) | RR 0.04 (0.00 to 0.61) | 113 | ⊕⊕⊝⊝2 | 188 fewer women, per 1000, with fascial sling (0 fewer to 76 fewer) (Analysis 11.4 |
| Perioperative surgical complications | Not estimable | 239 | ⊕⊝⊝⊝ | Results not pooled (Analysis 11.14) | ||
| Long‐term adverse effects | Not estimable | 421 | ⊕⊝⊝⊝ | Results not pooled (Analysis 11.23) | ||
| Condition‐specific quality of life | Not estimable | 282 | ⊕⊝⊝⊝ | Results not pooled* (Analysis 11.25) | ||
| *The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). | ||||||
| GRADE Working Group grades of evidence. | ||||||
| 1Downgraded two levels for imprecision (Analysis 11.2) and two levels for heterogeneity, as the trials used different materials for the traditional sling procedure. 2Downgraded two levels for imprecision (Analysis 11.4) 3Downgraded one level for risk of bias (sequence generation was judged to be at low risk of bias in two of three trials and unclear in the third trial; allocation concealment was unclear in two of three trials). Blinding (performance bias and detection bias) was judged to be unclear (two of three) or high risk (one of three). Downgraded two levels for heterogeneity, as the trials used three different materials for the traditional sling procedure, and one level for inconsistency, as 95% CIs did not overlap (Analysis 11.14). 4Downgraded two levels for heterogeneity, as the trials used four different materials for the traditional sling procedure, and one level for imprecision, as the 95% CIs were very wide (Analysis 11.23). 5Downgraded two levels for heterogeneity, as the trials used three different materials for the traditional sling procedure, and one level for inconsistency, as 95% CIs did not overlap (Analysis 11.25). * Data from two other trials were identified and are reported narratively in the text. These two trials did not report their data in a form suitable for meta‐analysis | ||||||
| Trial ID | Definition of outcome | Notes |
| WOMAN‐REPORTED | ||
| Overall success defined as no self‐reported symptoms of UI, no incontinence on 3‐day diary, negative stress test, no re‐treatment (combined outcome). Failure (self‐reported UI) at 5 years only (woman‐reported) | Also combined outcome before 5 years | |
| Cure defined as complete dryness with no usage of pads (woman‐reported) | ||
| Cure of incontinence defined as a quality of life (QoL) improvement of 90% and/or patient‐determined continent status as dry (woman‐reported) | Questionnaire‐based | |
| Dry (symptom‐free) patients (woman‐reported) | ||
| Assessment of cure not defined. Data abstracted from this trial therefore assumed to be woman‐reported | ||
| Cure stated as subjective (woman‐reported) at 24 months' follow‐up Objective (urodynamic diagnosis, pad test (clinician‐reported)) at 3 months | Also clinician‐reported outcome at 3 months | |
| Subjective cure consistent with complete dryness or a few drops of water with strong exercises (assumed to be woman‐reported) | Also separate clinician‐reported outcome | |
| Success rate measured by recurrence of stress leakage as reported in patient questionnaire (woman‐reported) | ||
| Subjective success: no or occasional (less than once a week) stress incontinence (woman‐reported) | Also separate clinician‐reported outcome | |
| Cure defined as subjective (history: woman‐reported) | Also separate clinician‐reported outcome | |
| Cure defined as of some degree of SUI at 1 year after surgery (woman‐reported) | ||
| Success rate (dry) (method unspecified: assumed woman‐reported) | ||
| Cure rate (method unspecified: assumed woman‐reported) | ||
| Stress urinary incontinence (method unspecified: assumed woman‐reported) | ||
| QUANTITATIVE | ||
| Cure = dry pads, improvement = 1 wet pad, failure ≥ 1 wet pad per day (quantitative) | Satisfaction separately measured by questionnaire | |
| Subjective cure assessed via comparison between pre‐operative and postoperative Incontinence Impact Questionnaire (IIQ), Urinary Distress Inventory (UDI) (quantitative) | Also separate clinician‐reported outcome | |
| Cure defined as no pad use (quantitative) | ||
| Subjective improvement only; subjective patient evaluations included QoL questionnaire, incontinence diary, pain and global outcome assessments (quantitative) | Also separate clinician‐reported outcome | |
| Objective cure defined as 1‐hour pad test ≤ 2 grams (quantitative) | Also separate clinician‐reported outcome | |
| Women declared objectively cured when they had a postoperative pad test < 8 grams (quantitative) | ||
| Objective assessment via 48‐hour frequency volume chart, 48‐hour pad test, and standardised stress test. Surgery was considered successful when there was no postoperative SUI (patient was dry (quantitative)) | Also separate clinician‐reported outcome | |
| CLINICIAN‐REPORTED | ||
| No leakage of urine during stress test and urodynamic testing (clinician‐reported) | ||
| Cure defined as complete freedom from SUI (clinician‐reported) | ||
| Urine loss during cough‐stress test defined as persistent stress incontinence (clinician‐assessed) | ||
| Objective cure by stress test, voiding dysfunction by urodynamic assessment if incontinence seen (clinician‐reported) | Also separate quantitative outcome | |
| Cure stated as objective (urodynamic diagnosis, pad test (clinician‐reported)) at 3 months | Also woman‐reported outcome at 24 months | |
| Objective cure defined as complete absence of leakage during cough‐stress test with 250 or 300 mL of water in the bladder (clinician‐reported) | Also separate woman‐reported outcome | |
| Objective success: no leakage due to SUI on repeat urodynamic study (clinician‐reported) | Also separate woman‐reported outcome | |
| Objective outcome assessment: urine loss via a provocative pad test (clinician‐reported) | Also separate quantitative outcome (improvement only) | |
| Cure defined as objective (urodynamic: clinician‐reported) | Also separate woman‐reported outcome | |
| Objective cure defined as negative cough‐induced stress test with full bladder (≥ 250 mL filled) in lithotomy and standing positions (clinician‐reported) | Also separate quantitative outcome | |
| Objective assessment via 48‐hour frequency volume chart, 48‐hour pad test, and standardised stress test. Surgery considered successful when stress test was negative (clinician‐reported) and postoperative cystocoele was < grade 2 | Also separate quantitative outcome | |
| COMBINED WOMAN‐ AND CLINICIAN‐REPORTED | ||
| Overall success defined as no self‐reported symptoms of UI, no incontinence on 3‐day diary, negative stress test, no re‐treatment (combined outcome). Failure (self‐reported UI) at 5 years only (woman‐reported) | Also woman‐reported outcome at 5 years | |
| Cure of SUI defined as significant dryness as perceived by the patient, no more use of pads, negative stress test, and acceptable voiding stream (combined primary outcome) | However, no data after first week, so not useable | |
| Cure defined as absence of subjective complaints of leakage and absence of urinary leakage on stress test (combined outcome) | ||
| Cure defined as dry, symptom‐free without objective urine loss during stress with bladder filled to 300 mL or positive urethral‐closure pressure during stress provocation (combined outcome) | ||
| Continence defined as no urinary leakage on a 3‐day voiding diary, no self‐reported stress incontinence symptoms, and no stress incontinence surgical treatment (combined outcome) | ||
| Cure defined as complete freedom from SUI (subjective and objective demonstrations) (combined outcome) | ||
| Patients evaluated by SEAPI score (subjective and objective) after urodynamic examination before and after treatment (combined outcome) | ||
| Cure defined as reported absence of SUI with no urinary loss during effort manoeuvres (combined outcome) | ||
| Cure defined as no leakage reported by the patient or noticed at examination (combined outcome) | ||
| Cure defined as complete dryness with no usage of pad and negative cough‐stress test (combined outcome) | ||
| Trials that did not report cure rates.
| ||
| Comparison 3. Traditional suburethral sling operation versus drugs | |
| Osman 2003 included 75 women with mixed urinary incontinence treated with surgery (either Burch colposuspension (n = 24) or rectus fascia sling (n = 26)) or oxybutynin (an anticholinergic drug treatment for urinary incontinence, overactive bladder, and detrusor overactivity ‐ not for stress incontinence; n = 25) (Osman 2003). The type of surgery was selected according to Valsalva leak point pressure (VLPP) ‐ those with VLPP < 90 cm of water had rectus fascia sling, and those with VLPP > 90 cm of water had Burch colposuspension) Results for the surgically managed group were similar to those of the subgroup having slings. Due to small sample sizes, data were too few to be reliable; we therefore compared only data from oxybutynin versus sling patients provided in tables Primary outcomes Number of continent (dry) women Data suggest that, within the first year, women were significantly more likely to be continent after undergoing surgery with slings than after treatment with oxybutynin (20/24; 83% vs 0/21; OR 195.89, 95% CI 9.91 to 3871.03; n = 45; Analysis 3.1) Number of women who have repeat continence surgery Not reported Secondary outcomes Fewer women had persistent urgency urinary incontinence after traditional sling surgery (3/24; 13% vs 9/21; 43% with oxybutynin; RR 0.29, 95% CI 0.09 to 0.94; n = 45; Analysis 3.2) | |
| Comparison 4. Traditional suburethral sling operation vs injectables | |
| Maher 2005 compared slings (21) vs injectable Macroplastique (22) in 45 women. Due to the small size of the trial, the data were too few to be reliable Primary outcomes Number of continent (dry) women Short‐term: data from 1 small trial were too few to reliably identify evidence of a difference between traditional sling and injectables in the number of continent women within the first year (OR 2.79, 95% CI 0.48 to 16.33; n = 43; Maher 2005; Analysis 4.1) Medium‐term: Maher 2005 found no evidence of a difference between groups in the number of continent women after the first year (13/13; 100% continent with a traditional sling vs 10/14, 71% with the injectable; OR 11.57, 95% CI 0.56 to 239.74; n = 27; very low‐quality evidence; Analysis 4.2;summary of findings Table 4) Number of women who have repeat continence surgery We found no evidence of a difference between groups in the numbers of women having repeat surgery for urinary incontinence (1 after traditional sling vs 2 after injectable: RR 0.52, 95% CI 0.05 to 5.36; n = 43; very low‐quality evidence; Maher 2005; Analysis 4.3;summary of findings Table 4) Secondary outcomes Number of women cured at 1 year or later (women's observations) The trial was too small to reliably identify evidence of a difference between groups in the number of women cured after the first year (OR 11.57, 95% CI 0.56 to 239.74; n = 27; Analysis 4.4) Number of women improved Not reported Number of women satisfied Data from Maher 2005 were too few to identify a difference between groups in satisfaction rates at 6 months (P = 0.41) or at 5 years (RR 2.42, 95% CI 0.98 to 5.98; n = 27; Analysis 4.5) Quantification of symptoms Not reported Clinician's observations Data suggest there were more women with incontinence (clinician‐observed) within the first year with injectables compared with the traditional sling: 4/21 vs 20/22 (RR 0.21, 95% 0.09 to 0.21; n = 43; Maher 2005; Analysis 4.6) Surgical outcome measures Injectables were quicker to perform, involved shorter hospital stay and time to catheter removal, and led to quicker return to normal activity than after traditional sling surgery, but the data were not suitable for meta‐analysis (Maher 2005) Further treatment Not reported Adverse events Perioperative surgical complications Not reported Bladder perforation Not reported Urinary tract infection Maher 2005 reported no evidence of a difference between traditional slings and injectables in the numbers of women with urinary tract infection (RR 1.57, 95% CI 0.29 to 8.49; very low‐quality evidence; Analysis 4.7;summary of findings Table 4) Urinary urgency symptoms, urgency urinary incontinence Not reported Detrusor overactivity (urodynamic overactivity) Maher 2005 reported no evidence of a difference between traditional slings and injectables in the numbers of women with de novo detrusor overactivity (RR 3.14, 95% CI 0.13 to 72.96; Analysis 4.8) Voiding dysfunction (with or without urodynamic confirmation) Maher 2005 reported no evidence of a difference between traditional slings and injectables in the numbers of women with voiding dysfunction (RR 4.19, 95% CI 0.51 to 34.50; Analysis 4.9) Long‐term adverse effects Not reported Quality of life Maher 2005 reported a significant reduction in Incontinence Impact Questionnaire (IIQ) scores compared with baseline (P < 0.01) in both groups, although he provided no data | |
| Comparison 6. Traditional suburethral sling operation vs bladder neck needle suspension (abdominal and vaginal) | |
| Only 1 trial compared porcine dermis sling vs Stamey needle suspension (Hilton 1989). This was a small trial with only 10 women in each arm. The women were unsuitable for abdominal colposuspension (the study author's preferred procedure) because they had vaginal narrowing secondary to previous interventions or atrophic vaginitis. Thus they constitute a population of women with SUI who are not typical of the majority. All women had urodynamic stress incontinence. Groups were comparable for age, parity, previous interventions, and hormonal status. Follow‐up was reported at 3 months and 24 months. Due to the small size of the trial, the data were too few to be reliable Primary outcomes Number of continent (dry) women Short‐term: within the first year after surgery, 1 small trial reported 9/10 and 8/10 continent women in the traditional sling and needle suspension groups, respectively (OR 2.25, 95% CI 0.17 to 29.77; n = 20; Hilton 1989; Analysis 6.1) Medium‐term: very low‐quality evidence from 1 trial comparing slings vs bladder neck needle suspension suggested no evidence of a difference between groups in the likelihood of being continent at 2 years after surgery (OR 3.86, 95% CI 0.33 to 45.57; n = 20; Hilton 1989; Analysis 6.2;summary of findings Table 6) Long‐term: not reported Number of women who have repeat continence surgery Not reported Secondary outcomes Women's observations Number of women cured at 1 year or later (women's observations) Evidence from 1 small trial comparing slings vs bladder neck needle suspension suggests no difference between groups in cure rates at 2 years after surgery (OR 3.86, 95% CI 0.33 to 45.57; n = 20; Hilton 1989) Quantification of symptoms Pad test at 12 months and 24 months stated but not reported (Hilton 1989) Clinician's observations Not reported Surgical outcome measures Duration of operation Not reported Length of hospital stay Sling group needed an indwelling catheter for longer and more adjuvant therapy, resulting in a longer stay in hospital than those with bladder neck needle suspension (MD 13 days longer, 95% CI 5 to 21; n = 20; Hilton 1989; Analysis 6.4) Time to return to normal activity level Not reported Blood loss Not reported Further treatment Not reported Adverse events Perioperative surgical complications Nine of the 10 women who had sling operations had complications, compared with 2/10 who had needle suspension. These included pyrexia, blood loss, wound infection, and pulmonary embolus (RR 4.50, 95% CI 1.28 to 15.81; n = 20; very low‐quality evidence; Hilton 1989; Analysis 6.5;summary of findings Table 6) Bladder perforation Not reported Urinary tract infection Not reported Urinary urgency symptoms, urgency urinary incontinence At 3 months: sling: 5/10, needle suspension: 3/10 (Hilton 1989; Analysis 6.6) Detrusor overactivity (urodynamic overactivity) At 3 months: sling: 2/10, needle suspension: 1/10 (Hilton 1989; Analysis 6.7) Voiding dysfunction (with or without urodynamic confirmation) At 3 months: sling: 4/10, needle suspension: 2/10 (Hilton 1989; Analysis 6.8) Long‐term adverse effects Not reported Quality of life Not reported | |
| Comparison 10. Traditional suburethral sling operation vs a single‐incision sling (mini‐sling) | |
| One small trial compared a rectus fascia pubovaginal traditional sling vs a single‐incision sling (mini‐sling; Ophira) and included women with urodynamically diagnosed stress urinary incontinence (USI) (Sharifiaghdas 2015) Due to the small size of the trial, the data were too few to be reliable Primary outcomes Number of continent (dry) women Short‐term: not reported Medium‐term: exactly the same proportion of women were continent at 1 year after surgery (traditional sling: 31/35; mini‐sling: 31/35; very low‐quality evidence; Sharifiaghdas 2015; Analysis 10.1;summary of findings Table 10) Long‐term: not reported Number of women who have repeat continence surgery Not reported Secondary outcomes Women's observations Cure For self‐report of cure at 1 year after surgery, exactly the same proportion of women were cured (traditional sling: 31/35; mini‐sling: 31/35; Sharifiaghdas 2015; Analysis 10.2) Number of women improved Not reported Number of women satisfied 10/35 women in the traditional sling group and 7/35 in the mini‐sling group reported that they were satisfied with their treatment at 1 year (RR 0.89, 95% CI 0.68 to 1.17; n = 70; Sharifiaghdas 2015; Analysis 10.3) Quantification of symptoms Not reported Clinician's observations The clinician's report of observed stress incontinence concurred with that reported by women ‐ 4 in each group (RR 1.00, 95% CI 0.27 to 3.69; n = 70; Sharifiaghdas 2015) Surgical outcome measures Not reported Further treatment Not reported Adverse effects Perioperative complications Not reported Bladder perforation One woman (of 35) had a bladder perforation in the traditional sling group compared with none (of 35) in the mini‐sling group (very low‐quality evidence; Sharifiaghdas 2008; Analysis 10.5;summary of findings Table 10) Urinary tract infection Not reported Urinary urgency symptoms, urgency urinary incontinence More women in the traditional sling group reported urinary urgency incontinence (5/35) compared with the mini‐sling group (1/35) (RR 5.00, 95% CI 0.62 to 40.64; n = 70; Sharifiaghdas 2015; Analysis 10.6) Detrusor overactivity (urodynamic overactivity) Not reported Voiding dysfunction (with or without urodynamic confirmation) Not reported Long‐term adverse effects Dyspareunia: 3/35 and 4/35 in traditional sling and mini‐sling groups, respectively, reported pain with intercourse (RR 0.75, 95% CI 0.18 to 3.11; n = 70; Sharifiaghdas 2008; Analysis 10.7) Tape or mesh exposure: 1 woman in the traditional sling group and 2 in the mini‐sling group were found to have tape or mesh exposure (RR 0.50, 95% CI 0.05 to 5.27; n = 70; Sharifiaghdas 2008; Analysis 10.8) Quality of life Based on mean IIQ score, quality of life was lower in the traditional sling group compared with the mini‐sling group (MD 7.50, 95% CI 2.23 to 12.77; very low‐quality evidence; Analysis 10.9;summary of findings Table 10) | |
| USI: urodynamically diagnosed stress urinary incontinence VLPP: Valsalva leak point pressure | |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1 Number of continent women within 1 year (any definition) Show forest plot | 1 | Odds Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 1.1 urodynamic stress incontinence (only) | 0 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 1.2 stress urinary incontinence (symptoms only) | 0 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 1.3 mixed incontinence | 1 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 2 Urge urinary symptoms, urgency urinary incontinence Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 2.1 urodynamic stress incontinence (only) | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 2.2 stress urinary incontinence (symptoms only) | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 2.3 mixed incontinence | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1 Number of continent women within 1 year (any definition) Show forest plot | 1 | Odds Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 1.1 urodynamic stress incontinence (only) | 1 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 1.2 stress urinary incontinence (symptoms only) | 0 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 1.3 mixed urinary incontinence | 0 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 2 Number of continent women at 1 to 5 years (any definition) Show forest plot | 1 | Odds Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 2.1 urodynamic stress incontinence (only) | 1 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 2.2 stress urinary incontinence (symptoms only) | 0 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 2.3 mixed urinary incontinence | 0 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 3 Repeat surgery for urinary incontinence Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 3.1 urodynamic stress incontinence (only) | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 3.2 stress urinary incontinence (symptoms only) | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 3.3 mixed urinary incontinence | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 4 Number of women cured after first year (women's observations) Show forest plot | 1 | Odds Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 4.1 urodynamic stress incontinence (only) | 1 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 4.2 stress urinary incontinence (symptoms only) | 0 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 4.3 mixed urinary incontinence | 0 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 5 Number of women satisfied (women's observations) Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 5.1 urodynamic stress incontinence (only) | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 5.2 stress urinary incontinence (symptoms only) | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 5.3 mixed incontinence | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 6 Number of women with urinary incontinence within first year (clinician's observations) Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 6.1 urodynamic stress incontinence (only) | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 6.2 stress urinary incontinence (symptoms only) | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 6.3 mixed urinary incontinence | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 7 Urinary tract infection Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 7.1 urodynamic stress incontinence (only) | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 7.2 stress urinary incontinence (symptoms only) | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 7.3 mixed urinary incontinence | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 8 De novo detrusor overactivity (urodynamic diagnosis) Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 8.1 urodynamic stress incontinence (only) | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 8.2 stress urinary incontinence (symptoms only) | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 8.3 mixed urinary incontinence | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 9 Voiding dysfunction Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 9.1 urodynamic stress incontinence (only) | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 9.2 stress urinary incontinence (symptoms only) | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 9.3 mixed urinary incontinence | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1 Number of continent women within 1 year (any definition) Show forest plot | 1 | Odds Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 1.1 urodynamic stress incontinence (only) | 1 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 1.2 stress urinary incontinence (symptoms only) | 0 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 1.3 mixed incontinence | 0 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 2 Number of continent women at 1 to 5 years (any definition) Show forest plot | 1 | Odds Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 2.1 urodynamic stress incontinence (only) | 1 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 2.2 stress urinary incontinence (symptoms only) | 0 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 2.3 mixed incontinence | 0 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 3 CURE: number of women cured after first year (women's observations) Show forest plot | 1 | Odds Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 3.1 urodynamic stress incontinence (only) | 1 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 3.2 stress urinary incontinence (symptoms only) | 0 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 3.3 mixed incontinence | 0 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 4 Length of hospital stay (hours) Show forest plot | 1 | Mean Difference (IV, Fixed, 95% CI) | Totals not selected | |
| 4.1 urodynamic stress incontinence (only) | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 4.2 stress urinary incontinence (symptoms only) | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 4.3 mixed incontinence | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 5 Perioperative surgical complications Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 5.1 urodynamic stress incontinence (only) | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 5.2 stress urinary incontinence (symptoms only) | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 5.3 mixed incontinence | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 6 Urinary urgency symptoms, urgency urinary incontinence Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 6.1 urodynamic stress incontinence (only) | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 6.2 stress urinary incontinence (symptoms only) | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 6.3 mixed incontinence | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 7 Detrusor overactivity (urodynamic diagnosis) Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 7.1 urodynamic stress incontinence (only) | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 7.2 stress urinary incontinence (symptoms only) | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 7.3 mixed incontinence | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 8 Voiding dysfunction after 3 months Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 8.1 urodynamic stress incontinence (only) | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 8.2 stress urinary incontinence (symptoms only) | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 8.3 mixed incontinence | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1 Number of continent women within 1 year (any definition) Show forest plot | 4 | 147 | Odds Ratio (M‐H, Fixed, 95% CI) | 2.70 [0.69, 10.55] |
| 1.1 urodynamic stress incontinence (only) | 4 | 147 | Odds Ratio (M‐H, Fixed, 95% CI) | 2.70 [0.69, 10.55] |
| 1.2 stress urinary incontinence (symptoms only) | 0 | 0 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 1.3 mixed incontinence | 0 | 0 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 2 Number of continent women at 1 to 5 years (any definition) Show forest plot | 4 | 687 | Odds Ratio (M‐H, Fixed, 95% CI) | 1.70 [1.22, 2.37] |
| 2.1 urodynamic stress incontinence (only) | 3 | 167 | Odds Ratio (M‐H, Fixed, 95% CI) | 1.84 [0.65, 5.24] |
| 2.2 stress urinary incontinence (symptoms only) | 1 | 520 | Odds Ratio (M‐H, Fixed, 95% CI) | 1.69 [1.19, 2.39] |
| 2.3 mixed incontinence | 0 | 0 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 3 Number of continent women after 5 years (any definition) Show forest plot | 2 | 481 | Odds Ratio (M‐H, Fixed, 95% CI) | 1.55 [1.06, 2.27] |
| 3.1 urodynamic stress incontinence (only) | 1 | 28 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.39 [0.03, 4.92] |
| 3.2 stress urinary incontinence (symptoms only) | 1 | 453 | Odds Ratio (M‐H, Fixed, 95% CI) | 1.61 [1.09, 2.37] |
| 3.3 mixed incontinence | 0 | 0 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 4 Repeat surgery for urinary incontinence Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 4.1 urodynamic stress incontinence (only) | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 4.2 stress urinary incontinence (symptoms only) | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 4.3 mixed incontinence | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 5 Number of women cured after first year (women's observations) Show forest plot | 3 | 515 | Odds Ratio (M‐H, Fixed, 95% CI) | 1.56 [1.07, 2.28] |
| 5.1 urodynamic stress incontinence (only) | 2 | 62 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.93 [0.18, 4.89] |
| 5.2 stress urinary incontinence (symptoms only) | 1 | 453 | Odds Ratio (M‐H, Fixed, 95% CI) | 1.61 [1.09, 2.37] |
| 5.3 mixed incontinence | 0 | 0 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 6 Number of women satisfied (women's observations) Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 6.1 urodynamic stress incontinence (only) | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 6.2 stress urinary incontinence (symptoms only) | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 6.3 mixed incontinence | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 7 Number of women with urinary incontinence within first year (clinician's observations) | 0 | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 7.1 urodynamic stress incontinence (only) | 0 | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 7.2 stress urinary incontinence (symptoms only) | 0 | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 7.3 mixed incontinence | 0 | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 8 Number of women with urinary incontinence at 1 to 5 years (clinician's observations) Show forest plot | 3 | 626 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.88 [0.59, 1.31] |
| 8.1 urodynamic stress incontinence (only) | 2 | 106 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.54 [0.16, 1.86] |
| 8.2 stress urinary incontinence (symptoms only) | 1 | 520 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.94 [0.62, 1.42] |
| 8.3 mixed incontinence | 0 | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 9 Number of women with urinary incontinence after 5 years (clinician's observations) Show forest plot | 2 | 461 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.90 [0.80, 1.01] |
| 9.1 urodynamic stress incontinence (only) | 1 | 28 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.23 [0.01, 4.37] |
| 9.2 stress urinary incontinence (symptoms only) | 1 | 433 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.91 [0.81, 1.02] |
| 9.3 mixed incontinence | 0 | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 10 Duration of operation (minutes) Show forest plot | 1 | Mean Difference (IV, Fixed, 95% CI) | Totals not selected | |
| 10.1 urodynamic stress incontinence (only) | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 10.2 stress urinary incontinence (symptoms only) | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 10.3 mixed incontinence | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 11 Length of hospital stay (days) Show forest plot | 3 | 137 | Mean Difference (IV, Fixed, 95% CI) | 2.03 [1.47, 2.59] |
| 11.1 urodynamic stress incontinence (only) | 3 | 137 | Mean Difference (IV, Fixed, 95% CI) | 2.03 [1.47, 2.59] |
| 11.2 stress urinary incontinence (symptoms only) | 0 | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 11.3 mixed incontinence | 0 | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 12 Time to catheter removal (days) Show forest plot | 2 | 108 | Mean Difference (IV, Fixed, 95% CI) | 8.01 [6.84, 9.18] |
| 12.1 urodynamic stress incontinence (only) | 2 | 108 | Mean Difference (IV, Fixed, 95% CI) | 8.01 [6.84, 9.18] |
| 12.2 stress urinary incontinence (symptoms only) | 0 | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 12.3 mixed incontinence | 0 | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 13 Time to return to normal activity level | 0 | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 13.1 urodynamic stress incontinence (only) | 0 | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 13.2 stress urinary incontinence (symptoms only) | 0 | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 13.3 mixed incontinence | 0 | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 14 Number of women requiring treatment for pelvic organ prolapse Show forest plot | 3 | 559 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.20 [0.05, 0.77] |
| 14.1 urodynamic stress incontinence (only) | 2 | 106 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.2 [0.04, 1.11] |
| 14.2 stress urinary incontinence (symptoms only) | 1 | 453 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.20 [0.02, 1.74] |
| 14.3 mixed incontinence | 0 | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 15 Perioperative surgical complications Show forest plot | 4 | 792 | Risk Ratio (M‐H, Fixed, 95% CI) | 1.24 [0.83, 1.86] |
| 15.1 urodynamic stress incontinence (only) | 3 | 137 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.85 [0.28, 2.52] |
| 15.2 stress urinary incontinence (symptoms only) | 1 | 655 | Risk Ratio (M‐H, Fixed, 95% CI) | 1.32 [0.86, 2.04] |
| 15.3 mixed incontinence | 0 | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 16 Bladder perforation Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 16.1 urodynamic stress incontinence (only) | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 16.2 stress urinary incontinence (symptoms only) | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 16.3 mixed incontinence | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 17 Urinary tract infection Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 17.1 urodynamic stress incontinence (only) | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 17.2 stress urinary incontinence (symptoms only) | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 17.3 mixed incontinence | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 18 Number of women with recurrent UTIs at > 5 years Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 18.1 urodynamic stress incontinence (only) | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 18.2 stress urinary incontinence (symptoms only) | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 18.3 mixed incontinence | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 19 Urinary urgency symptoms, urgency urinary incontinence Show forest plot | 2 | 525 | Risk Ratio (M‐H, Fixed, 95% CI) | 1.10 [0.74, 1.64] |
| 19.1 urodynamic stress incontinence (only) | 1 | 72 | Risk Ratio (M‐H, Fixed, 95% CI) | 2.0 [0.54, 7.39] |
| 19.2 stress urinary incontinence (symptoms only) | 1 | 453 | Risk Ratio (M‐H, Fixed, 95% CI) | 1.02 [0.67, 1.56] |
| 19.3 mixed incontinence | 0 | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 20 Detrusor overactivity (urodynamic diagnosis) Show forest plot | 4 | 203 | Risk Ratio (M‐H, Fixed, 95% CI) | 1.42 [0.52, 3.87] |
| 20.1 urodynamic stress incontinence (only) | 4 | 203 | Risk Ratio (M‐H, Fixed, 95% CI) | 1.42 [0.52, 3.87] |
| 20.2 stress urinary incontinence (symptoms only) | 0 | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 20.3 mixed incontinence | 0 | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 21 Voiding dysfunction after 3 months Show forest plot | 5 | 853 | Risk Ratio (M‐H, Fixed, 95% CI) | 6.08 [3.10, 11.95] |
| 21.1 urodynamic stress incontinence (only) | 4 | 198 | Risk Ratio (M‐H, Fixed, 95% CI) | 4.48 [1.16, 17.36] |
| 21.2 stress urinary incontinence (symptoms only) | 1 | 655 | Risk Ratio (M‐H, Fixed, 95% CI) | 6.63 [3.04, 14.47] |
| 21.3 mixed incontinence | 0 | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 22 Long‐term voiding dysfunction > 5 years Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 22.1 urodynamic stress incontinence (only) | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 22.2 stress urinary incontinence (symptoms only) | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 22.3 mixed incontinence | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 23 Condition‐specific measures to assess quality of life Show forest plot | 1 | Mean Difference (IV, Fixed, 95% CI) | Totals not selected | |
| 23.1 Urinary Distress Index (UDI) | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 23.2 Incontinence Impact Questionnaire (IIQ) | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1 Number of continent women within 1 year (any definition) Show forest plot | 11 | 841 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.94 [0.67, 1.32] |
| 1.1 urodynamic stress incontinence (only) | 5 | 427 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.97 [0.60, 1.56] |
| 1.2 stress urinary incontinence (symptoms only) | 1 | 53 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.88 [0.12, 6.79] |
| 1.3 mixed urinary incontinence | 5 | 361 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.91 [0.55, 1.51] |
| 2 Number of continent women at 1 to 5 years (any definition) Show forest plot | 6 | 458 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.67 [0.44, 1.02] |
| 2.1 urodynamic stress incontinence (only) | 4 | 364 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.77 [0.47, 1.25] |
| 2.2 stress urinary incontinence (symptoms only) | 0 | 0 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 2.3 mixed urinary incontinence | 2 | 94 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.42 [0.17, 1.04] |
| 3 Number of continent women after 5 years (any definition) Show forest plot | 1 | Odds Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 3.1 urodynamic stress incontinence (only) | 1 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 3.2 stress urinary incontinence (symptoms only) | 0 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 3.3 mixed urinary incontinence | 0 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 4 Repeat surgery for urinary incontinence Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 4.1 urodynamic stress incontinence (only) | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 4.2 stress urinary incontinence (symptoms only) | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 4.3 mixed incontinence | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 5 Number of women cured after first year (women's observations) Show forest plot | 4 | 337 | Odds Ratio (M‐H, Fixed, 95% CI) | 1.06 [0.65, 1.72] |
| 5.1 urodynamic stress incontinence (only) | 3 | 293 | Odds Ratio (M‐H, Fixed, 95% CI) | 1.21 [0.72, 2.03] |
| 5.2 stress urinary incontinence (symptoms only) | 0 | 0 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 5.3 mixed urinary incontinence | 1 | 44 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.42 [0.10, 1.72] |
| 6 Number of women improved or cured within 1 year (women's observations) Show forest plot | 3 | 425 | Odds Ratio (M‐H, Fixed, 95% CI) | 1.33 [0.74, 2.39] |
| 6.1 urodynamic stress incontinence (only) | 2 | 286 | Odds Ratio (M‐H, Fixed, 95% CI) | 1.06 [0.43, 2.64] |
| 6.2 stress urinary incontinence (symptoms only) | 0 | 0 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 6.3 mixed urinary incontinence | 1 | 139 | Odds Ratio (M‐H, Fixed, 95% CI) | 1.56 [0.72, 3.39] |
| 7 Number of women improved or cured at 1 to 5 years (women's observations) Show forest plot | 2 | 264 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.76 [0.31, 1.87] |
| 7.1 urodynamic stress incontinence (only) | 2 | 264 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.76 [0.31, 1.87] |
| 7.2 stress urinary incontinence (symptoms only) | 0 | 0 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 7.3 mixed urinary incontinence | 0 | 0 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 8 Number of women improved or cured after 5 years (women's observations) Show forest plot | 1 | Odds Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 8.1 urodynamic stress incontinence (only) | 1 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 8.2 stress urinary incontinence (symptoms only) | 0 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 8.3 mixed urinary incontinence | 0 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 9 Number of women satisfied (women's observations) Show forest plot | 2 | Risk Ratio (M‐H, Fixed, 95% CI) | Subtotals only | |
| 9.1 urodynamic stress incontinence (only) | 2 | 163 | Risk Ratio (M‐H, Fixed, 95% CI) | 1.09 [0.89, 1.33] |
| 9.2 stress urinary incontinence (symptoms only) | 0 | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 9.3 mixed urinary incontinence | 0 | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 10 Pad test of quantified leakage (mean weight of urine lost) Show forest plot | 1 | Mean Difference (IV, Fixed, 95% CI) | Totals not selected | |
| 10.1 urodynamic stress incontinence (only) | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 10.2 stress urinary incontinence (symptoms only) | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 10.3 mixed urinary incontinence | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 11 Number of women with urinary incontinence within first year (clinician's observations) Show forest plot | 2 | 105 | Risk Ratio (M‐H, Fixed, 95% CI) | 1.29 [0.45, 3.71] |
| 11.1 urodynamic stress incontinence (only) | 0 | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 11.2 stress urinary incontinence (symptoms only) | 0 | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 11.3 mixed urinary incontinence | 2 | 105 | Risk Ratio (M‐H, Fixed, 95% CI) | 1.29 [0.45, 3.71] |
| 12 Number of women with urinary incontinence at 1 to 5 years (any definition) (clinician's observations) Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 12.1 urodynamic stress incontinence (only) | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 12.2 stress urinary incontinence (symptoms only) | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 12.3 mixed urinary incontinence | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 13 Duration of operation (minutes) Show forest plot | 7 | 355 | Mean Difference (IV, Fixed, 95% CI) | 57.08 [54.67, 59.49] |
| 13.1 urodynamic stress incontinence (only) | 2 | 61 | Mean Difference (IV, Fixed, 95% CI) | 46.91 [42.31, 51.52] |
| 13.2 stress urinary incontinence (symptoms only) | 1 | 53 | Mean Difference (IV, Fixed, 95% CI) | 20.0 [7.08, 32.92] |
| 13.3 mixed urinary incontinence | 4 | 241 | Mean Difference (IV, Fixed, 95% CI) | 62.96 [60.07, 65.86] |
| 14 Length of hospital stay (days) Show forest plot | 4 | 194 | Mean Difference (IV, Fixed, 95% CI) | 0.74 [0.55, 0.93] |
| 14.1 urodynamic stress incontinence (only) | 1 | 20 | Mean Difference (IV, Fixed, 95% CI) | 0.65 [0.39, 0.91] |
| 14.2 stress urinary incontinence (symptoms only) | 0 | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 14.3 mixed urinary incontinence | 3 | 174 | Mean Difference (IV, Fixed, 95% CI) | 0.83 [0.56, 1.10] |
| 15 Time to catheter removal (days) Show forest plot | 2 | 113 | Mean Difference (IV, Fixed, 95% CI) | 0.11 [‐0.07, 0.30] |
| 15.1 urodynamic stress incontinence (only) | 0 | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 15.2 stress urinary incontinence (symptoms only) | 1 | 53 | Mean Difference (IV, Fixed, 95% CI) | 2.3 [0.01, 4.59] |
| 15.3 mixed urinary incontinence | 1 | 60 | Mean Difference (IV, Fixed, 95% CI) | 0.10 [‐0.09, 0.29] |
| 16 Perioperative surgical complications Show forest plot | 4 | 293 | Risk Ratio (M‐H, Fixed, 95% CI) | 1.74 [1.16, 2.60] |
| 16.1 urodynamic stress incontinence (only) | 2 | 183 | Risk Ratio (M‐H, Fixed, 95% CI) | 1.73 [1.01, 2.96] |
| 16.2 stress urinary incontinence (symptoms only) | 0 | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 16.3 mixed urinary incontinence | 2 | 110 | Risk Ratio (M‐H, Fixed, 95% CI) | 1.74 [0.94, 3.21] |
| 17 Bladder perforations Show forest plot | 10 | 844 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.59 [0.34, 1.01] |
| 17.1 urodynamic stress incontinence (only) | 3 | 334 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.74 [0.19, 2.86] |
| 17.2 stress urinary incontinence (symptoms only) | 1 | 53 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.56 [0.05, 5.81] |
| 17.3 mixed urinary incontinence | 6 | 457 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.56 [0.30, 1.03] |
| 18 Urethral injury Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 18.1 urodynamic stress incontinence (only) | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 18.2 stress urinary incontinence (symptoms only) | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 18.3 mixed urinary incontinence | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 19 Vaginal bleeding Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 19.1 urodynamic stress incontinence (only) | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 19.2 stress urinary incontinence (symptoms only) | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 19.3 mixed urinary incontinence | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 20 Urinary tract infection Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 20.1 urodynamic stress incontinence (only) | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 20.2 stress urinary incontinence (symptoms only) | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 20.3 mixed urinary incontinence | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 21 Voiding dysfunction Show forest plot | 8 | 629 | Risk Ratio (M‐H, Fixed, 95% CI) | 1.34 [0.85, 2.12] |
| 21.1 urodynamic stress incontinence (only) | 3 | 325 | Risk Ratio (M‐H, Fixed, 95% CI) | 1.22 [0.60, 2.46] |
| 21.2 stress urinary incontinence (symptoms only) | 1 | 53 | Risk Ratio (M‐H, Fixed, 95% CI) | 2.61 [0.76, 9.03] |
| 21.3 mixed urinary incontinence | 4 | 251 | Risk Ratio (M‐H, Fixed, 95% CI) | 1.18 [0.58, 2.40] |
| 22 Urinary urgency symptoms, urgency urinary incontinence Show forest plot | 4 | 295 | Risk Ratio (M‐H, Fixed, 95% CI) | 1.50 [0.58, 3.88] |
| 22.1 urodynamic stress incontinence (only) | 1 | 124 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.34 [0.01, 8.29] |
| 22.2 stress urinary incontinence (symptoms only) | 0 | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 22.3 mixed urinary incontinence | 3 | 171 | Risk Ratio (M‐H, Fixed, 95% CI) | 1.81 [0.65, 5.06] |
| 23 De novo detrusor overactivity (urodynamic diagnosis) Show forest plot | 4 | 325 | Risk Ratio (M‐H, Fixed, 95% CI) | 2.61 [1.17, 5.84] |
| 23.1 urodynamic stress incontinence (only) | 1 | 59 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 23.2 stress urinary incontinence (symptoms only) | 1 | 47 | Risk Ratio (M‐H, Fixed, 95% CI) | 3.13 [0.13, 73.01] |
| 23.3 mixed urinary incontinence | 2 | 219 | Risk Ratio (M‐H, Fixed, 95% CI) | 2.57 [1.12, 5.92] |
| 24 Long‐term adverse effects (release of sling required) Show forest plot | 3 | 326 | Risk Ratio (M‐H, Fixed, 95% CI) | 2.53 [0.87, 7.35] |
| 24.1 urodynamic stress incontinence (only) | 2 | 266 | Risk Ratio (M‐H, Fixed, 95% CI) | 1.68 [0.50, 5.66] |
| 24.2 stress urinary incontinence (symptoms only) | 0 | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 24.3 mixed urinary incontinence | 1 | 60 | Risk Ratio (M‐H, Fixed, 95% CI) | 9.6 [0.54, 170.84] |
| 25 Long‐term adverse effects (wound pain at 6 months) Show forest plot | 3 | 257 | Risk Ratio (M‐H, Fixed, 95% CI) | 6.40 [1.94, 21.12] |
| 25.1 urodynamic stress incontinence (only) | 1 | 124 | Risk Ratio (M‐H, Fixed, 95% CI) | 5.16 [0.25, 105.36] |
| 25.2 stress urinary incontinence (symptoms only) | 1 | 53 | Risk Ratio (M‐H, Fixed, 95% CI) | 3.92 [0.90, 17.15] |
| 25.3 mixed urinary incontinence | 1 | 80 | Risk Ratio (M‐H, Fixed, 95% CI) | 17.0 [1.01, 284.96] |
| 26 Long‐term adverse effects (vaginal mesh or graft exposure) Show forest plot | 5 | 348 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.28 [0.05, 1.65] |
| 26.1 urodynamic stress incontinence (only) | 2 | 165 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.35 [0.04, 3.24] |
| 26.2 stress urinary incontinence (symptoms only) | 1 | 53 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 26.3 mixed urinary incontinence | 2 | 130 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.2 [0.01, 3.97] |
| 27 Condition‐specific measures to assess quality of life: UDI‐6 Show forest plot | 1 | 63 | Mean Difference (IV, Fixed, 95% CI) | 7.30 [‐2.00, 16.60] |
| 27.1 urodynamic stress incontinence (only) | 0 | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 27.2 stress urinary incontinence (symptoms only) | 1 | 63 | Mean Difference (IV, Fixed, 95% CI) | 7.30 [‐2.00, 16.60] |
| 27.3 mixed urinary incontinence | 0 | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 28 Condition‐specific measures to assess quality of life: IIQ‐7 Show forest plot | 1 | 63 | Mean Difference (IV, Fixed, 95% CI) | 0.60 [‐10.17, 11.37] |
| 28.1 urodynamic stress incontinence (only) | 0 | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 28.2 stress urinary incontinence (symptoms only) | 1 | 63 | Mean Difference (IV, Fixed, 95% CI) | 0.60 [‐10.17, 11.37] |
| 28.3 mixed urinary incontinence | 0 | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1 Number of continent women at 1 to 5 years (any definition) Show forest plot | 1 | Odds Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 1.1 urodynamic stress incontinence (only) | 1 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 1.2 stress urinary incontinence (symptoms only) | 0 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 1.3 mixed incontinence | 0 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 2 Number of women cured after first year (women's observations) Show forest plot | 1 | Odds Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 2.1 urodynamic stress incontinence (only) | 1 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 2.2 stress urinary incontinence (symptoms only) | 0 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 2.3 mixed incontinence | 0 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 3 Number of women satisfied (women's observations) Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 3.1 urodynamic stress incontinence (only) | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 3.2 stress urinary incontinence (symptoms only) | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 3.3 mixed incontinence | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 4 Number of women with urinary incontinence (clinician's observations) within first year Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 4.1 urodynamic stress incontinence (only) | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 4.2 stress urinary incontinence (symptoms only) | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 4.3 mixed incontinence | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 5 Bladder perforation Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 5.1 urodynamic stress incontinence (only) | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 5.2 stress urinary incontinence (symptoms only) | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 5.3 mixed incontinence | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 6 Urinary urgency symptoms, urgency urinary incontinence Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 6.1 urodynamic stress incontinence (only) | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 6.2 stress urinary incontinence (symptoms only) | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 6.3 mixed incontinence | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 7 Pain with intercourse (dyspareunia) Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 7.1 urodynamic stress incontinence (only) | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 7.2 stress urinary incontinence (symptoms only) | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 7.3 mixed incontinence | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 8 Long‐term adverse effects (vaginal mesh or graft exposure) Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 8.1 urodynamic stress incontinence (only) | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 8.2 stress urinary incontinence (symptoms only) | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 8.3 mixed incontinence | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 9 Condition‐specific measures to assess quality of life: IIQ score Show forest plot | 1 | Mean Difference (IV, Fixed, 95% CI) | Totals not selected | |
| 9.1 urodynamic stress incontinence (only) | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 9.2 stress urinary incontinence (symptoms only) | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 9.3 mixed urinary incontinence | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1 Number of continent women within 1 year (any definition) Show forest plot | 5 | Odds Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 1.1 fascial sling vs Pelvicol sling | 1 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 1.2 standard sling vs short sling | 1 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 1.3 autologous fascial sling vs Fortaperm sling | 1 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 1.4 Vypro vs Ultrapro | 1 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 1.5 Vypro vs Prolene light | 1 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 1.6 Ultrapro vs Prolene light | 1 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 1.7 fascial sling vs vaginal wall sling | 1 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 2 Number of continent women at 1 to 5 years (any definition) Show forest plot | 7 | Odds Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 2.1 fascial sling vs Pelvicol sling | 1 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 2.2 standard sling vs short sling | 1 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 2.3 autologous dermal graft patch vs cadaveric fascia lata | 1 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 2.4 rectus fascia sling vs Goretex sling | 1 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 2.5 Vypro vs Ultrapro | 1 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 2.6 Vypro vs Prolene light | 1 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 2.7 Ultrapro vs Prolene light | 1 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 2.8 anterior vaginal wall sling vs biosynthetic mesh sling | 1 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 2.9 anterior rectus sheath sling vs Prolene strip | 1 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 2.10 anterior rectus sheath sling vs anterior vaginal wall patch | 1 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 2.11 Prolene strip vs anterior vaginal wall patch | 1 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 3 Number of continent women after 5 years (any definition) Show forest plot | 1 | Odds Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 3.1 standard sling vs short sling | 1 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 4 Repeat surgery for urinary incontinence Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 4.1 fascial sling vs Pelvicol sling | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 5 Number of women cured after first year (women's observations) Show forest plot | 3 | Odds Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 5.1 fascial sling vs Pelvicol sling | 1 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 5.2 standard sling vs short sling | 1 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 5.3 autologous dermal graft patch vs cadaveric fascia lata | 1 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 6 Number of women improved or cured within first year (women's observations) Show forest plot | 3 | Odds Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 6.1 fascial sling vs Pelvicol sling | 1 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 6.2 autologous fascial sling vs Fortaperm sling | 1 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 6.3 rectus fascia sling vs Goretex sling | 1 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 7 Number of women improved or cured at 1 to 5 years (women's observations) Show forest plot | 4 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 7.1 fascial sling vs Pelvicol sling | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 7.2 autologous dermal graft patch vs cadaveric fascia lata | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 7.3 rectus fascia sling vs Goretex sling | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 7.4 anterior rectus sheath sling vs Prolene strip | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 7.5 anterior rectus sheath sling vs anterior vaginal wall patch | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 7.6 Prolene strip vs anterior vaginal wall patch | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 8 Number of women satisfied (women's observations) Show forest plot | 3 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 8.1 fascial sling vs Pelvicol sling | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 8.2 Vypro vs Ultrapro | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 8.3 Vypro vs Prolene light | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 8.4 Ultrapro vs Prolene light | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 8.5 anterior vaginal wall sling vs biosynthetic mesh sling | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 9 Pad test of quantified leakage (mean weight of urine lost) within 1 year Show forest plot | 2 | Mean Difference (IV, Fixed, 95% CI) | Totals not selected | |
| 9.1 standard sling vs short sling | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 9.2 Vypro vs Ultrapro | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 9.3 Vypro vs Prolene light | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 9.4 Ultrapro vs Prolene light | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 10 Pad test of quantified leakage (mean weight of urine lost) at 1 to 5 years Show forest plot | 1 | Mean Difference (IV, Fixed, 95% CI) | Totals not selected | |
| 10.1 Vypro vs Ultrapro | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 10.2 Vypro vs Prolene light | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 10.3 Ultrapro vs Prolene light | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 11 Duration of operation (minutes) Show forest plot | 2 | Mean Difference (IV, Fixed, 95% CI) | Totals not selected | |
| 11.1 standard sling vs short sling | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 11.2 anterior rectus sheath sling vs Prolene strip | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 11.3 anterior rectus sheath sling vs anterior vaginal wall patch | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 11.4 Prolene strip vs anterior vaginal wall patch | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 12 Blood loss (mL) Show forest plot | 1 | Mean Difference (IV, Fixed, 95% CI) | Totals not selected | |
| 12.1 anterior rectus sheath sling vs Prolene strip | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 12.2 anterior rectus sheath sling vs anterior vaginal wall patch | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 12.3 Prolene strip vs anterior vaginal wall patch | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 13 Length of hospital stay (days) Show forest plot | 1 | Mean Difference (IV, Fixed, 95% CI) | Totals not selected | |
| 13.1 anterior rectus sheath sling vs Prolene strip | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 13.2 anterior rectus sheath sling vs anterior vaginal wall patch | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 13.3 Prolene strip vs anterior vaginal wall patch | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 14 Perioperative surgical complications Show forest plot | 3 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 14.1 standard sling vs short sling | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 14.2 rectus fascia sling vs Goretex sling | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 14.3 fascial sling vs vaginal wall sling | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 15 Bladder perforation Show forest plot | 3 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 15.1 standard sling vs short sling | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 15.2 fascial sling vs Pelvicol sling | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 15.3 anterior rectus sheath sling vs Prolene strip | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 15.4 anterior rectus sheath sling vs anterior vaginal wall patch | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 15.5 Prolene strip vs anterior vaginal wall patch | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 16 Urinary tract infection Show forest plot | 2 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 16.1 standard sling vs short sling | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 16.2 anterior vaginal wall sling vs biosynthetic mesh sling | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 17 Vaginal bleeding Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 17.1 anterior vaginal wall sling vs biosynthetic mesh sling | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 18 Long‐term adverse effects (wound pain) Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 18.1 fascial sling vs Pelvicol sling | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 19 Voiding dysfunction Show forest plot | 6 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 19.1 fascial sling vs Pelvicol sling | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 19.2 standard sling vs short sling | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 19.3 Vypro vs Ultrapro | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 19.4 Vypro vs Prolene light | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 19.5 Ultrapro vs Prolene light | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 19.6 anterior vaginal wall sling vs biosynthetic mesh sling | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 19.7 anterior rectus sheath sling vs Prolene strip | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 19.8 anterior rectus sheath sling vs anterior vaginal wall patch | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 19.9 Prolene strip vs anterior vaginal wall patch | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 19.10 fascial sling vs vaginal wall sling | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 20 Urinary urgency symptoms, urgency urinary incontinence Show forest plot | 3 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 20.1 standard sling vs short sling | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 20.2 Vypro vs Ultrapro | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 20.3 Vypro vs Prolene light | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 20.4 Ultrapro vs Prolene light | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 20.5 rectus fascia sling vs Goretex sling | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 21 Detrusor overactivity (urodynamic overactivity) Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 21.1 autologous dermal graft patch vs cadaveric fascia lata | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 22 Long‐term adverse effects (release of sling required) Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 22.1 fascial sling vs Pelvicol sling | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 23 Long‐term adverse effects (vaginal mesh or graft exposure) Show forest plot | 3 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 23.1 fascial sling vs Pelvicol sling | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 23.2 Vypro vs Ultrapro | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 23.3 Vypro vs Prolene light | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 23.4 Ultrapro vs Prolene light | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 23.5 anterior vaginal wall sling vs biosynthetic mesh sling | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 24 Condition‐specific measures to assess quality of life (ICI‐Q short form UI score at 1 year) Show forest plot | 1 | Mean Difference (IV, Fixed, 95% CI) | Totals not selected | |
| 24.1 Vypro vs Ultrapro | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 24.2 Vypro vs Prolene light | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 24.3 Ultrapro vs Prolene light | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 25 Condition‐specific measures to assess quality of life (ICI‐Q short form UI score at 1 to 5 years) Show forest plot | 1 | Mean Difference (IV, Fixed, 95% CI) | Totals not selected | |
| 25.1 Vypro vs Ultrapro | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 25.2 Vypro vs Prolene light | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 25.3 Ultrapro vs Prolene light | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1 Number of women with urinary incontinence (worse, unchanged, or improved) within first year (women's observations) Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 1.1 urodynamic stress incontinence (only) | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 1.2 stress urinary incontinence (symptoms only) | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 1.3 mixed incontinence | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 2 Urge urinary symptoms, urgency urinary incontinence Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 2.1 urodynamic stress incontinence (only) | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 2.2 stress urinary incontinence (symptoms only) | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 2.3 mixed incontinence | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1 Number of women with urinary incontinence (worse, unchanged, or improved) within first year (women's observations) Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 1.1 urodynamic stress incontinence (only) | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 1.2 stress urinary incontinence (symptoms only) | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 1.3 mixed urinary incontinence | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 2 Number of women with urinary incontinence (worse, unchanged, or improved) after first year (women's observations) Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 2.1 urodynamic stress incontinence (only) | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 2.2 stress urinary incontinence (symptoms only) | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 2.3 mixed urinary incontinence | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 3 Number of women with urinary incontinence (clinician's observations) within first year Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 3.1 urodynamic stress incontinence (only) | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 3.2 stress urinary incontinence (symptoms only) | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 3.3 mixed urinary incontinence | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 4 CURE: number of women cured after first year (women's observations) Show forest plot | 1 | Odds Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 4.1 urodynamic stress incontinence (only) | 1 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 4.2 stress urinary incontinence (symptoms only) | 0 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 4.3 mixed urinary incontinence | 0 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 5 Voiding dysfunction Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 5.1 urodynamic stress incontinence (only) | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 5.2 stress urinary incontinence (symptoms only) | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 5.3 mixed urinary incontinence | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 6 De novo detrusor overactivity (urodynamic diagnosis) Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 6.1 urodynamic stress incontinence (only) | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 6.2 stress urinary incontinence (symptoms only) | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 6.3 mixed urinary incontinence | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 7 Urinary tract infection Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 7.1 urodynamic stress incontinence (only) | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 7.2 stress urinary incontinence (symptoms only) | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 7.3 mixed urinary incontinence | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 8 Repeat surgery for urinary incontinence Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 8.1 urodynamic stress incontinence (only) | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 8.2 stress urinary incontinence (symptoms only) | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 8.3 mixed urinary incontinence | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1 Number with incontinence (worse, unchanged, or improved) within first year (women's observations) Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 1.1 urodynamic stress incontinence (only) | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 1.2 stress urinary incontinence (symptoms only) | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 1.3 mixed incontinence | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 2 Number with incontinence (worse, unchanged, or improved) after first year (women's observations) Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 2.1 urodynamic stress incontinence (only) | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 2.2 stress urinary incontinence (symptoms only) | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 2.3 mixed incontinence | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 3 CURE: number of women cured after first year (women's observations) Show forest plot | 1 | Odds Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 3.1 urodynamic stress incontinence (only) | 1 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 3.2 stress urinary incontinence (symptoms only) | 0 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 3.3 mixed incontinence | 0 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 4 Length of hospital stay (hours) Show forest plot | 1 | Mean Difference (IV, Fixed, 95% CI) | Totals not selected | |
| 4.1 urodynamic stress incontinence (only) | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 4.2 stress urinary incontinence (symptoms only) | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 4.3 mixed incontinence | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 5 Perioperative surgical complications Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 5.1 urodynamic stress incontinence (only) | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 5.2 stress urinary incontinence (symptoms only) | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 5.3 mixed incontinence | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 6 Urge urinary symptoms, urgency urinary incontinence Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 6.1 urodynamic stress incontinence (only) | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 6.2 stress urinary incontinence (symptoms only) | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 6.3 mixed incontinence | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 7 Voiding dysfunction after 3 months Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 7.1 urodynamic stress incontinence (only) | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 7.2 stress urinary incontinence (symptoms only) | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 7.3 mixed incontinence | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 8 Detrusor overactivity (urodynamic diagnosis) Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 8.1 urodynamic stress incontinence (only) | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 8.2 stress urinary incontinence (symptoms only) | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 8.3 mixed incontinence | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1 Number of women with urinary incontinence (worse, unchanged, or improved) within first year (women's observations) Show forest plot | 4 | 147 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.40 [0.11, 1.41] |
| 1.1 urodynamic stress incontinence (only) | 4 | 147 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.40 [0.11, 1.41] |
| 1.2 stress urinary incontinence (symptoms only) | 0 | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 1.3 mixed incontinence | 0 | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 2 Number not improved (worse or unchanged) within first year (women's observations) | 0 | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 2.1 urodynamic stress incontinence (only) | 0 | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 2.2 stress urinary incontinence (symptoms only) | 0 | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 2.3 mixed incontinence | 0 | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 3 Number of women with urinary incontinence (worse, unchanged, or improved) at 1 to 5 years (women's observations) Show forest plot | 4 | 687 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.73 [0.61, 0.89] |
| 3.1 urodynamic stress incontinence (only) | 3 | 167 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.58 [0.22, 1.49] |
| 3.2 stress urinary incontinence (symptoms only) | 1 | 520 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.75 [0.62, 0.91] |
| 3.3 mixed incontinence | 0 | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 4 Number not improved (worse or unchanged) at 1 to 5 years (women's observations) | 0 | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 4.1 urodynamic stress incontinence (only) | 0 | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 4.2 stress urinary incontinence (symptoms only) | 0 | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 4.3 mixed incontinence | 0 | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 5 Number of women with urinary incontinence (worse, unchanged, or improved) at > 5 years (women's observations) Show forest plot | 2 | 481 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.85 [0.74, 0.98] |
| 5.1 urodynamic stress incontinence (only) | 1 | 28 | Risk Ratio (M‐H, Fixed, 95% CI) | 2.31 [0.24, 22.62] |
| 5.2 stress urinary incontinence (symptoms only) | 1 | 453 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.84 [0.73, 0.97] |
| 5.3 mixed incontinence | 0 | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 6 CURE: number of women cured at > 1 year (women's observations) Show forest plot | 3 | 515 | Odds Ratio (M‐H, Fixed, 95% CI) | 1.56 [1.07, 2.28] |
| 6.1 urodynamic stress incontinence (only) | 2 | 62 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.93 [0.18, 4.89] |
| 6.2 stress urinary incontinence (symptoms only) | 1 | 453 | Odds Ratio (M‐H, Fixed, 95% CI) | 1.61 [1.09, 2.37] |
| 6.3 mixed incontinence | 0 | 0 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 7 Number of women not satisfied at > 5 years Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 7.1 urodynamic stress incontinence (only) | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 7.2 stress urinary incontinence (symptoms only) | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 7.3 mixed incontinence | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 8 Incontinent episodes over 24 hours | 0 | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 8.1 urodynamic stress incontinence (only) | 0 | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 8.2 stress urinary incontinence (symptoms only) | 0 | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 8.3 mixed incontinence | 0 | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 9 Number of women with urinary incontinence (clinician's observations) within first year | 0 | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 9.1 urodynamic stress incontinence (only) | 0 | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 9.2 stress urinary incontinence (symptoms only) | 0 | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 9.3 mixed incontinence | 0 | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 10 Number of women with urinary incontinence (clinician's observations) at 1 to 5 years Show forest plot | 2 | 592 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.90 [0.60, 1.34] |
| 10.1 urodynamic stress incontinence (only) | 1 | 72 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.6 [0.15, 2.33] |
| 10.2 stress urinary incontinence (symptoms only) | 1 | 520 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.94 [0.62, 1.42] |
| 10.3 mixed incontinence | 0 | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 11 Number of women with urinary incontinence (clinician's observations) at > 5 years Show forest plot | 2 | 461 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.90 [0.80, 1.01] |
| 11.1 urodynamic stress incontinence (only) | 1 | 28 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.23 [0.01, 4.37] |
| 11.2 stress urinary incontinence (symptoms only) | 1 | 433 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.91 [0.81, 1.02] |
| 11.3 mixed incontinence | 0 | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 12 Duration of operation (minutes) Show forest plot | 1 | Mean Difference (IV, Fixed, 95% CI) | Totals not selected | |
| 12.1 urodynamic stress incontinence (only) | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 12.2 stress urinary incontinence (symptoms only) | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 12.3 mixed incontinence | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 13 Time to catheter removal (days) Show forest plot | 2 | 108 | Mean Difference (IV, Fixed, 95% CI) | 8.01 [6.84, 9.18] |
| 13.1 urodynamic stress incontinence (only) | 2 | 108 | Mean Difference (IV, Fixed, 95% CI) | 8.01 [6.84, 9.18] |
| 13.2 stress urinary incontinence (symptoms only) | 0 | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 13.3 mixed incontinence | 0 | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 14 Length of hospital stay (days) Show forest plot | 3 | Mean Difference (IV, Fixed, 95% CI) | Totals not selected | |
| 14.1 urodynamic stress incontinence (only) | 3 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 14.2 stress urinary incontinence (symptoms only) | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 14.3 mixed incontinence | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 15 Time to return to normal activity level | 0 | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 15.1 urodynamic stress incontinence (only) | 0 | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 15.2 stress urinary incontinence (symptoms only) | 0 | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 15.3 mixed incontinence | 0 | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 16 Perioperative surgical complications Show forest plot | 4 | 792 | Risk Ratio (M‐H, Fixed, 95% CI) | 1.24 [0.83, 1.86] |
| 16.1 urodynamic stress incontinence (only) | 3 | 137 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.85 [0.28, 2.52] |
| 16.2 stress urinary incontinence (symptoms only) | 1 | 655 | Risk Ratio (M‐H, Fixed, 95% CI) | 1.32 [0.86, 2.04] |
| 16.3 mixed incontinence | 0 | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 17 Bladder perforation Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 17.1 urodynamic stress incontinence (only) | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 17.2 stress urinary incontinence (symptoms only) | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 17.3 mixed incontinence | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 18 Urinary tract infection Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 18.1 urodynamic stress incontinence (only) | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 18.2 stress urinary incontinence (symptoms only) | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 18.3 mixed incontinence | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 19 Number of women with recurrent UTIs at > 5 years Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 19.1 urodynamic stress incontinence (only) | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 19.2 stress urinary incontinence (symptoms only) | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 19.3 mixed incontinence | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 20 Urge urinary symptoms, urgency urinary incontinence Show forest plot | 2 | 525 | Risk Ratio (M‐H, Fixed, 95% CI) | 1.10 [0.74, 1.64] |
| 20.1 urodynamic stress incontinence (only) | 1 | 72 | Risk Ratio (M‐H, Fixed, 95% CI) | 2.0 [0.54, 7.39] |
| 20.2 stress urinary incontinence (symptoms only) | 1 | 453 | Risk Ratio (M‐H, Fixed, 95% CI) | 1.02 [0.67, 1.56] |
| 20.3 mixed incontinence | 0 | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 21 Detrusor overactivity (urodynamic diagnosis) Show forest plot | 4 | 203 | Risk Ratio (M‐H, Fixed, 95% CI) | 1.42 [0.52, 3.87] |
| 21.1 urodynamic stress incontinence (only) | 4 | 203 | Risk Ratio (M‐H, Fixed, 95% CI) | 1.42 [0.52, 3.87] |
| 21.2 stress urinary incontinence (symptoms only) | 0 | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 21.3 mixed incontinence | 0 | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 22 Voiding dysfunction after 3 months Show forest plot | 5 | 853 | Risk Ratio (M‐H, Fixed, 95% CI) | 6.08 [3.10, 11.95] |
| 22.1 urodynamic stress incontinence (only) | 4 | 198 | Risk Ratio (M‐H, Fixed, 95% CI) | 4.48 [1.16, 17.36] |
| 22.2 stress urinary incontinence (symptoms only) | 1 | 655 | Risk Ratio (M‐H, Fixed, 95% CI) | 6.63 [3.04, 14.47] |
| 22.3 mixed incontinence | 0 | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 23 Long‐term voiding dysfunction > 5 years Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 23.1 urodynamic stress incontinence (only) | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 23.2 stress urinary incontinence (symptoms only) | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 23.3 mixed incontinence | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 24 Number of women requiring treatment for pelvic organ prolapse Show forest plot | 3 | 559 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.20 [0.05, 0.77] |
| 24.1 urodynamic stress incontinence (only) | 2 | 106 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.2 [0.04, 1.11] |
| 24.2 stress urinary incontinence (symptoms only) | 1 | 453 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.20 [0.02, 1.74] |
| 24.3 mixed incontinence | 0 | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 25 Repeat surgery for urinary incontinence Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 25.1 urodynamic stress incontinence (only) | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 25.2 stress urinary incontinence (symptoms only) | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 25.3 mixed incontinence | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 26 Condition‐specific measures to assess quality of life Show forest plot | 1 | Mean Difference (IV, Fixed, 95% CI) | Totals not selected | |
| 26.1 Urinary Distress Index (UDI) | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 26.2 Incontinence Impact Questionnaire (IIQ) | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1 Number of women with urinary incontinence (worse, unchanged, or improved) within first year (women's observations) Show forest plot | 11 | 841 | Risk Ratio (M‐H, Fixed, 95% CI) | 1.04 [0.85, 1.28] |
| 1.1 urodynamic stress incontinence (only) | 5 | 427 | Risk Ratio (M‐H, Fixed, 95% CI) | 1.02 [0.77, 1.36] |
| 1.2 stress urinary incontinence (symptoms only) | 1 | 53 | Risk Ratio (M‐H, Fixed, 95% CI) | 1.12 [0.17, 7.37] |
| 1.3 mixed urinary incontinence | 5 | 361 | Risk Ratio (M‐H, Fixed, 95% CI) | 1.06 [0.78, 1.42] |
| 2 Number not improved (worse or unchanged) within first year (women's observations) Show forest plot | 3 | 425 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.79 [0.49, 1.29] |
| 2.1 urodynamic stress incontinence (only) | 2 | 286 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.95 [0.40, 2.21] |
| 2.2 stress urinary incontinence (symptoms only) | 0 | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 2.3 mixed urinary incontinence | 1 | 139 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.72 [0.40, 1.29] |
| 3 Number of women with urinary incontinence (worse, unchanged, or improved) at 1 to 5 years (women's observations) Show forest plot | 6 | 458 | Risk Ratio (M‐H, Fixed, 95% CI) | 1.29 [0.98, 1.68] |
| 3.1 urodynamic stress incontinence (only) | 4 | 364 | Risk Ratio (M‐H, Fixed, 95% CI) | 1.18 [0.87, 1.59] |
| 3.2 stress urinary incontinence (symptoms only) | 0 | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 3.3 mixed urinary incontinence | 2 | 94 | Risk Ratio (M‐H, Fixed, 95% CI) | 1.79 [0.96, 3.31] |
| 4 Number not improved (worse or unchanged) after first year (women's observations) Show forest plot | 2 | 264 | Risk Ratio (M‐H, Fixed, 95% CI) | 1.28 [0.56, 2.94] |
| 4.1 urodynamic stress incontinence (only) | 2 | 264 | Risk Ratio (M‐H, Fixed, 95% CI) | 1.28 [0.56, 2.94] |
| 4.2 stress urinary incontinence (symptoms only) | 0 | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 4.3 mixed urinary incontinence | 0 | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 5 Number of women with urinary incontinence after 5 years (women's observations) Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 5.1 urodynamic stress incontinence (only) | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 5.2 stress urinary incontinence (symptoms only) | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 5.3 mixed urinary incontinence | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 6 Number with incontinence not improved after 5 years (women's observations) Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 6.1 urodynamic stress incontinence (only) | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 6.2 stress urinary incontinence (symptoms only) | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 6.3 mixed urinary incontinence | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 7 CURE: number of women cured at > 1 year (women's observations) Show forest plot | 4 | 337 | Odds Ratio (M‐H, Fixed, 95% CI) | 1.06 [0.65, 1.72] |
| 7.1 urodynamic stress incontinence (only) | 3 | 293 | Odds Ratio (M‐H, Fixed, 95% CI) | 1.21 [0.72, 2.03] |
| 7.2 stress urinary incontinence (symptoms only) | 0 | 0 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 7.3 mixed urinary incontinence | 1 | 44 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.42 [0.10, 1.72] |
| 8 Repeat surgery for urinary incontinence Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 8.1 urodynamic stress incontinence (only) | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 8.2 stress urinary incontinence (symptoms only) | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 8.3 mixed incontinence | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 9 Number of women not satisfied Show forest plot | 2 | Risk Ratio (M‐H, Fixed, 95% CI) | Subtotals only | |
| 9.1 urodynamic stress incontinence (only) | 2 | 163 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.82 [0.51, 1.32] |
| 9.2 stress urinary incontinence (symptoms only) | 0 | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 9.3 mixed urinary incontinence | 0 | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 10 Pad test of quantified leakage (mean weight of urine loss) Show forest plot | 1 | Mean Difference (IV, Fixed, 95% CI) | Totals not selected | |
| 10.1 urodynamic stress incontinence (only) | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 10.2 stress urinary incontinence (symptoms only) | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 10.3 mixed urinary incontinence | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 11 Number of women with urinary incontinence (clinician's observations) within first year Show forest plot | 2 | 105 | Risk Ratio (M‐H, Fixed, 95% CI) | 1.29 [0.45, 3.71] |
| 11.1 urodynamic stress incontinence (only) | 0 | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 11.2 stress urinary incontinence (symptoms only) | 0 | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 11.3 mixed urinary incontinence | 2 | 105 | Risk Ratio (M‐H, Fixed, 95% CI) | 1.29 [0.45, 3.71] |
| 12 Number of women with urinary incontinence (clinician's observations) after first year Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 12.1 urodynamic stress incontinence (only) | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 12.2 stress urinary incontinence (symptoms only) | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 12.3 mixed urinary incontinence | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 13 Duration of operation (minutes) Show forest plot | 7 | 355 | Mean Difference (IV, Fixed, 95% CI) | 57.08 [54.67, 59.49] |
| 13.1 urodynamic stress incontinence (only) | 2 | 61 | Mean Difference (IV, Fixed, 95% CI) | 46.91 [42.31, 51.52] |
| 13.2 stress urinary incontinence (symptoms only) | 1 | 53 | Mean Difference (IV, Fixed, 95% CI) | 20.0 [7.08, 32.92] |
| 13.3 mixed urinary incontinence | 4 | 241 | Mean Difference (IV, Fixed, 95% CI) | 62.96 [60.07, 65.86] |
| 14 Length of hospital stay (days) Show forest plot | 4 | 194 | Mean Difference (IV, Fixed, 95% CI) | 0.74 [0.55, 0.93] |
| 14.1 urodynamic stress incontinence (only) | 1 | 20 | Mean Difference (IV, Fixed, 95% CI) | 0.65 [0.39, 0.91] |
| 14.2 stress urinary incontinence (symptoms only) | 0 | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 14.3 mixed urinary incontinence | 3 | 174 | Mean Difference (IV, Fixed, 95% CI) | 0.83 [0.56, 1.10] |
| 15 Time to catheter removal (days) Show forest plot | 2 | 113 | Mean Difference (IV, Fixed, 95% CI) | 0.11 [‐0.07, 0.30] |
| 15.1 urodynamic stress incontinence (only) | 0 | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 15.2 stress urinary incontinence (symptoms only) | 1 | 53 | Mean Difference (IV, Fixed, 95% CI) | 2.3 [0.01, 4.59] |
| 15.3 mixed urinary incontinence | 1 | 60 | Mean Difference (IV, Fixed, 95% CI) | 0.10 [‐0.09, 0.29] |
| 16 Perioperative surgical complications Show forest plot | 4 | 293 | Risk Ratio (M‐H, Fixed, 95% CI) | 1.74 [1.16, 2.60] |
| 16.1 urodynamic stress incontinence (only) | 2 | 183 | Risk Ratio (M‐H, Fixed, 95% CI) | 1.73 [1.01, 2.96] |
| 16.2 stress urinary incontinence (symptoms only) | 0 | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 16.3 mixed urinary incontinence | 2 | 110 | Risk Ratio (M‐H, Fixed, 95% CI) | 1.74 [0.94, 3.21] |
| 17 Bladder perforations Show forest plot | 10 | 844 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.59 [0.34, 1.01] |
| 17.1 urodynamic stress incontinence (only) | 3 | 334 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.74 [0.19, 2.86] |
| 17.2 stress urinary incontinence (symptoms only) | 1 | 53 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.56 [0.05, 5.81] |
| 17.3 mixed urinary incontinence | 6 | 457 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.56 [0.30, 1.03] |
| 18 Urethral injury Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 18.1 urodynamic stress incontinence (only) | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 18.2 stress urinary incontinence (symptoms only) | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 18.3 mixed urinary incontinence | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 19 Vaginal bleeding Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 19.1 urodynamic stress incontinence (only) | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 19.2 stress urinary incontinence (symptoms only) | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 19.3 mixed urinary incontinence | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 20 Urinary tract infection Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 20.1 urodynamic stress incontinence (only) | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 20.2 stress urinary incontinence (symptoms only) | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 20.3 mixed urinary incontinence | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 21 Voiding dysfunction Show forest plot | 8 | 629 | Risk Ratio (M‐H, Fixed, 95% CI) | 1.34 [0.85, 2.12] |
| 21.1 urodynamic stress incontinence (only) | 3 | 325 | Risk Ratio (M‐H, Fixed, 95% CI) | 1.22 [0.60, 2.46] |
| 21.2 stress urinary incontinence (symptoms only) | 1 | 53 | Risk Ratio (M‐H, Fixed, 95% CI) | 2.61 [0.76, 9.03] |
| 21.3 mixed urinary incontinence | 4 | 251 | Risk Ratio (M‐H, Fixed, 95% CI) | 1.18 [0.58, 2.40] |
| 22 De novo detrusor urgency or urge symptoms Show forest plot | 5 | 348 | Risk Ratio (M‐H, Fixed, 95% CI) | 1.62 [0.66, 3.99] |
| 22.1 urodynamic stress incontinence (only) | 1 | 124 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.34 [0.01, 8.29] |
| 22.2 stress urinary incontinence (symptoms only) | 1 | 53 | Risk Ratio (M‐H, Fixed, 95% CI) | 3.35 [0.14, 78.60] |
| 22.3 mixed urinary incontinence | 3 | 171 | Risk Ratio (M‐H, Fixed, 95% CI) | 1.81 [0.65, 5.06] |
| 23 De novo detrusor overactivity (urodynamic diagnosis) Show forest plot | 4 | 325 | Risk Ratio (M‐H, Fixed, 95% CI) | 2.61 [1.17, 5.84] |
| 23.1 urodynamic stress incontinence (only) | 1 | 59 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 23.2 stress urinary incontinence (symptoms only) | 1 | 47 | Risk Ratio (M‐H, Fixed, 95% CI) | 3.13 [0.13, 73.01] |
| 23.3 mixed urinary incontinence | 2 | 219 | Risk Ratio (M‐H, Fixed, 95% CI) | 2.57 [1.12, 5.92] |
| 24 Long‐term adverse effects (release of sling required) Show forest plot | 3 | 326 | Risk Ratio (M‐H, Fixed, 95% CI) | 2.53 [0.87, 7.35] |
| 24.1 urodynamic stress incontinence (only) | 2 | 266 | Risk Ratio (M‐H, Fixed, 95% CI) | 1.68 [0.50, 5.66] |
| 24.2 stress urinary incontinence (symptoms only) | 0 | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 24.3 mixed urinary incontinence | 1 | 60 | Risk Ratio (M‐H, Fixed, 95% CI) | 9.6 [0.54, 170.84] |
| 25 Long‐term adverse effects (wound pain at 6 months) Show forest plot | 3 | 257 | Risk Ratio (M‐H, Fixed, 95% CI) | 6.40 [1.94, 21.12] |
| 25.1 urodynamic stress incontinence (only) | 1 | 124 | Risk Ratio (M‐H, Fixed, 95% CI) | 5.16 [0.25, 105.36] |
| 25.2 stress urinary incontinence (symptoms only) | 1 | 53 | Risk Ratio (M‐H, Fixed, 95% CI) | 3.92 [0.90, 17.15] |
| 25.3 mixed urinary incontinence | 1 | 80 | Risk Ratio (M‐H, Fixed, 95% CI) | 17.0 [1.01, 284.96] |
| 26 Long‐term adverse effects (vaginal mesh or graft exposure) Show forest plot | 5 | 348 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.28 [0.05, 1.65] |
| 26.1 urodynamic stress incontinence (only) | 2 | 165 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.35 [0.04, 3.24] |
| 26.2 stress urinary incontinence (symptoms only) | 1 | 53 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 26.3 mixed urinary incontinence | 2 | 130 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.2 [0.01, 3.97] |
| 27 Condition‐specific measures to assess quality of life: UDI‐6 Show forest plot | 1 | 63 | Mean Difference (IV, Fixed, 95% CI) | 7.30 [‐2.00, 16.60] |
| 27.1 urodynamic stress incontinence (only) | 0 | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 27.2 stress urinary incontinence (symptoms only) | 1 | 63 | Mean Difference (IV, Fixed, 95% CI) | 7.30 [‐2.00, 16.60] |
| 27.3 mixed urinary incontinence | 0 | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 28 Condition‐specific measures to assess quality of life: IIQ‐7 Show forest plot | 1 | 63 | Mean Difference (IV, Fixed, 95% CI) | 0.60 [‐10.17, 11.37] |
| 28.1 urodynamic stress incontinence (only) | 0 | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 28.2 stress urinary incontinence (symptoms only) | 1 | 63 | Mean Difference (IV, Fixed, 95% CI) | 0.60 [‐10.17, 11.37] |
| 28.3 mixed urinary incontinence | 0 | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1 Number of women with urinary incontinence in the medium term (1 to 5 years) Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 1.1 urodynamic stress incontinence (only) | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 1.2 stress urinary incontinence (symptoms only) | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 1.3 mixed incontinence | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 2 Number of women not satisfied within first year Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 2.1 urodynamic stress incontinence (only) | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 2.2 stress urinary incontinence (symptoms only) | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 2.3 mixed incontinence | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 3 Number of women with urinary incontinence (clinician's observations) within first year Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 3.1 urodynamic stress incontinence (only) | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 3.2 stress urinary incontinence (symptoms only) | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 3.3 mixed incontinence | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 4 CURE: number of women cured at > 1 year (women's observations) Show forest plot | 1 | Odds Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 4.1 urodynamic stress incontinence (only) | 1 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 4.2 stress urinary incontinence (symptoms only) | 0 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 4.3 mixed incontinence | 0 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 5 Bladder perforation Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 5.1 urodynamic stress incontinence (only) | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 5.2 stress urinary incontinence (symptoms only) | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 5.3 mixed incontinence | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 6 Urge urinary symptoms, urgency urinary incontinence Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 6.1 urodynamic stress incontinence (only) | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 6.2 stress urinary incontinence (symptoms only) | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 6.3 mixed incontinence | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 7 Pain with intercourse (dyspareunia) Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 7.1 urodynamic stress incontinence (only) | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 7.2 stress urinary incontinence (symptoms only) | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 7.3 mixed incontinence | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 8 Long‐term adverse effects (vaginal mesh or graft exposure) Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 8.1 urodynamic stress incontinence (only) | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 8.2 stress urinary incontinence (symptoms only) | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 8.3 mixed incontinence | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 9 Condition‐specific measures to assess quality of life: IIQ score Show forest plot | 1 | Mean Difference (IV, Fixed, 95% CI) | Totals not selected | |
| 9.1 urodynamic stress incontinence (only) | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 9.2 stress urinary incontinence (symptoms only) | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 9.3 mixed urinary incontinence | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1 Number of women with urinary incontinence (worse, unchanged, or improved) within first year (women's observations) Show forest plot | 5 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 1.1 fascial sling vs Pelvicol sling | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 1.2 standard sling vs short sling | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 1.3 autologous fascial sling vs Fortaperm sling | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 1.4 Vypro vs Ultrapro | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 1.5 Vypro vs Prolene light | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 1.6 Ultrapro vs Prolene light | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 1.7 fascial sling vs vaginal wall sling | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 2 Number not improved (worse or unchanged) within first year (women's observations) Show forest plot | 3 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 2.1 fascial sling vs Pelvicol sling | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 2.2 autologous fascial sling vs Fortaperm sling | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 2.3 rectus fascia sling vs Goretex sling | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 3 Number of women with urinary incontinence (worse, unchanged, or improved) at 1 to 5 years (women's observations) Show forest plot | 7 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 3.1 fascial sling vs Pelvicol sling | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 3.2 standard sling vs short sling | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 3.3 autologous dermal graft patch vs cadaveric fascia lata | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 3.4 rectus fascia sling vs Goretex sling | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 3.5 Vypro vs Ultrapro | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 3.6 Vypro vs Prolene light | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 3.7 Ultrapro vs Prolene light | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 3.8 anterior vaginal wall sling vs biosynthetic mesh sling | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 3.9 anterior rectus sheath sling vs Prolene strip | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 3.10 anterior rectus sheath sling vs anterior vaginal wall patch | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 3.11 Prolene strip vs anterior vaginal wall patch | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 4 Number not improved (worse or unchanged) after first year (women's observations) Show forest plot | 4 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 4.1 fascial sling vs Pelvicol sling | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 4.2 autologous dermal graft patch vs cadaveric fascia lata | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 4.3 rectus fascia sling vs Goretex sling | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 4.4 anterior rectus sheath sling vs Prolene strip | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 4.5 anterior rectus sheath sling vs anterior vaginal wall patch | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 4.6 Prolene strip vs anterior vaginal wall patch | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 5 Number of women with urinary incontinence (worse, unchanged, or improved) after 5 years (women's observations) Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 5.1 standard sling vs short sling | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 6 CURE: number of women with urinary incontinence > 1 year (women's observations) Show forest plot | 3 | Odds Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 6.1 fascial sling vs Pelvicol sling | 1 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 6.2 standard sling vs short sling | 1 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 6.3 autologous dermal graft patch vs cadaveric fascia lata | 1 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 7 Number of women not satisfied Show forest plot | 3 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 7.1 fascial sling vs Pelvicol sling | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 7.2 Vypro vs Ultrapro | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 7.3 Vypro vs Prolene light | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 7.4 Ultrapro vs Prolene light | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 7.5 anterior vaginal wall sling vs biosynthetic mesh sling | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 8 Pad test of quantified leakage (mean weight of urine loss) at 1 year Show forest plot | 2 | Mean Difference (IV, Fixed, 95% CI) | Totals not selected | |
| 8.1 standard sling vs short sling | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 8.2 Vypro vs Ultrapro | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 8.3 Vypro vs Prolene light | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 8.4 Ultrapro vs Prolene light | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 9 Pad test of quantified leakage (mean weight of urine loss) at 1 to 5 years Show forest plot | 1 | Mean Difference (IV, Fixed, 95% CI) | Totals not selected | |
| 9.1 Vypro vs Ultrapro | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 9.2 Vypro vs Prolene light | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 9.3 Ultrapro vs Prolene light | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 10 Duration of operation (minutes) Show forest plot | 2 | Mean Difference (IV, Fixed, 95% CI) | Totals not selected | |
| 10.1 standard sling vs short sling | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 10.2 anterior rectus sheath sling vs Prolene strip | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 10.3 anterior rectus sheath sling vs anterior vaginal wall patch | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 10.4 Prolene strip vs anterior vaginal wall patch | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 11 Blood loss (mL) Show forest plot | 1 | Mean Difference (IV, Fixed, 95% CI) | Totals not selected | |
| 11.1 anterior rectus sheath sling vs Prolene strip | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 11.2 anterior rectus sheath sling vs anterior vaginal wall patch | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 11.3 Prolene strip vs anterior vaginal wall patch | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 12 Length of hospital stay (days) Show forest plot | 1 | Mean Difference (IV, Fixed, 95% CI) | Totals not selected | |
| 12.1 anterior rectus sheath sling vs Prolene strip | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 12.2 anterior rectus sheath sling vs anterior vaginal wall patch | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 12.3 Prolene strip vs anterior vaginal wall patch | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 13 Perioperative surgical complications Show forest plot | 3 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 13.1 standard sling vs short sling | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 13.2 rectus fascia sling vs Goretex sling | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 13.3 fascial sling vs vaginal wall sling | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 14 Bladder perforation Show forest plot | 3 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 14.1 standard sling vs short sling | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 14.2 fascial sling vs Pelvicol sling | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 14.3 anterior rectus sheath sling vs Prolene strip | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 14.4 anterior rectus sheath sling vs anterior vaginal wall patch | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 14.5 Prolene strip vs anterior vaginal wall patch | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 15 Urinary tract infection Show forest plot | 2 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 15.1 standard sling vs short sling | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 15.2 anterior vaginal wall sling vs biosynthetic mesh sling | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 16 Vaginal bleeding Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 16.1 anterior vaginal wall sling vs biosynthetic mesh sling | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 17 Long‐term adverse effects (wound pain) Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 17.1 fascial sling vs Pelvicol sling | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 18 Voiding dysfunction Show forest plot | 6 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 18.1 fascial sling vs Pelvicol sling | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 18.2 standard sling vs short sling | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 18.3 Vypro vs Ultrapro | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 18.4 Vypro vs Prolene light | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 18.5 Ultrapro vs Prolene light | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 18.6 anterior vaginal wall sling vs biosynthetic mesh sling | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 18.7 anterior rectus sheath sling vs Prolene strip | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 18.8 anterior rectus sheath sling vs anterior vaginal wall patch | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 18.9 Prolene strip vs anterior vaginal wall patch | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 18.10 fascial sling vs vaginal wall sling | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 19 Long‐term adverse effects (release of sling required) Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 19.1 fascial sling vs Pelvicol sling | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 20 De novo detrusor urgency or urge symptoms or detrusor overactivity Show forest plot | 4 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 20.1 standard sling vs short sling | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 20.2 Vypro vs Ultrapro | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 20.3 Vypro vs Prolene light | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 20.4 Ultrapro vs Prolene light | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 20.5 autologous dermal graft patch vs cadaveric fascia lata | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 20.6 rectus fascia sling vs Goretex sling | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 21 Repeat surgery for urinary incontinence at first year Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 21.1 Fascial sling vs Pelvicol sling | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 22 Long‐term adverse effects (vaginal mesh or graft exposure) Show forest plot | 3 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 22.1 fascial sling vs Pelvicol sling | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 22.2 Vypro vs Ultrapro | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 22.3 Vypro vs Prolene light | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 22.4 Ultrapro vs Prolene light | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 22.5 anterior vaginal wall sling vs biosynthetic mesh sling | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 23 Condition‐specific measures to assess quality of life (ICI‐Q short form UI score at 1 year) Show forest plot | 1 | Mean Difference (IV, Fixed, 95% CI) | Totals not selected | |
| 23.1 Vypro vs Ultrapro | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 23.2 Vypro vs Prolene light | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 23.3 Ultrapro vs Prolene light | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 24 Condition‐specific measures to assess quality of life (ICI‐Q short form UI score at 1 to 5 years) Show forest plot | 1 | Mean Difference (IV, Fixed, 95% CI) | Totals not selected | |
| 24.1 Vypro vs Ultrapro | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 24.2 Vypro vs Prolene light | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 24.3 Ultrapro vs Prolene light | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
