女性压力性尿失禁的吊带手术：一项系统评价和荟萃分析。

Sling surgery for stress urinary incontinence in women: a systematic review and metaanalysis.

作者信息

Schimpf Megan O, Rahn David D, Wheeler Thomas L, Patel Minita, White Amanda B, Orejuela Francisco J, El-Nashar Sherif A, Margulies Rebecca U, Gleason Jonathan L, Aschkenazi Sarit O, Mamik Mamta M, Ward Renée M, Balk Ethan M, Sung Vivian W

机构信息

Division of Gynecology and Urogynecology, Department of Obstetrics and Gynecology, University of Michigan Medical School, Ann Arbor, MI.

Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX.

出版信息

Am J Obstet Gynecol. 2014 Jul;211(1):71.e1-71.e27. doi: 10.1016/j.ajog.2014.01.030. Epub 2014 Jan 30.

DOI:10.1016/j.ajog.2014.01.030

PMID:24487005

Abstract

OBJECTIVE

Understanding the long-term comparative effectiveness of competing surgical repairs is essential as failures after primary interventions for stress urinary incontinence (SUI) may result in a third of women requiring repeat surgery.

STUDY DESIGN

We conducted a systematic review including English-language randomized controlled trials from 1990 through April 2013 with a minimum 12 months of follow-up comparing a sling procedure for SUI to another sling or Burch urethropexy. When at least 3 randomized controlled trials compared the same surgeries for the same outcome, we performed random effects model metaanalyses to estimate pooled odds ratios (ORs).

RESULTS

For midurethral slings (MUS) vs Burch, metaanalysis of objective cure showed no significant difference (OR, 1.18; 95% confidence interval [CI], 0.73-1.89). Therefore, we suggest either intervention; the decision should balance potential adverse events (AEs) and concomitant surgeries. For women considering pubovaginal sling vs Burch, the evidence favored slings for both subjective and objective cure. We recommend pubovaginal sling to maximize cure outcomes. For pubovaginal slings vs MUS, metaanalysis of subjective cure favored MUS (OR, 0.40; 95% CI, 0.18-0.85). Therefore, we recommend MUS. For obturator slings vs retropubic MUS, metaanalyses for both objective (OR, 1.16; 95% CI, 0.93-1.45) and subjective cure (OR, 1.17; 95% CI, 0.91-1.51) favored retropubic slings but were not significant. Metaanalysis of satisfaction outcomes favored obturator slings but was not significant (OR, 0.77; 95% CI, 0.52-1.13). AEs were variable between slings; metaanalysis showed overactive bladder symptoms were more common following retropubic slings (OR, 1.413; 95% CI, 1.01-1.98, P = .046). We recommend either retropubic or obturator slings for cure outcomes; the decision should balance AEs. For minislings vs full-length MUS, metaanalyses of objective (OR, 4.16; 95% CI, 2.15-8.05) and subjective (OR, 2.65; 95% CI, 1.36-5.17) cure both significantly favored full-length slings. Therefore, we recommend a full-length MUS.

CONCLUSION

Surgical procedures for SUI differ for success rates and complications, and both should be incorporated into surgical decision-making. Low- to high-quality evidence permitted mostly level-1 recommendations when guidelines were possible.

摘要

目的

了解相互竞争的手术修复方法的长期比较疗效至关重要，因为压力性尿失禁（SUI）初次干预失败可能导致三分之一的女性需要再次手术。

研究设计

我们进行了一项系统评价，纳入1990年至2013年4月期间的英文随机对照试验，这些试验至少有12个月的随访，比较了SUI吊带手术与另一种吊带或Burch尿道悬吊术。当至少3项随机对照试验针对相同结局比较相同手术时，我们进行随机效应模型荟萃分析以估计合并比值比（OR）。

结果

对于中段尿道吊带（MUS）与Burch手术，客观治愈率的荟萃分析显示无显著差异（OR，1.18；95%置信区间[CI]，0.73 - 1.89）。因此，我们建议两种干预方法均可；决策应权衡潜在不良事件（AE）和伴随手术情况。对于考虑耻骨后阴道吊带与Burch手术的女性，证据表明吊带在主观和客观治愈率方面均更具优势。我们推荐耻骨后阴道吊带以最大化治愈效果。对于耻骨后阴道吊带与MUS，主观治愈率的荟萃分析显示MUS更具优势（OR，0.40；95% CI，0.18 - 0.85）。因此，我们推荐MUS。对于闭孔吊带与耻骨后MUS，客观治愈率（OR，1.16；95% CI，0.93 - 1.45）和主观治愈率（OR，1.17；95% CI，0.91 - 1.51）的荟萃分析均显示耻骨后吊带更具优势，但差异不显著。满意度结局的荟萃分析显示闭孔吊带更具优势，但差异不显著（OR，0.77；95% CI，0.52 - 1.13）。不同吊带的AE各不相同；荟萃分析显示耻骨后吊带术后膀胱过度活动症状更常见（OR，1.413；95% CI，1.01 - 1.98，P = 0.046）。为获得治愈效果，我们推荐耻骨后或闭孔吊带；决策应权衡AE。对于迷你吊带与全长MUS，客观治愈率（OR，4.16；95% CI，2.15 - 8.05）和主观治愈率（OR，2.65；95% CI，1.36 - 5.17）的荟萃分析均显著显示全长吊带更具优势。因此，我们推荐全长MUS。