Up to 30 percent of women experience urinary incontinence at some time during their lives. In approximately one half of these women, the etiology is isolated stress incontinence. In an additional 29 percent of women, stress and urge incontinence are present. Although up to one half of women with incontinence benefit from physiotherapy and other conservative treatments, surgery frequently is recommended to control symptoms. Various techniques have been used to provide support of the bladder neck and provide functional urinary continence. More recently, support of the mid-urethra has been advocated, and a minimally invasive procedure, the tension-free vaginal tape (TVT) procedure, has been developed. Valpas and colleagues compared TVT and laparoscopic mesh colposuspension in a randomized clinical trial.
They studied 121 women with stress incontinence who were referred to six gynecology clinics in Finland. Stress incontinence was confirmed through a test of coughing while in a supine position with 300 mL of saline in the bladder. Women older than 70 years and women with previous surgery for incontinence, repeated urinary tract infections, or contraindications to surgery or anesthesia were excluded from the study, as were women with a body mass index greater than 32 kg per m2 or unsuitable preoperative urodynamic evaluation. After evaluation, women were assigned to TVT or laparoscopic mesh colposuspension. In addition to clinical and urodynamic measures, patient outcomes were measured using several validated instruments, including: the Urinary Incontinence Severity Score and the Urge Score to assess symptoms; the King’s College Health Questionnaire to monitor changes in quality of life; the Visual Analog Scale to quantify the severity of incontinence; and the Urinary Incontinence Severity Score to assess social and other types of handicap attributed to incontinence. Patients were evaluated six weeks and one year after surgery.
|Outcome at 12 months||TVT group (%)||LMC group (%)|
|Negative stress test||85.7||56.9|
|Negative 48-hour pad test (< 8 g per 48 hours)||72.9||58.8|
|Procedure met patient expectations||82.9||58.8|
|Would recommend procedure to a friend||92.9||74.5|
|Still using pads||0.0||11.8|
The two groups were well balanced in all significant variables. The average age was 48 to 50 years, and the average duration of symptoms was six to eight years. Five women were lost to follow-up. After one year, 60 women (85.7 percent) treated with TVT had a negative stress test compared with 29 women (56.9 percent) who underwent colposuspension (see accompanying table). The reduction in the mean values of the 48-hour pad test also was significantly greater in the TVT group. At one year, only one patient in the TVT group reported using medication for incontinence, and none used pads; in the colposuspension group, three women were using medication and six required pads. The TVT procedure also was significantly better than colposuspension in measures of patient satisfaction. The procedure met expectations for 82.9 percent of TVT patients; only 58.8 percent of colposuspension patients said their treatment met their expectations. Similarly, 92.9 percent of the TVT group said they would recommend the procedure to a friend compared with 74.5 percent of the colposuspension group.
The authors conclude that TVT surgery provides a higher rate of cure in women with urinary incontinence. It also is associated with better patient-related outcomes than laparoscopic mesh colposuspension.