Open retropubic colposuspension for urinary incontinence in women

  • Review
  • Intervention

Authors


Abstract

Background

Urinary incontinence is a common and potentially debilitating problem. Open retropubic colposuspension is a surgical treatment which involves lifting the tissues near the bladder neck and proximal urethra in the area behind the anterior pubic bones to correct deficient urethral closure.

Objectives

To assess the effects of open retropubic colposuspension for the treatment of urinary incontinence.

Search methods

We searched the Cochrane Incontinence Group Specialised Register (searched 30 June 2008) and reference lists of relevant articles. We contacted investigators to locate extra studies.

Selection criteria

Randomised or quasi-randomised controlled trials in women with symptoms or urodynamic diagnoses of stress or mixed urinary incontinence that included open retropubic colposuspension surgery in at least one trial group.

Data collection and analysis

Studies were evaluated for methodological quality/susceptibility to bias and appropriateness for inclusion and data extracted by two of the reviewers. Trial data were analysed by intervention. Where appropriate, a summary statistic was calculated.

Main results

This review included 46 trials involving a total of 4738 women.

Overall cure rates were 68.9% to 88.0% for open retropubic colposuspension. Two small studies suggest lower failure rates after open retropubic colposuspension compared with conservative treatment. Similarly, one trial suggests lower failure rates after open retropubic colposuspension compared to anticholinergic treatment. Evidence from six trials showed a lower failure rate for subjective cure after open retropubic colposuspension than after anterior colporrhaphy. Such benefit was maintained over time (RR of failure 0.51; 95% CI 0.34 to 0.76 before the first year, RR 0.43; 95% CI 0.32 to 0.57 at one to five years, RR 0.49; 95% CI 0.32 to 0.75 in periods beyond 5 years). In comparison with needle suspensions there was a lower failure rate after colposuspension in the first year after surgery (RR 0.66; 95% CI 0.42 to 1.03), after the first year (RR 0.48; 95% CI 0.33 to 0.71), and beyond five years (RR 0.32; 95% CI 15 to 0.71). Evidence from twelve trials in comparison with suburethral slings found no significant difference in failure rates in all time periods assessed. Patient-reported failure rates in short, medium and long-term follow-up showed no significant difference between open and laparoscopic retropubic colposuspension, but with wide confidence intervals. In two trials failure was less common after Burch (RR 0.38 95% CI 0.18 to 0.76) than after the Marshall Marchetti Krantz procedure at one to five year follow-up. There were few data at any other follow-up time.

In general, the evidence available does not show a higher morbidity or complication rate with open retropubic colposuspension, compared to the other open surgical techniques, although pelvic organ prolapse is more common than after anterior colporrhaphy and sling procedures.

Authors' conclusions

The evidence available indicates that open retropubic colposuspension is an effective treatment modality for stress urinary incontinence especially in the long term. Within the first year of treatment, the overall continence rate is approximately 85 to 90%. After five years, approximately 70% of patients can expect to be dry. Newer minimal access procedures like tension free vaginal tape look promising in comparison with open colposuspension but their long-term performance is not known and closer monitoring of its adverse event profile must be done. Laparoscopic colposuspension should allow speedier recovery but its relative safety and effectiveness is not known yet.

摘要

背景

應用在尿失禁婦女的開腹式恥骨後陰道懸吊術

尿失禁是常見且可能令人衰弱的問題。開腹式恥骨後陰道懸吊術是將位於恥骨後方的膀胱頸、近端尿道及其附近組織提舉以矯正尿道閉鎖不全的問題的外科手術。

目標

評估開腹式恥骨後陰道懸吊術應用於尿失禁的治療成效。

搜尋策略

我們搜尋了Cochrane 資料庫的失禁群組的特別登錄資料(Incontinence Group specialised register)(2004年6月30日搜尋),及相關文獻的參考資料索引。我們與研究者們連繫以取得額外的研究資料。

選擇標準

針對依據臨床症狀或是尿動力學診斷有應力性或混合性尿失禁(stress or mixed incontinence)的婦女所做的隨機或半隨機對照試驗(Randomised or quasirandomised controlled trials),且其中至少有一試驗的群組包含開腹性恥骨後陰道懸吊術。

資料收集與分析

由兩位研究者來評估研究資料的方法學品質以及納入選擇與擷取數據資料的合適與否。試驗的數據資料經過分析,計算出整合後適當的統計資料。

主要結論

這篇文章包含了39篇試驗,共3301位婦女為研究對象。開腹式恥骨後陰道懸吊術的整體治癒率為68.9%至88.0%。2個小型研究顯示開腹式恥骨後陰道懸吊術比起傳統的治療方式,有較低的失敗率。類似地,1篇試驗顯示開腹式恥骨後陰道懸吊術比起抗膽鹼治療(anticholinergic treatment),也有較低的失敗率。根據6篇試驗的研究証據,開腹式恥骨後陰道懸吊術比起陰道前壁修補術(anterior colporrhaphy)治療,在患者主觀的認定上也有較低的失敗率。隨著術後時間的拉長,開腹式恥骨後陰道懸吊術仍保有一定的益處(在術後第1年內失敗率的RR為0.51;95%CI為0.34到0.76,術後1到5年失敗率的RR為0.43;95%CI為0.32到0.57,術後5年以上失敗率的RR為0.49;95%CI為0.32到0.75)。與穿刺懸吊術(needle suspensions) 相較,開腹式恥骨後陰道懸吊術在術後1年內及術後5年以上有較低的失敗率(術後1年內的RR為0.66;95%CI為0.42到1.03,術後5年以上的RR為0.32;95% CI 15到0.71)。根據12篇試驗的研究証據顯示開腹式恥骨後陰道懸吊術與尿道下吊帶懸吊術(suburethral slings)在無論哪個時間點,手術失敗率並無顯著不同。腹腔鏡或是開腹式的陰道懸吊術不論在短期、中期或長期的追蹤後,依據病人的回報其失敗率並無顯著不同,然而其信賴區間較大。在2篇試驗中顯示在施行Burch比起施行Marshall Marchetti Krantz 術式,在術後1到5年的追蹤中,施行Burch的手術失敗較不常見(RR為0.38 95% CI為0.18到0.76)。除了以上提及的幾個時間點外,在其餘時間點的追蹤資料並不多。大致上,依據研究資料所得的証據顯示,開腹式恥骨後陰道懸吊術相較其他的開腹式外科手術並無較高的致病率(morbidity)或併發症,雖然相較陰道前壁修補術及吊帶懸吊術式,開腹式恥骨後陰道懸吊術後發生骨盆腔器官脫垂較為常見。

作者結論

目前所得的証據顯示開腹式恥骨後陰道懸吊術,特別是在長期治療效果方面,是治療應力性尿失禁有效的治療方法。在治療後一年內,整體的無尿失禁率(continence rate)約是85到90%。治療後5年,約70%的病人可以預期是不會失禁的。新的微創式手術像是無張力性陰道吊帶(tension free vaginal tape)比起開腹式陰道懸吊術看來大有前途,但微創式手術的長期效果仍屬未知,而更仔細的手術副作用監測是必須要施行的。腹腔鏡式陰道懸吊術能讓病人更快速的康復,但是它的治療效果仍未知。

翻譯人

本摘要由中國醫藥大學附設醫院王弼慧翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

雖然有新興的手術技術看來極具潛力,開腹式恥骨前陰道懸吊術對於治療女性的應力性尿失禁是一種有效的手術方式。應力性尿失禁是在咳嗽、笑、打噴嚏及運動時會有尿液滲出的狀況。它可能是由於支持膀胱的肌肉及韌帶有變化而造成。訓練肌肉強化的運動對這狀況可以有幫助,另外也有手術可以加強支持膀胱的力量或是直接矯正病灶處。開腹式恥骨後陰道懸吊術是在提舉膀胱及尿道間的組織。這篇回顧文章發現在治療婦女的應力性及混合性尿失禁上,開腹式恥骨後陰道懸吊術是個有效的手術方法,能達到長期的治癒效果。新的技術尤其是吊帶手術(包含無張力性陰道吊帶術(TVT  tensionfree vaginal tape))及腹腔鏡式陰道懸吊術(keyhole (laparoscopic) colposuspension)雖然看來大有前途,但需要進一步的研究,尤其是長期的治療效果方面。

Plain language summary

Open retropubic colposuspension for urinary incontinence in women.

Stress urinary incontinence is losing urine when coughing, laughing, sneezing or exercising. It can be caused by changes to muscles and ligaments holding up the bladder. Muscle-strengthening exercises can help, and there are surgical techniques to improve support or correct problems. Open retropubic colposuspension involves lifting the tissues around the junction between the bladder and the urethra. The review of trials found that this is an effective surgical technique for stress and mixed urinary incontinence in women, resulting in long term cure for most women. New techniques, particularly sling operations (including the use of TVT - tension-free vaginal tape) and keyhole (laparoscopic) colposuspension, look promising but need further research particularly on long term performance.

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