What's new in slings: an update on midurethral slings

PURPOSE OF REVIEW: Surgical management of female stress incontinence has progressed rapidly over the past decade. The purpose of this review is to provide up-to-date information regarding surgical outcomes of midurethral slings and to discuss management of sling complications. Additionally, the newer commercially available products will be outlined and the data comparing new versus established techniques will be examined. RECENT FINDINGS: Long-term data are available for the Tension-free Vaginal Tape procedure which demonstrates durable efficacy. Comparisons between the Tension-free Vaginal Tape and Suprapubic Arch sling procedure demonstrate no significant difference in cure rates or complications. In an effort to avoid the retropubic space, the transobturator slings were developed and short-term data suggest similar efficacy to the transabdominal techniques. The transobturator approach, while limiting abdominal complications, is not without its own complication profile. Increased experience with synthetic mesh in vaginal surgery has allowed for a more systematic approach to managing mesh erosions. SUMMARY: The literature indicates that midurethral slings, despite the specific approach, are efficacious and an important therapy in managing stress incontinence. Prospective data will be needed before the surgeon can determine if the new products and techniques are truly an improvement over the existing products or merely a proprietary modification.     

Retropubic synthetic midurethral slings: Techniques and outcomes

Retropubic midurethral slings have evolved to become one of the standard therapies for treatment of stress urinary incontinence. The current slings can be placed through a small vaginal incision, with minimal dissection, in the ambulatory setting. With improvements in technique, complications are minimal. Although the tension-free vaginal tape has the most prospective data in the literature, the suprapubic arc sling appears to have equal cure and complication rates in shorterterm studies. Other retropubic slings have a paucity of data, and long-term equivalency studies have yet to be reported. This article describes the techniques of the most commonly performed retropubic synthetic slings and reports on efficacy and outcomes based on recently published studies.     

Informed consent: a review

Of paramount importance is the respect for autonomy and right to self-determination inherent in an ethically sound decision-making process. The President's Commission clearly summarized the prevailing view of informed consent when it stated: "ethically valid consent is a process of shared decision making based on mutual respect and participation, not a ritual to be equated with reciting the content of a form that details the risks of a particular treatment or intervention".     

Effectiveness of midurethral slings in mixed urinary incontinence: a systematic review and meta-analysis

Introduction and hypothesis  

Mixed urinary incontinence (MUI) is a coexistence of stress (SUI) and urgency urinary incontinence (UUI). There is conflicting evidence on the effectiveness of midurethral slings (MUS) in this condition. The objective of this study is to evaluate the effectiveness of MUS in women with MUI by systematic review of the literature.     

Effectiveness of midurethral slings in recurrent stress urinary incontinence: a systematic review and meta-analysis

Introduction and hypothesis

Midurethral slings (MUS) are the gold standard primary procedure for the surgical treatment of stress urinary incontinence (SUI). There is no robust evidence on the success with MUS in the treatment of recurrent SUI. Our objective was to evaluate the effectiveness and complications of MUS in women with recurrent SUI by systematic review and meta-analysis of the literature.

Methods

A systematic literature search was carried out (up to August 2011) using relevant search terms in MEDLINE, EMBASE, CENTRAL and Google Scholar. Relevant randomised controlled trials (RCT) and prospective studies were selected and then analysed by two independent reviewers. Meta-analysis of cure stated in prospective cohort studies was performed with a random effects model using Stata 8.

Results

There was 1 randomised trial and 11 good quality prospective studies included in this systematic review. The overall subjective cure rate per meta-analysis of prospective cohort studies following MUS for recurrent SUI after any previous surgery was found to be 78.5?% [95?% confidence interval (CI) 69–88] at the follow-up of 29.72?±?29.49?months. The subjective cure rate following MUS after previous failed MUS was 73.3?% (95?% CI 55–97) at the follow-up of 15.7?±?7.7?months.

Conclusions

The studies report good cure rates of SUI after MUS surgery following previous incontinence surgery (62–100?%). There seems to be a lower cure rate with transobturator compared to the retropubic tape for recurrent SUI after previous surgery.     

Informed consent for the neurosurgeon

Obtaining informed consent from patients contemplating neurosurgical procedures is an important process in preoperative care. A surgeon's failure to fulfill his or her legally prescribed duty to inform the patient and obtain consent can result in unnecessary exposure to liability. This paper describes the legal background, doctrine, and elements of informed consent. It also outlines the dialog that should legally take place between physician and patient before a planned procedure and discusses special circumstances that may affect the informed consent process.     

Informed consent for facial transplantation

Now that partial face transplantation has been performed, attention is focused on likely functional, aesthetic and immunological outcomes, and full facial transplantation is the likely next step. Facial transplantation has been the source of ethical debate, a key part of which focuses on valid informed consent. We review the process of informed consent in health settings, assessing how applicable the current standards are for facial transplantation. The factors which need to be assessed during the screening programme are outlined. We conclude that both individual and process factors are important in obtaining consent for radical new procedures, and outline our own gold standard for ensuring informed consent in facial transplantation.     

Informed consent: is it a myth?

The issue of informed consent at it relates to neurosurgical professional malpractice liability and litigation has been of concern for 20 years or more. The problem persists, and the subject has been addressed by providing patient education with full disclosure regarding neurosurgical procedures. In the process of imparting informed consent, the authors studied the effectiveness of specific neurosurgical health care teaching. One hundred six persons undergoing anterior cervical fusion or lumbar laminectomy were instructed by a neurosurgeon and clinical nurse specialist with a master's degree in neurosurgery. Written testing was performed in each case immediately after a formal teaching session before surgery. Questions were simple and covered only four general topics: 1) diagnosis and surgical techniques; 2) operative risks; 3) postoperative care; and 4) goals and benefits relating to surgery. The mean score on testing immediate retention of information revealed a 43.5% overall performance rate. When patients were tested approximately 6 weeks later, the score dropped to 38.4%. This was statistically significant (chi 2, P less than 0.05). The authors encourage the concept of patient education. The data in the current study, however, suggest that the reasonable and prudent neurosurgeon making a concerted effort at patient education, with the assistance of a professional educator, cannot necessarily expect accurate patient or family recall or comprehension. Fulfillment of the doctrine of informed consent by neurosurgeons may very well be mythical.