不同手术方式治疗女性压力性尿失禁中长期疗效和并发症的网状Meta分析

背景　女性压力性尿失禁（SUI）是一种泌尿外科常见疾病，给女性患者造成了巨大的生活及经济负担。SUI患者通常在保守治疗不理想时选择手术治疗，自Kelly术运用于治疗SUI后，多种新型术式相继发展并在疗效上取得了重大进展，目前仍缺乏新型术式之间中长期疗效及安全性的直接或间接比较。目的　运用网状Meta分析比较经耻骨后尿道固定悬吊术（Burch）、经耻骨后无张力尿道中段吊带术（TVT）、由外向内经闭孔吊带术（TOT）、由内向外无张力尿道中段吊带术（TVT-O）、无张力经阴道尿道中段吊带术（TVT-S）、单切口可调节吊带术（Ajust）治疗女性SUI的有效性及安全性，筛选治疗SUI的最佳手术方式。方法　基于计算机系统检索PubMed，the Cochrane Library，Medline，EMBase数据库中关于比较Burch、TVT、TOT、TVT-O、TVT-S、Ajust术式治疗SUI的随机对照试验（RCT），检索时间从建库至2018年7月。两名研究者对纳入的RCT进行数据提取及质量评价，提取信息包括：第一作者、发表时间、干预措施、样本量、年龄、随访时间和客观治愈率、主观治愈率、排尿困难、阴道黏膜穿孔、下尿路感染、吊带暴露、术后新发急迫症状/急迫性尿失禁、术后大腿疼痛/腹股沟疼痛。采用RevMan 5.3和Stata 14.0进行数据处理。结果　共纳入42篇RCT，6 065例患者。网状Meta分析结果显示，TOT客观治愈率低于TVT〔OR=0.96，95%CI（0.91，1.00），P<0.05〕；Ajust主观治愈率高于Burch、TOT、TVT-O、TVT-S〔OR=1.27，95%CI（1.01，1.61）；OR=1.14，95%CI（1.01，1.27）；OR=1.05，95%CI（1.00，1.10）；OR=1.12，95%CI（1.04，1.22），P<0.05〕，TOT低于TVT〔OR=0.93，95%CI（0.86，1.00），P<0.05〕；TVT-O排尿困难发生率低于TVT〔OR=0.57，95%CI（0.34，0.95），P<0.05〕；TOT阴道黏膜穿孔发生率高于TVT〔OR=4.17，95%CI（1.37，12.74），P<0.05〕，TVT-O阴道黏膜穿孔发生率低于TOT〔OR=0.20，95%CI（0.06，0.66），P<0.05〕；TOT术后下尿路感染发生率低于TVT〔OR=0.62，95%CI（0.42，0.91），P<0.05〕；TVT-O术后大腿/腹股沟疼痛发生率高于Burch〔OR=12.89，95%CI（1.22，135.66），P<0.05〕，TOT、TVT-O术后大腿/腹股沟疼痛发生率高于TVT〔OR=2.37，95%CI（1.00，5.58）；OR=3.07，95%CI（1.50，6.27），P<0.05〕，TVT-S、Ajust术后大腿/腹股沟疼痛发生率低于TVT-O〔OR=0.25，95%CI（0.10，0.63）；OR=0.18，95%CI（0.04，0.84），P<0.05〕。曲线下面积（SUCRA）排序结果显示，在客观治愈率、吊带暴露和术后新发急迫症状/急迫性尿失禁方面，TVT效果较好；在主观治愈率、排尿困难、阴道黏膜穿孔方面，Ajust效果较好；在下尿路感染方面，TOT效果较好；在术后大腿疼痛/腹股沟疼痛方面，Burch效果较好。结论　Ajust在治疗SUI的中长期研究中可能具有较好的疗效和安全性。

Comparison of Medium and Long Term Efficacy and Complications of Different Surgical Methods in the Treatment of Female Stress Urinary Incontinence:a Network Meta-analysis

Background　Female stress urinary incontinence（SUI） is a common urological disease that causes enormous life and financial burden on female patients.SUI patients usually choose surgical treatment when conservative treatment is not ideal.Since Kelly has been used to treat SUI，a variety of new surgical procedures has achieved significant progress in clinical practice.There is still lack of direct or indirect comparison in terms with medium and long-term efficacy and safety between new surgical procedures.Objective　To compare the efficacy and safety of Burch，tension-free vaginal tape（TVT），outside-in transobturator tape（TOT），inside-out tension-free vaginal tape-obturator（TVT-O），tension-free vaginal tape -sling（TVT-S） and adjustable anchored single-incision mini-slings（Ajust） in the treatment of SUI by using network meta-analysis，and screen out the most optimal surgical approach for SUI.Methods　All studies of randomized controlled trials（RCTs） were searched in the PubMed，the Cochrane Library，Medline，EMBase database to compare the efficacy and safety of Burch，TVT，TOT，TVT-O，TVT-S and Ajust from database building to July 2018.Two researchers evaluated the quality of the included RCT and extracted the data，including the first author，publication time，intervention measures，sample size，age，follow-up time and objective cure rate，subjective cure rate，dysuria，vaginal mucosal perforation，lower urinary tract infection，sling exposure，new emergent symptoms after operation/urgent urinary incontinence，thigh pain/inguinal pain after operation.We used RevMan 5.3 software and Stata 14.0 to analyse the data involved.Results　A total of 42 RCTs and 6，065 patients were included.The network meta-analysis showed that the objective cure rate of TOT was lower than that of TVT 〔OR=0.96，95%CI（0.91，1.00），P<0.05〕.Subjective cure rate of Ajust was higher than Burch，TOT，TVT-O，TVT-S〔OR=1.27，95%CI（1.01，1.61）；OR=1.14，95%CI（1.01，1.27）；OR=1.05，95%CI（1.00，1.10）；OR=1.12，95%CI（1.04，1.22），P<0.05〕，and subjective cure rate of TOT was lower than that of TVT 〔OR=0.93，95%CI（0.86，1.00），P<0.05〕.Dysuria incidence of TVT-O was lower than that of TVT 〔OR=0.57，95%CI（ 0.34，0.95），P<0.05〕.The incidence of vaginal epithelial perforation in TOT was higher than that in TVT 〔OR=4.17，95%CI（1.37，12.74），P<0.05〕，and incidence of vaginal epithelial perforation in TVT-O was lower than that in TOT 〔OR=0.20，95 %CI（0.06，0.66），P<0.05〕.The incidence of urinary tract infection in TOT was lower than that in TVT〔OR=0.62，95%CI（0.42，0.91），P<0.05〕.The incidence of groin or thigh pain in TVT-O was higher than that in Burch 〔OR=12.89，95%CI（1.22，135.66），P<0.05〕；incidence of groin or thigh pain in TOT and TVT-O was higher than that in TVT 〔OR=2.37，95%CI（1.00，5.58）；OR=3.07，95%CI（1.50，6.27），P<0.05〕；incidence of groin or thigh pain in TVT-S and Ajust was lower than that in TVT-O 〔OR=0.25，95%CI（0.10，0.63）；OR=0.18，95%CI（0.04，0.84），P<0.05〕.The surface under the cumulative ranking curves（SUCRA） value ranking results showed that TVT had better objective cure rate，sling exposure and fewer new emergent symptoms/urgent urinary incontinence after operation；Ajust had significantly better subjective cure rate，fewer dysuria and vaginal perforation；TOT had a better superiority in urinary tract infection；Burch had a better superiority in groin or thigh pain.Conclusion　Ajust is probably associated with better efficacy and safety in the medium and long term study of SUI treatment.