No difference in urinary continence after surgery between retropubic and transobturatoric

transvaginal sling operations when correcting for predisposing factors

No difference in urinary continence after surgery between retropubic and transobturatoric

transvaginal sling operations when correcting for predisposing factors

A Kjaeldgaard1), F Taheri-Johansson2), M Ankardal3)

Dept. Gynecol Obstet. 1)Karolinska University Hospital, 2)Värnamo County Hospital, 3)Sahlgrenska University Hospital , SWEDEN

A Kjaeldgaard1), F Taheri-Johansson2), M Ankardal3)

Dept. Gynecol Obstet. 1)Karolinska University Hospital, 2)Värnamo County Hospital, 3)Sahlgrenska University Hospital , SWEDEN

Material & Methods

• Registerdata 2006-2009 from National Quality Register on Incontinence Surgery in Sweden

• High validity (94% included, 8% drop-outs)• Questionaire preop, 2 months and 12 months

- same questions asked every time• 4024 patients with 2 months follow-up• 1935 of these have also one year follow-up• Continence the primary outcome• Chi 2 test. Significance level p <0,05)

Risk groups

• low risk: no risk factors

• risk

- Urge incontinence- History of incontinence or prolapse surgery- Hysterectomy- BMI > 30- Elderly (age > 75 yy)

• high risk: all risk factors present

Continence at 2 and 12 months follow-up (unselected registerdata)

• TVT superior already at 8 w(p<0.002)

• TVT also better at one year (p<0.02)

• No difference between TOT and TVT-O

• Treatment results decrease only by a good 5% in one year 0%

10%

20%

30%

40%

50%

60%

70%

80%

TVT** TVT-O TOT mean

% continent after 8 weeks

% continent after one year

Predisposing factors-A clinical problem seldomly adressed by RCTs

• Urge incontinence ~60%

• Over-weight ~20%• Over-aged ~10%

• Previous vaginal surgery ~ 15%

• Hysterectomy ~10%

• TO has significant over-representation of risk factors

0%

10%

20%

30%

40%

50%

60%

70%

no traditional riskfactor

urge incontinence BMI>30 age > 75 yy hysterectomy

Risk factors with significant overrepresentation in transobturatoric slings

TVT

TVT-O

TOT

> 80% of our patients present with some risk factor

Risk group does matter when it comes to treatment results

• No difference between TVs in low-risk patients

• Slightly better (p<0,02) result for TVT in risk patients

• Results are reduced by ~20% in the risk group

• Only 50% continent in high risk patients

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

TVT TVT-O TOT

low risk

risk group

high risk

Continence at 2 months follow-up related to risk group

Influence of a single riskfactor on continence after 2 months

Urge

ConclusionsThe Swedish National Quality Register for

Incontinence Surgery

• In low risk patients all sling operations go very well• However >80% of our patients have some risk factor

reducing treatment result at 2 months by nearly 20%• Significantly more patients with one or more risk factors

are treated with transobturatoric methods• Previous hysterectomy is no risk factor• No influence of age per se can be demonstrated until

>75 yy.• Presenting with all risk factors reduces postoperative

continence at 2 months follow-up from nearly 90% to less than 40%

• RCTs will not tell us the fate of the many risk patients

Influence of a single riskfactor on continence after 2 months

Age-related results in low risk group

0

10

20

30

40

50

60

70

80

90

100

<35 35-45 45-55 55-65 65-75 >75*

Age (years)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

never almost never 1-3 times amonth

1-3 times aweek

daily

Postop continent 8 w

Postop continent 1 y

Treatment results in low risk patients

65%

70%

75%

80%

85%

90%

BMI*<30 BMI 30-35 BMI>40

% continent 8w

Treatment results in low risk group

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

no hysterectomy

% continent after 8 weeks