Comparison between the retro-pubic approach with tension-free vaginal mesh (TVT) and the transobturator approach (TVT-O / TOT) in the treatment of stress urinary incontinence: A meta-analysis of effectiveness and complications

Abstract

Introduction: Urinary incontinence is a potentially treatable condition, which can be a cause of significant anxiety and shame for women. Historically, the retropubic access TVT was considered gold-standard for the surgical management of this condition. Over a decade ago, the transobturator approach emerged as a surgical alternative to avoid complications associated with the retropubic approach. The aim of this study is to compare the effectiveness of both approaches (Retropubic and Transobturator) as well as the complications associated with these.
Methodology: A systematic search was conducted in the literature in PUBMED, LILACS and CENTRAL; 117 studies were initially identified, of which 14 were included in our analysis according to inclusion/exclusion criteria. Among the results of interest, we analyzed the objective and subjective cure rate, and the rate of associated complications to both approaches, by estimation of relative risk with a confidence interval of 95%.
Results: A total of 3022 women who underwent surgical interventions for urinary incontinence were included; 1496 women were subjected to the transobturator approach and 1526 women underwent the retropubic approach. We analyzed the subgroup of transobturator TVT IN-OUT vs retropubic TVT without finding significant differences compared to our initial analysis. We determined that the objective cure rate between transobturator approach vs retropubic is similar, with a tendency to favor cure in the retropubic group, a difference that was only statistically significant 12 months post-surgery. The subjective cure rate, on the other hand, didn’t reach a statistically significant difference between both surgical approaches in any of the periods analyzed. Among the complications observed, we found a higher incidence of post-operative pain in the transobturator approach (RR:2,14; 95% CI, 1.42-3.22); a higher incidence of emptying anomalies was found in the patients who underwent a retropubic TVT compared to the group that underwent the transobturator TVT, specifically in the IN-OUT group (TVT-O VS TVT: RR 0.61, 95% CI, 0.39-0.94); and in regards to the rate of bladder injury, there was a lower incidence after the transobturator approach (RR: 0.20, 95% CI, 0.11-0.37). No other complication reached statistically significant differences.
Conclusion: As was found in the existing literature, when comparing the transobturator and retropubic approach, no difference was found between the rates of objective cure and subjective cure, nevertheless there is a clear tendency towards a higher rate of objective cure in the patients subjected to a retropubic TVT. However, there is a higher incidence of post-surgical pain related to the transobturator approach and a higher rate of bladder injury and emptying disorders after a retropubic approach.