NEUROUROLOGY & FEMALE UROLOGY

Outcomes following sling surgery: importance of definition of success
Rapp DE, Kobashi KC
Continence Center at Virginia Mason Medical Center, Seattle, Washington, USA
J Urol. 2008; 180: 998-1002

• Purpose: The assessment of incontinence therapies is complicated by the diverse outcomes instruments and definitions of success used by investigators. We defined this effect by using varied definitions of success to perform outcomes analysis following sling placement.
• Materials and Methods: A retrospective review of patients undergoing SPARC (314) and autologous rectus pubovaginal sling (127) placement was performed, with 204 patients with the SPARC and 67 with pubovaginal sling completing questionnaire surveillance with the minimum 12-month follow-up. Outcomes were assessed using a questionnaire comprising validated incontinence questionnaires (Urogenital Distress Inventory and Incontinence Impact Questionnaire) and additional items addressing satisfaction. Success rates were compared using alternate definitions of success across all outcomes measures (eg dry rate, pad rate, percent improvement, degree of satisfaction).
• Results: Wide variations in outcomes were seen depending on the definition used for success (SPARC success range 33% to 87%, pubovaginal sling 40% to 79%). Total absence of leakage was the strictest definition of success while continued use of 1 to 3 liners was associated with the highest success rates. In addition, 74% of patients with SPARC placement and 66% with the pubovaginal sling reported willingness to undergo sling surgery again despite the treatment failing to meet the criteria for success under multiple definitions. Finally, the individual sling type (SPARC vs. pubovaginal) associated with the superior success rate varied with the definition of success. However, these differences failed to achieve statistical significance.
• Conclusions: Our data suggest that success rates following sling placement are significantly affected by the definition of success. Investigation to define standardized outcomes measures following incontinence surgery is of great importance to the urological community.
  
  
• Editorial Comment
  The authors delve into the complicated world of gauging success after sling surgery. Their study pool for analysis was 271 patients of which 204 received the SPARC™ suburethral sling while 67 underwent a pubovaginal sling using autologous fascia. The authors found that if the strictest definition of success was utilized, that is, “dry is dry”, patients had a markedly lower success rate than when light pads was used as the definition of success. In addition, they noted that if the patient was improved by greater than 50% they were more prone to recommending the surgery or repeating the surgery as opposed to those not reaching 50%. These authors also compared the two techniques in a sliding scale of metrics of success noting the potential significant difference in the reported success rate. The two operations did have some disparity in that the SPARC™ operation had a higher pad free rate reported while the pubovaginal sling had more patients stating that they were dry.
  One should strongly consider reading this excellent article in its entirety prior to judging the efficacy of reported sling operations. The authors make several excellent points in their discussion section including the call for completely dry to be used only in the strictest sense of the word. Of note is that the paper did not expand into postoperative complications including voiding dysfunction and its affect on sling success and outcomes.

Dr. Steven P. Petrou
Associate Professor of Urology
Chief of Surgery, St. Luke’s Hospital
Associate Dean, Mayo School of Graduate Medical Education
Jacksonville, Florida, USA
E-mail: petrou.steven@mayo.edu