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Surgery versus Physiotherapy

for Stress Urinary Incontinence


Julien Labrie, M.D., Bary L.C.M. Berghmans, Ph.D., Kathelijn Fischer, M.D., Ph.D.,
Alfred L. Milani, M.D., Ph.D., !leana "an Der #ij$, M.D., Dina J.C. %malbraa$, M.D.,
Astrid "llebregt, M.D., Ph.D., &en' P. %chellart, M.D., (iuse))e C.M. (ra*isi, M.D.,
Ph.D., J. Marinus "an Der Pleg, M.D., Jse)h F.(.M. Bruns, M.D., Ph.D., +. %tella M.
,iersma, M.D., Ph.D., Annette (. (renendij$, M.D., Ph.D., Piet %chlten, M.D., Ph.D.,
Ben #illem Ml, M.D., Ph.D., +lisabeth +. Bl$huis, M.D., Albert -. Adriaanse, M.D.,
Ph.D., Aaltje %chram, M.D., Ph.D., Jan.)aul #.&. &/ers, M.D., Ph.D., Antine L.M.
Lagr.janssen, M.D., Ph.D., And Carl -. "an Der "aart, M.D., Ph.D.
0 +ngl J Med 12345 46783319.33
dr. Risa Yolanda M (OSA)
Introduction

The International Consultation on


Incontinence => stress urinary incontinence
as an involuntary loss of urine on hysical
e!ertion" snee#in$" or cou$hin$.

%rst&line 'ana$e'ent => (hysioteray )ith


su*+ective success (,- to ./0) and o*+ective
success (, to 1.0)

Second line 'ana$e'ent => Midurethral&


slin$ sur$ery )ith su*+ective cure rates
*et)een /,0 and .10 and o*+ective cure
rates *et)een ,/0 and .20.
Introduction

After - to 3, years" 2, to ,40 of


)o'en initially treated )ith
hysiotheray have roceeded to
sur$ery.
Introduction

the 5uestion of )hether all )o'en


)ith 'oderate&to&severe stress&
redo'inant urinary incontinence
should initially *e treated )ith
hysiotheray or sur$ery

Midurethral&slin$ sur$ery and


hysiotheray have not *een directly
co'ared

Rando'i#ed trial to co'are initial


'idurethral&slin$ sur$ery )ith initial
hysiotheray" usin$ standardi#ed
outco'e 'easures at 32 'onths.
Methods

Rando'i#ed trial at 1 university


'edical centers and 3. 6utchs $eneral
hositals.

Inclusion 7

)o'en -, & 84 years old

)ith stress urinary incontinence classi%ed


as 'oderate or severe accordin$ to the
severity inde! develoed *y Sandvi9

(asien )ho had under$one hysiotheray


'ore than : 'onths *efore rando'i#ation

;!clusion 7

<o'en )ho had under$one revious


incontinence sur$ery

)ho had conco'itant elvic&or$an


rolase of sta$e 2 or hi$her

Tar$et oulation => 2 $rou


(sur$ery and hysioteray) => each
$rou have four *loc9 =>accordin$
to the severity ('oderate or severe)

The treat'ent assi$n'ents )ere not


concealed.

Sur$ical => 1. $ynecolo$ists and


urolo$ists

(hysiotheray => 8-
hysiotheraists

(hysiotheray 7

ro$ra' to hel )o'en *uild u to 8 to 32


'a!i'al contractions three ti'es er day

$iven at 3&)ee9 or 2&)ee9 intervals

nine sessions in . to 38 )ee9s

If a )o'an )as una*le to contract her elvic&


=oor 'uscles => functional electrosti'ulation.

If a )o'an )as dissatis%ed )ith the result =>


cross over to the alternative treat'ent" )hich
is consistent )ith usual clinical ractice

ri'ary outco'e 7

su*+ective i'rove'ent => (atient >lo*al


I'ression of I'rove'ent ((>I&I) => 2" 1"
:" and 38 'onths to 'onitor chan$es

Secondary outco'e 7

uro$enital sy'to' i'rove'ent? disease&


seci%c 5uality of life =>@ro$enital
6istress Inventory (@6I) and the
Incontinence I'act Auestionnaire (IIA)

6ata )ere collected at 2" 1" :" 32"


and 38 'onths B
RESULTS

Cro' March 2448 & May 2434" total


:,: )o'en )ith stress urinary
incontinence or 'i!ed urinary
incontinence.

hysiotheray $rou

)o'en )ho had under$one seciali#ed


hysiotheray *efore 1/.10 (38 of -8)

)o'en )ho had not received revious


treat'ent 1..10 (83 of 3:1)

22 )o'en (33"20) $rou sur$ery


=> additional hysiotheray after
sur$ery

At 32 'onths" the sur$ery $rou


reorted i'rove'ent is hi$her than
)o'en the hysiotheray $rou?
the diDerence *et)een the $rous
)as 2:.1 0

Su*+ective cure and o*+ective cure


si$ni%cantly > fre5uent in the
sur$ery $rou than in the
hysiotheray $rou

i'rove'ent in @6I and IIA do'ain scores"


as co'ared )ith *aseline values

I'rove'ents in the @6I scores for


incontinence and overactive *ladder )ere
si$ni%cantly $reater in the sur$ery $rou
than in the hysiotheray $rou

In the co'arison of IIA do'ain scores


*et)een $rous" i'rove'ents in 'o*ility
and e'*arrass'ent scores )ere si$ni%cantly
$reater in the sur$ery $rou than in the
hysiotheray $rou

A total of :, adverse events occurred in 13


(..80) of 13/ )o'en? all adverse events
)ere related to sur$ery

Intraoerative *ladder erforatio

va$inal eithelial erforations

Three )o'en had a recorded *lood loss of ,44


'l or 'ore

One )o'an needed reoeration to loosen the


synthetic slin$

si! reoerations )ere erfor'ed for tae


e!osure.

)o'en )ho under)ent only


hysiotheray (34-)

those )ho under)ent sur$ery after


hysiotheray (..)

those )ho under)ent initial sur$ery


(23,)

<o'en )ho under)ent only


hysiotheray also had lo)er
fre5uencies of su*+ective and
o*+ective cure" as co'ared )ith
*oth $rous of )o'en )ho
under)ent sur$ery.
Discussion

co'ared strate$ies of initial


sur$ery and initial hysiotheray"
)ith an otion to cross over to
sur$ery" in the treat'ent of )o'en
)ith 'oderate&to&severe stress&
redo'inant urinary incontinence

Sur$ery also resulted in $reater


i'rove'ent than did hysiotheray
on all secondary end oints.

The fre5uency of i'rove'ent in the sur$ery


$rou (.4.80) )as sli$htly hi$her than that
reorted in the literature (:8 to 8/0)

The i'rove'ent rate (:1.10) )e o*served in


the hysiotheray $rou" )hich included )o'en
)ho crossed over to sur$ery" )as hi$her than the
rates in t)o other hysiotheray studies" )hich
did not allo) crossover (--0 and 1-0).-,"-: Our
hi$h crossover rate is the 'ost li9ely e!lanation?
the fre5uency of i'rove'ent a'on$ )o'en
)ho did not cross over to sur$ery (-3./0) is
si'ilar to the fre5uencies in the other studies.

In contrast to the %ndin$s in another rior


study", the rate of su*+ective cure a'on$
)o'en in the hysiotheray $rou in our
study )as lo)er than the rate of o*+ective
cure (3,..0 vs. 11.40).

In su''ary" the results of our trial sho) that


)o'en )ith 'oderate&to&severe stress
urinary incontinence have si$ni%cantly
*etter su*+ective and o*+ective outco'es at
32 'onths after sur$ery than after
hysiotheray.