Articulo De Anatomia

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original article

Retropubic versus Transobturator Midurethral Slings for Stress Incontinence
Holly E. Richter, Ph.D., M.D., Michael E. Albo, M.D., Halina M. Zyczynski, M.D., Kimberly Kenton, M.D., Peggy A. Norton, M.D., Larry T. Sirls, M.D., Stephen R. Kraus, M.D., Toby C. Chai, M.D., Gary E. Lemack, M.D., Kimberly J. Dandreo,M.Sc., R. Edward Varner, M.D., Shawn Menefee, M.D., Chiara Ghetti, M.D., Linda Brubaker, M.D., Ingrid Nygaard, M.D., Salil Khandwala, M.D., Thomas A. Rozanski, M.D., Harry Johnson, M.D., Joseph Schaffer, M.D., Anne M. Stoddard, Sc.D., Robert L. Holley, M.D., Charles W. Nager, M.D., Pamela Moalli, M.D., Ph.D., Elizabeth Mueller, M.D., Amy M. Arisco, M.D., Marlene Corton, M.D., Sharon Tennstedt,Ph.D., T. Debuene Chang, M.D., E. Ann Gormley, M.D., and Heather J. Litman, Ph.D., for the Urinary Incontinence Treatment Network*

A bs t r ac t
Background
From the University of Alabama at Birmingham, Birmingham (H.E.R., R.E.V., R.L.H.); the University of California at San Diego (M.E.A., C.W.N.) and Kaiser Permanente California (S.M.) — both in San Diego; the University of Pittsburgh,Magee–Womens Hospital, Pittsburgh (H.M.Z., C.G., P.M.); Loyola University, Maywood, IL (K.K., L.B., E.M.); the University of Utah, Salt Lake City (P.A.N., I.N.); William Beaumont Hospital, Royal Oak, MI (L.T.S.); the University of Texas, San Antonio (S.R.K., T.A.R., A.M.A.); the University of Maryland Baltimore, Baltimore (T.C.C., H.J.); the University of Texas Southwestern Medical Center, Dallas (G.E.L.,J.S., M.C.); New England Research Institutes, Watertown, MA (K.J.D., A.M.S., S.T., H.J.L.); Oakwood Hospital, Dearborn, MI (S.K.); the National Institutes of Health, Bethesda, MD (T.D.C.); and Dartmouth–Hitchcock Medical Center, Lebanon, NH (E.A.G.). Address reprint requests to Dr. Richter at the Department of Obstetrics and Gynecology, University of Alabama at Birmingham, 1700 6th Ave. South, Suite10382, Birmingham, AL 35233, or at hrichter@uabmc.edu. *The names of the Urinary Incontinence Treatment Network investigators are listed in the Supplementary Appendix, available with the full text of this article at NEJM.org. This article (10.1056/NEJMoa0912658) was published on May 17, 2010, and was updated on May 18, 2010, at NEJM.org. N Engl J Med 2010;362:2066-76.
Copyright © 2010Massachusetts Medical Society.

Midurethral slings are increasingly used for the treatment of stress incontinence, but there are limited data comparing types of slings and associated complications.
Methods

We performed a multicenter, randomized equivalence trial comparing outcomes with retropubic and transobturator midurethral slings in women with stress incontinence. The primary outcome was treatmentsuccess at 12 months according to both objective criteria (a negative stress test, a negative pad test, and no retreatment) and subjective criteria (self-reported absence of symptoms, no leakage episodes recorded, and no retreatment). The predetermined equivalence margin was ±12 percentage points.
Results

A total of 597 women were randomly assigned to a study group; 565 (94.6%) completed the12-month assessment. The rates of objectively assessed treatment success were 80.8% in the retropubic-sling group and 77.7% in the transobturatorsling group (3.0 percentage-point difference; 95% confidence interval [CI], −3.6 to 9.6). The rates of subjectively assessed success were 62.2% and 55.8%, respectively (6.4 percentage-point difference; 95% CI, −1.6 to 14.3). The rates of voidingdysfunction requiring surgery were 2.7% in those who received retropubic slings and 0% in those who received transobturator slings (P = 0.004), and the respective rates of neurologic symptoms were 4.0% and 9.4% (P = 0.01). There were no significant differences between groups in postoperative urge incontinence, satisfaction with the results of the procedure, or quality of life.
Conclusions

The...