Traditional suburethral sling operations for urinary incontinence in women

Lucky Saraswat*, Haroon Rehman, Muhammad Imran Omar, June D. Cody, Patricia Aluko, Cathryn M. A. Glazener

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

17 Citations (Scopus)
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Stress urinary incontinence constitutes a significant health and economic burden to society. Traditional suburethral slings are surgical operations used to treat women with symptoms of stress urinary incontinence.


To assess the effectiveness of traditional suburethral sling procedures for treating stress urinary incontinence in women; and summarise the principal findings of relevant economic evaluations.

Search methods

We searched the Cochrane Incontinence Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), as well as MEDLINE, MEDLINE In‐Process, MEDLINE Epub Ahead of Print, the Cumulative Index to Nursing and Allied Health Literature (CINAHL),, and the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP); we handsearched journals and conference proceedings (searched 27 February 2017) and the reference lists of relevant articles. On 23 January 2019, we updated this search; as a result, several additional reports of studies are awaiting classification.

Selection criteria

Randomised or quasi‐randomised trials that assessed traditional suburethral slings for treating stress or mixed urinary incontinence.

Data collection and analysis

At least two review authors independently extracted data from included trials and assessed risk of bias. When appropriate, a summary statistic was calculated: risk ratio (RR) for dichotomous data, odds ratio (OR) for continence and cure rates that were expected to be high, and mean difference (MD) for continuous data. We adopted the GRADE approach to assess the quality of evidence.

Main results

A total of 34 trials involving 3244 women were included. Traditional slings were compared with 10 other treatments and with each other.

We did not identify any trials comparing suburethral slings with no treatment or sham treatment, conservative management, anterior repair, or laparoscopic retropubic colposuspension. Most trials did not distinguish between women having surgery for primary or recurrent incontinence. One trial compared traditional slings with bladder neck needle suspension, and another trial compared traditional slings with single‐incision slings. Both trials were too small to be informative.

Traditional suburethral sling operation versus drugs

One small trial compared traditional suburethral sling operations with oxybutynin to treat women with mixed urinary incontinence. This trial did not report any of our GRADE‐specific outcomes. It is uncertain whether surgery compared with oxybutynin leads to more women being dry (83% vs 0%; OR 195.89, 95% confidence interval (CI) 9.91 to 3871.03) or having less urgency urinary incontinence (13% vs 43%; RR 0.29, 95% CI 0.09 to 0.94) because the quality of this evidence is very low.

Traditional suburethral sling versus injectables

One small trial compared traditional slings with suburethral injectable treatment. The impact of surgery versus injectables is uncertain in terms of the number of continent women (100% were dry with a traditional sling versus 71% with the injectable after the first year; OR 11.57, 95% CI 0.56 to 239.74), the need for repeat surgery for urinary incontinence (RR 0.52, 95% CI 0.05 to 5.36) or the occurrence of perioperative complications (RR 1.57, 95% CI 0.29 to 8.49), as the quality of evidence is very low.

Traditional suburethral sling versus open abdominal retropubic colposuspension

Eight trials compared slings with open abdominal retropubic colposuspension. Moderate‐quality evidence shows that the traditional suburethral sling probably leads to more continent women in the medium term (one to five years) (69% vs 59% after colposuspension: OR 1.70, 95% CI 1.22 to 2.37). High‐quality evidence shows that women were less likely to need repeat continence surgery after a traditional sling operation than after colposuspension (RR 0.15, 95% CI 0.05 to 0.42). We found no evidence of a difference in perioperative complications between the two groups, but the CI was very wide and the quality of evidence was very low (RR 1.24, 95% CI 0.83 to 1.86).

Traditional suburethral sling operation versus mid‐urethral slings

Fourteen trials compared traditional sling operations and mid‐urethral sling operations. Depending on judgements about what constitutes a clinically important difference between interventions with regard to continence, traditional suburethral slings are probably no better, and may be less effective, than mid‐urethral slings in terms of number of women continent in the medium term (one to five years) (67% vs 74%; OR 0.67, 95% CI 0.44 to 1.02; n = 458; moderate‐quality evidence). One trial reported more continent women with the traditional sling after 10 years (51% vs 32%: OR 2.22, 95% CI 1.07 to 4.61). Mid‐urethral slings may be associated with fewer perioperative complications (RR 1.74, 95% CI 1.16 to 2.60; low‐quality evidence).

One type of traditional sling operation versus another type of traditional sling operation

Nine trials compared one type of traditional sling operation with another. The different types of traditional slings, along with the number of different materials used, mean that trial results could not be pooled due to clinical heterogeneity. Complications were reported by two trials ‐ one comparing non‐absorbable Goretex with a rectus fascia sling, and the second comparing Pelvicol with a rectus fascial sling. The impact was uncertain due to the very low quality of evidence.

Authors' conclusions

Low‐quality evidence suggests that women may be more likely to be continent in the medium term (one to five years) after a traditional suburethral sling operation than after colposuspension. It is very uncertain whether there is a difference in urinary incontinence after a traditional suburethral sling compared with a mid‐urethral sling in the medium term. However, these findings should be interpreted with caution, as long‐term follow‐up data were not available from most trials. Long‐term follow‐up of randomised controlled trials (RCTs) comparing traditional slings with colposuspension and mid‐urethral slings is essential. Evidence is insufficient to suggest whether traditional suburethral slings may be better or worse than other management techniques. This review is confined to RCTs and therefore may not identify all of the adverse effects that may be associated with these procedures.

A brief economic commentary (BEC) identified three eligible economic evaluations, which are not directly comparable due to differences in methods, time horizons, and settings. End users of this review will need to assess the extent to which methods and results of identified economic evaluations may be applicable (or transferable) to their own setting.
Original languageEnglish
Article numberCD001754
Number of pages256
JournalCochrane Database of Systematic Reviews
Issue number1
Publication statusPublished - 28 Jan 2020

Bibliographical note

Funding Information:
We are grateful to Adrian Grant, Jonathan Cook, Aldemar Araujo Castro, and several anonymous peer-referees for assistance and valuable comments on this and previous versions of the review. Sheila Wallace provided support for each version of the review as well as for this update and in the classification and identification of new studies. Fiona Stewart assisted with rewriting the effects of interventions section, conversion of incontinence to continence outcomes, and related changes in 'Summary of findings' tables. The review was originally conceived and conducted by Carlos CB Bezerra and Homero Bruschini. An earlier version of this review was completed as part of a project to add brief economic commentaries to Cochrane Incontinence's Reviews on surgery for urinary incontinence in women (Dean 2017). This project was supported by the National Institute for Health Research (NIHR) via the Cochrane Review Incentive Scheme 2016.


  • *Suburethral Slings [adverse effects] [economics]
  • Polytetrafluoroethylene [therapeutic use]
  • Randomized Controlled Trials as Topic
  • Treatment Outcome
  • Urinary Incontinence [drug therapy] [surgery]
  • Urinary Incontinence, Stress [drug therapy] [*surgery]
  • Adult
  • Female
  • Humans


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