Is LESS is actually more?

There has been significant evolution in the treatment of stress urinary incontinence (SUI). Prior to the mid-urethral tapes, options of transvaginal needle suspension, Burch colposuspension, and the autologous facial slings were available. A minimally invasive sling using polypropylene tension-free vaginal tape (TVT) was introduced in 1996. Since then, several attempts have been made to make this procedure even less invasive. The first major adjustment, the trans-obturator approach, appears to have good long-term results, with comparative trials showing fairly equivalent efficacy between the retropubic and transobturator approaches. The most recent modification is a transvaginal single-incision sling using polypropylene tape. Hinoul and colleagues in a multi-institutional study, prospectively compared the efficacy of the Gynecare TVT™ Obturator (TVT-O) sling with single-incision Gynecare TVT Secur™ sling in 194 randomly assigned patients. The authors excluded patients with a prior failed repair for SUI, prolapse of stage II or more, and those requiring concomitant surgery, from their study. The primary outcome was defined as 12-month objective SUI cure rate, determined using a standing cough stress test at a bladder volume of 300 mL or a volume greater than 70% of the maximum bladder capacity based on the patient's bladder diary. Secondary outcome measures included subjective evaluation of voiding and SUI, visual analog scale (VAS) pain scores, and quality-of-life outcomes using the Dutch version of the Urogenital Distress Inventory (UDI). In this study, authors found that objective SUI cure rates were higher with TVT-O at both 6 and 12 months. At 6 months, SUI was identified in 24.4% of TVT Secur patients compared with none of the TVT-O patients (P < 0.0001) and at 12 months, SUI was identified in 16.4% of TVT Secur patients compared with 2.4% of TVT-O patients (P = 0.002). A similar observation was seen with subjective SUI outcomes at 24 months, with 24% of TVT Secur patients complaining of SUI vs 8.3% of TVT-O patients. De-novo urgency and/or urge incontinence at 12 months were noted in 23% of TVT Secur patients and 16.7% of TVT-O patients, which was not statistically significant. Anticholinergic treatment was given for 12 TVT Secur and 14 TVT-O patients during the first 12 months after surgery. A significantly greater improvement in the urinary incontinence subscale of the UDI was noted in TVT-O patients compared with TVT Secur patients. The authors observed less pain with TVT Secur, with patients having a lower VAS pain score the first 2 weeks after surgery (but not thereafter), and less need for analgesics the first 5 days after surgery (but not thereafter). Mesh exposures were noted in 7 of 96 TVT Secur patients, all of which required surgical closure as compared to one in TVT-O group, in which mesh exposure resolved with local estrogen therapy. In TVT-O group, 92% were available for follow-up at 12 months compared with 65% only in the TVT Secur arm. At the end of one year, 8 patients in TVT Secur group had retreatment with another procedure (type not specified) and 6 patients of TVT Secur arm awaiting next procedure for unresolved SUI. Two patients in the TVT-O arm underwent tape release for persistent voiding symptoms.