Hypothesis / aims of study
The severity of stress urinary incontinence (SUI) can be evaluated with a variety of instruments (1). It is not known whether the assessment of the severity of SUI is important before any attempt for the correction of it. It is widely accepted that if a treatment offers certain success rates of cure, these rates apply to all the patients with SUI, irrespective of the severity of the condition. This may be true, however different treatments can be associated with different kind of complications, and it could be more logical to decide which treatment to apply to each patient with a strategy of maximum results with minimum complications. The aim of the study is to systematically review the current literature in order to answer the question whether the pre-operative grade of SUI severity affects the post-operative outcome.
Study design, materials and methods
This systematic review was conducted according to PRISMA guidelines (2) and registered in the PROSPERO (ID: CRD420251017900). It was conducted by searching the three primary online medical databases: PubMed), Scopus, and Cochrane Library Database from inception to December 2024. The PICO (i.e. population, intervention, comparison, and outcomes) criteria were utilized for selection of studies (2). Population: women with incontinence who had evaluation of the pre-op SUI severity; Intervention: any surgical intervention, Comparison: results of different interventions; Outcomes: success rates and/or dry rates according to pre-operative SUI severity. Main exclusion criteria: (i) No report of pre-operative and post-operative of severity of SUI was found, (ii) SUI was recurrent (n=5), and (iii) not standardized techniques were used.
Results
From a total of 11,535 studies, 24 (4380 patients) were included for further analysis (6 RCTs, 11 were prospective, and 7 retrospective cohort studies. In 13 studies (n=3599) a synthetic or autologous graft was used (TVT, TOT, TVT-O, SIMS, fascia lata); in 11 studies (n=781) energy-based devices (Er:Yag, CO2, RF) or platelet-rich plasma were used. The results are depicted in Table 1. In summary, successful treatment of mild or Grade 1 incontinence was achieved in 84.73% of the patients (333/393; 89.64%, 277 in 309 patients who had MUS, and 66.67%, 56 in 84 who had EBD), treatment of moderate or Grade 2 incontinence in 88.35% of the patients (1145/1296; 92.01%, 1082 in 1176 patients who had MUS, and 52.50%, 63 in 120 who had EBD), and treatment of severe/very severe or Grade 3 incontinence in 75.73% of the patients (447/591; 83.94%, 392 in 467 patients who had MUS, and 44.35%, 55 in 124 who had EBD).
Interpretation of results
This is the first review that offers information about the success of SUI treatment according to the grade of pre-operative incontinence severity. The study suggests that there is significant difference between treatment modalities and that the more severe the incontinence, the more aggressive the intervention should be in order to accomplish dry rates. The study suggests that mid-urethral slings perform constantly better compared to non-surgical alternatives (i.e.energy-based devices or PRF) in the treatment of SUI. However, the more severe the incontinence, the less efficacious the methods (both MUS and EBD) are. Moreover, the same studies, indicate that when improvement is the main outcome, all methods have acceptable results in the groups of mild and moderate SUI.