In addition to these evidence-based recommendations, the guideline development group also identifies points of best clinical practice in the original guideline document.
Levels of evidence (Ia-IV) and grading of recommendations (A-C) are defined at the end of the "Major Recommendations" field.
Surgical Procedures
Anterior Vaginal Repair
A - Anterior repair is less successful as an operation for continence than retropubic procedures and has been superseded by sling procedures. Anterior repair still has a role in the treatment of prolapse without incontinence.
Burch Colposuspension
A - Burch colposuspension is the most effective surgical procedure for stress incontinence, with a continence rate of 85–90% at one year. The continence rate falls to 70% at five years; this shows better longevity than other methods of treatment.
Alternative Suprapubic Surgery
B - The role of other suprapubic operations such as Marshall-Marchetti-Krantz, paravaginal repair, and laparoscopic colposuspension, is unclear.
Needle Suspension Procedures
A - Needle suspension procedures should not be performed: initial success rates are not maintained with time and the risk of failure is higher than for retropubic suspension procedures.
Sling Procedures
A - Sling procedures, using autologous or synthetic materials, produce a continence rate of approximately 80% and an improvement rate of 90%, with little reduction in continence over time. Only one synthetic sling procedure (tension-free vaginal tape) has been subjected to randomised study to date.
Numerous materials are available for use in a suburethral sling. As a generalization, autologous material is associated with a greater continence rate and fewer complications than either cadaveric material or synthetic materials [Evidence level Ia].
Injectable Agents
B - Injectable agents have a lower success rate than other procedures: a short-term continence rate of 48% and an improvement rate of 76%. Long term, there is a continued decline in continence. However, the procedure has a low morbidity and may have a role after other procedures have failed (e.g., when a diagnosis of intrinsic sphincter deficiency is made).
Artificial Sphincters
B - Artificial sphincters can be successfully used after previous failed continence surgery but have a high morbidity and need for further surgery (17%).
Preoperative Management
It is recommended that women undergoing surgery for urodynamic stress incontinence should have urodynamic investigations prior to treatment (including cystometry). There was a paucity of data on urodynamics prior to surgery identified in a 2003 Cochrane review; one small study showed that women were more likely to be treated with drugs or surgery as a result of testing. Nevertheless, prior to performing irreversible bladder-neck surgery, it would appear to be beneficial to have assessed objectively the type of incontinence and the presence of any complicating factors such as voiding difficulty or detrusor overactivity, which may affect the surgical decision and provide the basis for informed consent. Surgery should be performed by a surgeon who has been trained in the operation and who has a caseload that enables him or her to provide a suitable level of expertise, especially when any repeat surgery is considered.
Definitions:
Grading of Recommendations
Grade A - Requires at least one randomised controlled trial as part of a body of literature of overall good quality and consistency addressing the specific recommendation (evidence levels Ia, Ib)
Grade B - Requires the availability of well-conducted clinical studies but no randomised clinical trials on the topic of recommendations (evidence levels IIa, IIb, III)
Grade C - Requires evidence obtained from expert committee reports or opinions and/or clinical experience of respected authorities. Indicates an absence of directly applicable clinical studies of good quality (evidence level IV)
Levels of Evidence
Ia: Evidence obtained from meta-analysis of randomised controlled trials
Ib: Evidence obtained from at least one randomised controlled trial
IIa: Evidence obtained from at least one well-designed controlled study without randomisation
IIb: Evidence obtained from at least one other type of well-designed quasi-experimental study
III: Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies, and case studies
IV: Evidence obtained from expert committee reports or opinions and/or clinical experience of respected authorities