Subjective versus objective measurement of surgical outcomes of treatment of female stress urinary incontinence: it is not just black and white

Abstract

The best interest of the patient is the only interest to be considered.William J. MayoStress urinary incontinence (SUI) is encountered in as many as 20% of women with adverse social and hygienic consequences [1]. Recently, most studies have shown that the majority of surgical procedures, particularly the minimally invasive midurethral slings, are both safe and effective treatment of female SUI. However, the success rates reported varied between studies, depending on whether objective or subjective outcomes had been measured. The postoperative objective and subjective cure rates were not also correlated in most of these studies. For example, a recent review gives a very wide range of short-term success rates of various surgical procedures for treatment of female SUI, from 32% to 100% [1]. It is extremely important that comparison of the results of surgical treatment of SUI between different surgeons and centers as well as patient counseling is based on robust scientific evidence that includes valid and accurate assessment of the treatment outcome. It seems timely, therefore, to discuss this topic further mainly by addressing three main questions: What do we mean by surgical cure of SUI? How do we measure this cure? What is the definition of success of operative intervention for SUI?There has been a lack of consensus in the urogynecologic community about which postoperative outcome measure to use to evaluate the efficacy of surgical procedures for SUI. Castillo et al. [2] analyzed 91 surgical series of SUI and reported that 33% of these studies used only subjective measures, 4% only objective measures, and 63% both objective and subjective measures, for the definition of "cure." Not surprisingly, therefore, the cure rates of the same surgical procedure for SUI differed among these studies. A universal definition of cure is thus obviously needed for accurate interpretation of cure rates when surgical treatment of SUI is contemplated.Surgeons tend to define the cure of SUI as the successful anatomical repair of defective tissue support of the urethra measured by objective improvement in urinary incontinence. As a direct result, earlier studies of surgical treatment of SUI focused on objective outcomes for measurement and definition of "surgical" cure. However, these measures tend to underestimate the impact of lower urinary tract symptoms on social limitations and emotional well-being of the woman [3]. Patients may have completely different expectations of cure after surgery for SUI other than the anatomical cure, such as absence of odor, lack of disruption of routine activities, use of less pads, and/or improvement of emotional status. For patients, the improvement of these symptoms might be more important than the "objective" demonstration of leakage of urine. In fact, a number of patients who are considered as objectively cured from SUI might even feel worse following the operation due to surgery-induced negative outcomes such as de novo urge urinary incontinence or intermittent selfcatheterization because of voi...

Transobturator mid urethral sling surgery for stress urinary incontinence: our experience

“…7 However, the success rates reported varied between studies, depending on whether objective or subjective outcomes had been measured. There has been a lack of consensus in the urogynecologic community about which postoperative outcome measure to use to evaluate the efficacy of surgical procedures for SUI 8 . In our study, we have evaluated both subjective and objective cure rates.…”

Definition of recurrence of pelvic organ prolapse: is it really important?

“…This endeavor will increase the scientific validity of outcome measures of surgical intervention for recurrent POP with a potential for selecting the most effective procedures and will contribute to our understanding of the pathogenesis of recurrence. A standardized terminology of POP recurrence will also allow comparison of the results of surgical treatment between different surgeons and centers and will provide robust clinical evidence to assist in counseling women about the expected treatment outcome [9]. Hence, the ambiguous postoperative outcome measures that are currently used in the biomedical literature such as "surgical failure," "persistent," "recurrence," "relapse," or "de novo" should now be replaced by the appropriate medical terminology that facilitates interpretation of data obtained by different researchers in this field.…”

“…There is also mounting evidence at present that anatomical evaluation, per se, does not often reflect patient perception of their condition and women with the same preoperative POP stage may have completely different expectations [9]. Moreover, the concept of restoring normal vaginal anatomy in women with POP using reconstructive pelvic surgery is difficult to define since some postoperative "residual" vaginal descent can be completely asymptomatic.…”

“…Does this have an impact on defining our surgical success or failure? Is it important to consider the re-operation rate as the best indirect measure of patients' satisfaction when evaluating the global efficacy of surgical procedures for recurrent POP [8,9]?…”

“…A true surgical cure, in fact, should not be considered as just an anatomical restoration of the prolapsed organ but also as an improvement of any subjective pelvic complaints noted before surgery for recurrent POP with the aim of improving the patients quality of life (QoL) after the operation [8,9]. Finally, we are aware that the clinical evaluation of POP, whether primary or recurrent, and of its treatment represents a challenging issue especially with the growing prevalence of the disease [5].…”