Systematic review and meta-analysis of “inside-out” versus “outside-in” transobturator tapes in management of stress urinary incontinence in women

Objectives To directly compare the current evidence for the efficacy, complications, quality of life and cost to health services of both transobturator tension free vaginal tape procedures – “inside-out” versus “outside-in” – in the surgical treatment of female stress urinary incontinence. Study design A prospective peer-reviewed protocol was prepared a priori, and a systematic search of relevant databases from 1966 to January 2011 was performed. Meta-analyses of five randomised trials and three cohort studies were performed separately in accordance with PRISMA and MOOSE, respectively. Results There was no significant difference in patient-reported cure/improvement (OR 1.25, 95%CI 0.78, 1.99; p = 0.35) nor in objective cure/improvement (OR 1.66, 95%CI 0.8, 3.43, p = 0.17) between the two groups at 12-month follow-up. Vaginal angle injuries were significantly higher with the outside-in route (OR 0.14, 95%CI 0.05, 0.41, p = 0.0003). Groin/thigh pain and de-novo urgency were non-significantly higher with the inside-out route (OR 1.42, 95%CI 0.94, 2.13, p = 0.10 and OR 1.46, 95%CI 0.63, 3.36, p = 0.38, respectively). There was no significant difference in postoperative quality of life scores between the two groups (WMD -1.65; 95% CI -5.76, 2.46, p = 0.43). None of the trials reported a “health-cost” analysis. Meta-analysis of cohort studies confirmed similar results. Conclusions This is the first reported direct meta-analysis comparing both routes of transobturator tapes. It showed no evidence of significant differences in the efficacy and impact on women's quality of life between “inside-out” and “outside-in” transobturator tapes up to one-year follow-up. The “inside-out” route was associated with significantly fewer vaginal angle injuries but with trends towards higher risk of postoperative groin pain. Long-term follow-up of adequately powered RCTs is required to assess if these results pertain