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.