Minimally invasive synthetic suburethral sling operations for stress urinary incontinence in women: a short version Cochrane review.

BACKGROUND: Stress urinary incontinence (SUI) is a common condition affecting up to 30% of women. Minimally invasive synthetic suburethral sling operations are among the latest forms of procedures introduced to treat SUI. OBJECTIVES: To assess the effects of minimally invasive synthetic suburethral sling operations for treatment of SUI, urodynamic stress incontinence (USI), or mixed urinary incontinence (MUI) in women. SEARCH METHODS: We searched the Cochrane Incontinence Group Specialised Register (searched March 20, 2008), MEDLINE (January 1950-April 2008), EMBASE (January 1988-April 2008), CINAHL (January 1982-April 2008), AMED (January 1985-April 2008), the UK National Research Register, ClinicalTrials.gov, and reference lists of relevant articles. SELECTION CRITERIA: Randomized or quasi-randomized controlled trials amongst women with SUI, USI, or symptoms of stress or MUI, in which at least one trial arm involved a minimally invasive synthetic suburethral sling operation. DATA COLLECTION AND ANALYSIS: Two review authors assessed the methodological quality of potentially eligible studies and independently extracted data from the included trials. RESULTS: Sixty-two trials involving 7,101 women were included. The quality of evidence was moderate for most trials. Minimally invasive synthetic suburethral sling operations appeared to be as effective as traditional suburethral slings [8 trials, n=599, risk ratio (RR) 1.03, 95% confidence interval (CI) 0.94-1.13] but with shorter operating time and less postoperative voiding dysfunction and de novo urgency symptoms. Minimally invasive synthetic suburethral sling operations appeared to be as effective as open retropubic colposuspension (subjective cure rate at 12 months RR 0.96, 95% CI: 0.90-1.03; at 5 years RR 0.91, 95% CI: 0.74-1.12) with fewer perioperative complications, less postoperative voiding dysfunction, shorter operative time, and hospital stay but significantly more bladder perforations (6% vs. 1%, RR 4.24, 95% CI: 1.71-10.52). There was conflicting evidence about the effectiveness of minimally invasive synthetic suburethral sling operations compared to laparoscopic colposuspension in the short term (objective cure, RR 1.15, 95% CI: 1.06-1.24; subjective cure RR 1.11, 95% CI: 0.99-1.24). Minimally invasive synthetic suburethral sling operations had significantly less de novo urgency and urgency incontinence, shorter operating time, hospital stay, and time to return to daily activities. A retropubic bottom-to-top route was more effective than top-to-bottom route (RR 1.10, 95% CI: 1.01-1.20; RR 1.06, 95% CI: 1.01-1.11) and incurred significantly less voiding dysfunction, bladder perforations, and tape erosions. Monofilament tapes had significantly higher objective cure rates (RR 1.15, 95% CI: 1.02-1.30) compared to multifilament tapes and fewer tape erosions (1.3% vs. 6% RR 0.25, 95% CI: 0.06-1.00). The obturator route was less favorable than the retropubic route in objective cure (84% vs. 88%; RR 0.96, 95% CI: 0.93-0.99; 17 trials, n=2,434), although there was no difference in subjective cure rates. However, there was less voiding dysfunction, blood loss, bladder perforation (0.3% vs. 5.5%, RR 0.14, 95% CI: 0.07-0.26), and shorter operating time with the obturator route. CONCLUSIONS: The current evidence base suggests that minimally invasive synthetic suburethral sling operations are as effective as traditional suburethral slings, open retropubic colposuspension and laparoscopic colposuspension in the short-term but with less postoperative complications. Objective cure rates are higher with retropubic tapes than with obturator tapes but retropubic tapes attract more complications. Most of the trials had short-term follow-up and the quality of the evidence was variable.

Traditional suburethral sling operations for urinary incontinence in women.

BACKGROUND: Traditional suburethral slings are surgical operations used to treat women with symptoms of stress urinary incontinence. OBJECTIVES: To determine the effects of traditional suburethral slings on stress incontinence alone or stress with other types of urinary (mixed) incontinence in comparison with other management options. SEARCH STRATEGY: We searched the Cochrane Incontinence Group Specialised Trials Register (searched 22 December 2004), The UK National Research Register (Issue 1, 2001) and the reference lists of relevant articles. We hand searched the proceedings of the Brazilian Congress of Urology from 1991 to 2003, inclusive. SELECTION CRITERIA: Randomised or quasi-randomised trials that included traditional suburethral slings for the treatment of stress or mixed urinary incontinence. DATA COLLECTION AND ANALYSIS: All three reviewers independently extracted data from included trials onto a standard form and assessed trial methodological quality. The data abstracted were relevant to predetermined outcome measures. Where appropriate, a summary statistic was calculated: a relative risk for dichotomous data and a weighted mean difference for continuous data. MAIN RESULTS: Thirteen trials were identified including 760 women of whom 627 were treated with suburethral slings. Five compared suburethral slings with open abdominal retropubic colposuspension (Burch/Marshall-Marchetti-Krantz) and one compared suburethral slings with needle suspension (Stamey). In six trials, different types of suburethral sling were compared with each other. Nine types of slings were included (Teflon, polytetrafluoroethylene, prolene used for transvaginal tape (TVT), porcine dermis, lyophilised dura mater, fascia lata, vaginal wall, autologous dermis and rectus fascia). There were no comparisons of suburethral sling with anterior repair, laparoscopic retropubic suspension, peri-urethral injections or artificial sphincters. One trial compared surgery (including slings) with anticholinergic medication.There were no statistically significant differences between traditional slings and other types of continence surgery, or between one type of traditional sling and another sling. Confidence intervals around the estimates were wide, reflecting the few data available, and so clinically important differences could not be ruled out. AUTHORS' CONCLUSIONS: The data on sub urethral sling operations remain too few to address the effects of this type of surgical treatment. Few trials are reported by authors in a complete fashion and most information came from abstracts presented in annual meetings. The broader effects of suburethral slings could not be established since trials did not include appropriate outcome measures such as general health status, health economics, pad testing, third party analysis and time to return to normal activity level. Data obtained from thirteen trials did not provide reliable estimates because of their sizes, and heterogeneity of designs, populations studied, and types of comparisons made. Reliable evidence on which to judge whether or not suburethral slings are better or worse than other surgical or conservative management is currently not available.

Open retropubic colposuspension for urinary incontinence in women.

BACKGROUND: Urinary incontinence is a common and potentially debilitating problem. Open retropubic colposuspension is a surgical treatment which involves lifting the tissues near the bladder neck and proximal urethra in the area behind the anterior pubic bones to correct deficient urethral closure. OBJECTIVES: To assess the effects of open retropubic colposuspension for the treatment of urinary incontinence. SEARCH STRATEGY: We searched the Cochrane Incontinence Group specialised register (searched 30 June 2004)and reference lists of relevant articles. We contacted investigators to locate extra studies. SELECTION CRITERIA: Randomised or quasi-randomised controlled trials in women with symptoms or urodynamic diagnoses of stress or mixed incontinence that included open retropubic colposuspension surgery in at least one trial group. DATA COLLECTION AND ANALYSIS: Studies were evaluated for methodological quality and appropriateness for inclusion and data extracted by two of the reviewers. Trial data were analysed by intervention. Where appropriate, a summary statistic was calculated. MAIN RESULTS: This review included 39 trials involving a total of 3301 women. Overall cure rates were 68.9% to 88.0% for open retropubic colposuspension. Two small studies suggest lower failure rates after open retropubic colposuspension than conservative treatment. Similarly, one trial suggests lower failure rates after open retropubic colposuspension compared to anticholinergic treatment. Evidence from six trials showed a lower failure rate for subjective cure after open retropubic colposuspension than after anterior colporrhaphy. Such benefit was maintained over time (RR of failure 0.51; 95% CI 0.34 to 0.76 before the first year, RR 0.43; 95% CI 0.32 to 0.57 at one to five years, RR 0.49; 95% CI 0.32 to 0.75 in periods beyond 5 years). In comparison with needle suspensions there was a lower failure rate after colposuspension in the first year after surgery (RR 0.66; 95% CI 0.42 to 1.03), after the first year (RR 0.48; 95% CI 0.33 to 0.71), and beyond five years (RR 0.32; 95% CI 15 to 0.71). Evidence from twelve trials in comparison with suburethral slings found no significant difference in failure rates in all time periods assessed. Patient-reported failure rates in short-, medium- and long-term follow-up showed no significant difference between open and laparoscopic retropubic colposuspension, but with wide confidence intervals. In two trials failure was less common after Burch (RR 0.38 95% CI 0.18 to 0.76) than after the Marshall Marchetti Krantz procedure at one to five year follow-up. There were few data at any other follow-up time.In general, the evidence available does not show a higher morbidity or complication rate with open retropubic colposuspension, compared to the other open surgical techniques, although pelvic organ prolapse is more common than after anterior colporrhaphy and sling procedures. AUTHORS' CONCLUSIONS: The evidence available indicates that open retropubic colposuspension is an effective treatment modality for stress urinary incontinence especially in the long term. Within the first year of treatment, the overall continence rate is approximately 85-90%. After five years, approximately 70% patients can expect to be dry. Newer minimal access procedures like tension free vaginal tape look promising in comparison with open colposuspension but their long-term performance is not known and closer monitoring of its adverse event profile must be done. Laparoscopic colposuspension should allow speedier recovery but its relative safety and effectiveness is not known yet.

Conservative management for postprostatectomy urinary incontinence.

BACKGROUND: Urinary incontinence is common after both radical prostatectomy and transurethral resection. Conservative management includes pelvic floor muscle training, biofeedback, electrical stimulation, compression devices (penile clamps), lifestyle changes, extra-corporeal magnetic innervation or a combination of methods. OBJECTIVES: To assess the effects of conservative managements for urinary incontinence prostatectomy. SEARCH STRATEGY: We searched the Cochrane Incontinence Group trials register (searched 2 July 2003), MEDLINE (January 1966 to January 2004), EMBASE (January 1988 to January 2004), CINAHL (January 1982 to January 2004), PsycLIT (January 1984 to January 2004), ERIC (January 1984 to January 2004), the reference lists of relevant articles, handsearched conference proceedings and contacted investigators to locate studies. SELECTION CRITERIA: Randomised controlled trials evaluating conservative interventions for urinary continence after prostatectomy. DATA COLLECTION AND ANALYSIS: At least two reviewers assessed the methodological quality of trials and abstracted data. MAIN RESULTS: Ten trials met the inclusion criteria, eight trials amongst men after radical prostatectomy, one trial after transurethral resection of prostate and one after either operation. There was considerable variation in the interventions, populations and outcome measures. The trials were of moderate quality and data were not available for many of the pre-stated outcomes. Confidence intervals were wide: it was not possible to reliably identify or rule out a useful effect. There was some support from five trials for pelvic floor muscle training with biofeedback being better than no treatment or sham treatment in the short term for men after radical prostatectomy: relative risk for incontinence with pelvic floor muscle training and biofeedback versus no treatment: 0.74 (95% confidence interval 0.60 to 0.93). Analysis of other conservative interventions such as pelvic floor muscle training alone, transcutaneous electrical nerve stimulation and rectal electrical stimulation, or combinations of these interventions were inconclusive. There were too few data to determine effects on incontinence after transurethral resection of the prostate. The findings should be treated with caution as there were few studies, all of moderate quality. Men in one trial reported a preference for one type of external compression device compared to two others or no treatment. The effect of other conservative interventions such as lifestyle changes remains undetermined as no trials involving these interventions were identified. Men's symptoms tended to improve over time, irrespective of management. REVIEWERS' CONCLUSIONS: The value of the various approaches to conservative management of postprostatectomy incontinence remains uncertain. There may be some benefit of offering pelvic floor muscle training with biofeedback early in the postoperative period immediately following removal of the catheter as it may promote an earlier return to continence. Long-term incontinence may be managed by external penile clamp, but there are safety problems.

Periurethral injection therapy for urinary incontinence in women.

BACKGROUND: Stress urinary incontinence is a common, troublesome symptom amongst adult women. Periurethral injection of bulking agents is a surgical procedure used for the treatment of urinary incontinence. OBJECTIVES: To assess the effects of periurethral injection therapy in the treatment of urinary incontinence in women. SEARCH STRATEGY: We searched the Cochrane Incontinence Group trials register (February 2003), MEDLINE (January 1996 to January 2003), PREMEDLINE (7 February 2003) and the reference lists of relevant articles. Date of the most recent searches: February 2003. SELECTION CRITERIA: All randomised or quasi-randomised controlled trials of treatment for urinary incontinence, in which at least one management arm involved periurethral injection therapy. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed methodological quality of each study using explicit criteria. Data extraction was undertaken independently using a standard form and clarification concerning possible unreported data sought directly from the investigators. MAIN RESULTS: We identified seven trials that met the inclusion criteria. The limited data available prevented meta-analysis. Injection of autologous fat was compared to placebo in a study of 68 women which was terminated early because of safety concerns. No differences in subjective or objective outcome were found in the two groups. No studies were found comparing injection therapy with conservative treatment. The single study that compared injection with a variety of surgical management in 133 women found no significant difference in subjective outcome but did note significantly better objective outcome in the surgical group. The four studies that compared different agents found that silicone particles and carbon spheres gave improvement at 12 months equivalent to collagen. A comparison of paraurethral and transurethral methods of delivery of the bulking agent found similar outcome but a higher rate of early complications in the paraurethral group. REVIEWER'S CONCLUSIONS: Data from the available randomised trials suggest, but do not prove, that periurethral injection of established manufactured bulking agents results in subjective and objective short term improvement of symptomatic female stress urinary incontinence in adults. Future recommendation as a first line treatment would require evidence of patient benefit and cost-effectiveness from randomised trials involving placebo and conservative treatment arms. Future studies should also record long-term outcome and monitor for delayed particle migration. Injection therapy is probably inferior to surgery but a long term comparative study against a single standard procedure (Burch colposuspension) is required to prove this. It is recommended that phase III studies of newer agents will not be worthwhile until the aforementioned trials have been performed and a rationale for the use of injection therapy decided. For women with extensive co-morbidity precluding anaesthesia, injection therapy may represent a useful option for relief of symptoms for a 12 month period although 2 or 3 injections are likely to be required to achieve a satisfactory result.

Open retropubic colposuspension for urinary incontinence in women.

BACKGROUND: Urinary incontinence is a common and potentially debilitating problem. Open retropubic colposuspension is a surgical treatment which involves lifting the tissues near the bladder neck and proximal urethra in the area behind the anterior pubic bones to correct deficient urethral closure. OBJECTIVES: To assess the effects of open retropubic colposuspension for the treatment of urinary incontinence. SEARCH STRATEGY: We searched the Cochrane Incontinence Group specialised register (to April 2002) and reference lists of relevant articles. We contacted investigators to locate extra studies. Date of the most recent search: April 2002. SELECTION CRITERIA: Randomised or quasi-randomised controlled trials in women with symptoms or urodynamic diagnoses of stress or mixed incontinence that included open retropubic colposuspension surgery in at least one trial group. DATA COLLECTION AND ANALYSIS: Studies were evaluated for methodological quality and appropriateness for inclusion and data extracted by two of the reviewers. Trial data were analysed by intervention. Where appropriate, a summary statistic was calculated. MAIN RESULTS: This review included 33 trials involving a total of 2403 women. Overall cure rates were 68.9% to 88.0% for open retropubic colposuspension. Two small studies suggests lower failure rates after open retropubic colposuspension than conservative treatment. Evidence from six trials showed a lower failure rate for subjective cure after open retropubic colposuspension than after anterior colporrhaphy. Such benefit was maintained over time (RR of failure 0.51; 95% CI 0.34 to 0.76 before the first year, RR 0.43; 95% CI 0.32 to 0.57 at one to five years, RR 0.49; 95% CI 0.32 to 0.75 in periods beyond 5 years). In comparison with needle suspensions there was a lower failure rate after colposuspension in the first year after surgery (RR 0.66; 95% CI 0.42 to 1.03), after the first year (RR 0.48; 95% CI 0.33 to 0.71) and beyond 5 years (RR 0.32; 95% CI 15 to 0.71). Evidence from three trials in comparison with suburethral slings found no significant difference in failure rates. Patient-reported failure rates in short-, medium- and long-term follow-ups showed no significant difference between open and laparoscopic retropubic colposuspension, but with wide confidence intervals. In two trials failure was less common after Burch (RR 0.38 95% CI 0.18 to 0.76) as than the Marshall Marchetti Krantz procedure at one to five year follow-up There were few data at any other follow-up. In general, the evidence available does not show a higher morbidity or complication rate with open retropubic colposuspension, compared to the other surgical techniques, although pelvic organ prolapse is more common than after anterior colporrhaphy and sling procedures. REVIEWER'S CONCLUSIONS: The evidence available indicates that Open retropubic colposuspension is the most effective treatment modality for stress urinary incontinence especially in the long term. Within the first year of treatment, the overall continence rate is approximately 85-90%. After five years, approximately 70% patients can expect to be dry. Newer minimal access procedures like tension free vaginal tape look promising in comparison with open colposuspension but their long-term performance is not known. Laparoscopic colposuspension should allow speedier recovery but its relative safety and effectiveness is not known yet.

Urinary diversion and bladder reconstruction/replacement using intestinal segments for intractable incontinence or following cystectomy.

BACKGROUND: Surgery performed to improve or replace the function of the diseased urinary bladder has been carried out for over a century. Main reasons for improving or replacing the function of the urinary bladder are bladder cancer, neurogenic bladder dysfunction, detrusor overactivity and chronic inflammatory diseases of the bladder (such as interstitial cystitis, tuberculosis and schistosomiasis). There is still much uncertainty about the best surgical approach. Options available at the present time include: (1) conduit diversion (the creation of various intestinal conduits to the skin) or continent diversion (which includes either a rectal reservoir or continent cutaneous diversion), (2) bladder reconstruction and (3) replacement of the bladder with various intestinal segments. OBJECTIVES: To determine the best way of improving or replacing the function of the lower urinary tract using intestinal segments when the bladder has to be removed or when it has been rendered useless or dangerous by disease. SEARCH STRATEGY: We searched the Cochrane Incontinence Group's specialised register (3 May 2001), The Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 2, 2001), MEDLINE (1966 to May 2001), PREMEDLINE (4 June 2001), Dissertation Abstracts (18.6.2001) and the reference lists of relevant articles. Date of most recent search: June 2001. SELECTION CRITERIA: All randomised or quasi-randomised controlled trials of surgery involving transposition of an intestinal segment into the urinary tract. DATA COLLECTION AND ANALYSIS: Trials were evaluated for appropriateness for inclusion and for methodological quality by the reviewers. Three reviewers were involved in the data extraction. The data collected was then analysed for statistical significance. MAIN RESULTS: Two trials met the inclusion criteria with a total of 164 participants. These trials addressed only four of the 14 comparisons pre-specified in the protocol. There were no statistically significant differences found in the incidence of upper urinary tract infection, ureterointestinal stenosis and renal deterioration in the comparison of continent diversion with conduit diversion. There was no evidence of a difference in incidence of upper urinary tract infection and uretero-intestinal stenosis when conduit diversions were fashioned from either ileum or colon. No statistically significant difference was found in the incidence of renal scarring between anti-refluxing versus freely refluxing uretero-intestinal anastomotic techniques in conduit diversions. The confidence intervals were all wide, however, and did not rule out important differences. There was some limited evidence that use of the more complex nipple valve at the ureteroileal anastomosis was more likely to lead to upper tract deterioration than implantation into a non-detubularised, isoperistaltic ileal afferent limb. REVIEWER'S CONCLUSIONS: The evidence from the included trials was very limited. Only two studies met the inclusion criteria; these were small, of moderate or poor methodological quality, and reported few of the pre-selected outcome measures. This review did not find any evidence that bladder replacement (orthotopic or continent diversion) was better than conduit diversion following cystectomy for cancer. There was no evidence to suggest that bladder reconstruction was better than conduit diversion for benign disease. The small amount of usable evidence for this review suggests that collaborative multicentre studies should be organised, using random allocation where possible.

Conservative management for post prostatectomy urinary incontinence.

BACKGROUND: Urinary incontinence after prostatectomy is a common problem. Conservative management of this condition includes pelvic floor muscle training, biofeedback, electrical stimulation using a rectal electrode, transcutaneous electrical nerve stimulation, or a combination of methods. OBJECTIVES: To assess the effects of conservative management for urinary incontinence after transurethral, suprapubic, radical retropubic or perineal prostatectomy. SEARCH STRATEGY: The Cochrane Incontinence Group's trials register, Medline, Cinahl, Embase, PsycLit and ERIC all up to January 1999, and reference lists of relevant articles. We contacted investigators to locate studies and we handsearched the following conference proceedings: American Urological Association (1989-1999); Society of Urologic Nurses and Associates (1991-1998); Wound Ostomy and Continence Nurses (1996-1999); and International Continence Society (1980-1998). Date of most recent searches: January 1999. SELECTION CRITERIA: Randomised or quasi-randomised trials which evaluated conservative management aimed at improving urinary continence after prostatectomy. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed the methodological quality of studies and abstracted data from included trials onto a standard form. MAIN RESULTS: Only five randomised trials were identified which included 365 men, each evaluating different treatments, and all studying men after radical prostatectomy. The trials were of moderate quality and data were not available for many of the pre-stated outcomes. Confidence intervals for both dichotomous and continuous data were wide; it was not possible to reliably identify or rule out a useful effect. Men's symptoms tended to improve over time, irrespective of management. REVIEWER'S CONCLUSIONS: The value of the various approaches to conservative management of post prostatectomy incontinence remains uncertain. Further well designed trials are needed.

Do the Y-set and double-bag systems reduce the incidence of CAPD peritonitis? A systematic review of randomized controlled trials.

BACKGROUND: Peritonitis is the most frequent serious complication of continuous ambulatory peritoneal dialysis (CAPD). It has a major influence on the number of patients switching from CAPD to haemodialysis and has probably restricted the wider acceptance and uptake of CAPD as an alternative mode of dialysis. This systematic review sought to determine if modifications of the transfer set (Y-set or double-bag systems) used in CAPD exchanges are associated with a reduction in peritonitis and an improvement in other relevant outcomes. METHODS: Based on a comprehensive search strategy, we undertook a systematic review of randomized or quasi-randomized controlled trials comparing double-bag and/or Y-set CAPD exchange systems with standard systems, or comparing double-bag with Y-set systems, in patients with end-stage renal disease (ESRD) treated with CAPD. Only published data were used. Data were abstracted by a single investigator onto a standard form and subsequently entered into Review Manager 4.0.4. Its statistical package, Metaview 3.1, calculated an odds ratio (OR) for dichotomous data and a (weighted) mean difference for continuous data with 95% confidence intervals. RESULTS: Twelve eligible trials with a total of 991 randomized patients were identified. In trials comparing either the Y-set or double-bag systems with the standard systems, significantly fewer patients (133/363 vs 158/263; OR 0.33, 95% CI 0.24-0.46) experienced peritonitis and the number of patient-months on CAPD per episode of peritonitis was consistently greater. When the double-bag systems were compared with the Y-set systems significantly fewer patients experienced peritonitis (44/154 vs 66/138; OR 0.44, 95% CI 0.27-0.71) and the number of patient-months on CAPD per episode of peritonitis was also greater. CONCLUSIONS: Double-bag systems should be the preferred exchange systems in CAPD.

Evidence-based medicine in nephrology: identifying and critically appraising the literature.

BACKGROUND: Uncertainties about best management of end-stage renal disease (ESRD) are reflected in wide variations in practice. Systematic reviews aim to reduce uncertainty by strengthening the evidence base for clinical practice, allowing estimation of the benefits and risks of particular interventions, whilst minimizing the potential for bias. This paper describes the methods and conduct of six systematic reviews of aspects of the management of ESRD, and the yield in terms of trials found. METHODS: Our methodology was based on that recommended by the Cochrane Collaboration (an international initiative set up to perform and disseminate systematic reviews of health care). It involved a systematic search of electronic databases and bibliographic reference lists, together with handsearching of Kidney International for studies relevant to the management of ESRD, followed by a systematic assessment of study quality. RESULTS: Around 12,000 abstracts were assessed which had been identified from electronic sources. Of these, 2085 (18%) were deemed to be reports of possible randomized or quasi-randomized controlled trials relevant to the management of ESRD. Three hundred and forty were relevant to the six specific reviews, and after assessment of the full manuscripts, 39 studies were finally included in our reviews. Reports of a further nine trials, which were identified from other sources, were also included. The broad search adopted allowed the parallel development of a register of trials of all aspects of the management of ESRD. CONCLUSIONS: This study has demonstrated that the methodology of systematic reviews, as promoted by the Cochrane Renal Group, is feasible but has significant resource implications. The development of a register of randomized controlled trials (RCTs) related to the management of ESRD will facilitate this form of research in the future.

Conservative management of post prostatectomy incontinence.

BACKGROUND: Urinary incontinence after prostatectomy is a common problem. Conservative management of this condition includes pelvic floor muscle training, biofeedback, electrical stimulation using a rectal electrode, transcutaneous electrical nerve stimulation, or a combination of methods. OBJECTIVES: To assess the effects of conservative management for urinary incontinence after transurethral, suprapubic, radical retropubic or perineal prostatectomy. SEARCH STRATEGY: The Cochrane Incontinence Group's trials register, Medline, Cinahl, Embase, PsycLit and ERIC all up to January 1999, and reference lists of relevant articles. We contacted investigators to locate studies and we handsearched the following conference proceedings: American Urological Association (1989-1999); Society of Urologic Nurses and Associates (1991-1998); Wound Ostomy and Continence Nurses (1996-1999); and International Continence Society (1980-1998). Date of most recent searches: January 1999. SELECTION CRITERIA: Randomised or quasi-randomised trials which evaluated conservative management aimed at improving urinary continence after prostatectomy. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed the methodological quality of studies and abstracted data from included trials onto a standard form. MAIN RESULTS: Only five randomised trials were identified which included 365 men, each evaluating different treatments, and all studying men after radical prostatectomy. The trials were of moderate quality and data were not available for many of the pre-stated outcomes. Confidence intervals for both dichotomous and continuous data were wide; it was not possible to reliably identify or rule out a useful effect. Men's symptoms tended to improve over time, irrespective of management. REVIEWER'S CONCLUSIONS: The value of the various approaches to conservative management of post prostatectomy incontinence remains uncertain. Further well designed trials are needed.

Patients' perception of health on renal replacement therapy: evaluation using a new instrument.

Patients' perception of their health is an important outcome measure in the management of chronic disease. Comparing that perception from patients receiving different forms of renal replacement therapy (RRT) with data from the general population could be used to monitor the effectiveness of treatment. The short form 36 (SF-36) questionnaire is a general measure of health status which has been validated in the UK and uses eight health scales comprising physical function, social function, role limitation (physical and emotional), mental health, energy, pain and overall health. Using the SF-36 questionnaire, the perception of health of patients receiving RRT was compared with data from healthy control subjects. One hundred and seventy-two of 185 (93%) patients receiving RRT--transplant (n = 102), haemodialysis (n = 43), and peritoneal dialysis (n = 27) completed the questionnaire; scores were compared with those from 542 healthy control subjects. The perception of health of haemodialysis and peritoneal dialysis patients was significantly worse than transplanted patients and controls in six of the eight scales (P < 0.05 dialysis versus transplant and controls). That of transplanted patients was worse in only two and better in one of the eight scales compared with the general population (P < 0.05). Patients were also stratified into low, medium, and high-risk groups based on age and comorbidity and were analysed irrespective of treatment modality. Scores were significantly different across the risk groups in five of the eight scales. We conclude that the SF-36 questionnaire is acceptable to patients on RRT and enables the perception of health of patients receiving RRT to be compared with that of the general population.(ABSTRACT TRUNCATED AT 250 WORDS)