CESA/VASA 63 DISCUSSION Principal findings Our findings suggest that CESA or VASA may be effective in treating urge and mixed urinary incontinence and/or apical prolapse in the short term, although the overall level of evidence is low. Results in the context of what is known MIU and UUI cure rates were 47.5% and 73.8%, respectively, after subsequent or concomitant sling procedures in 51.8% of cases. There was a remarkably higher cure rate of the CESA or VASA technique for MUI and UUI when an additional TOT was performed (76% compared to 36% and 84% versus 71%, respectively). However, cure rates for MUI and UUI of 36% and 71% respectively (without additional sling procedure) may need further research, since they are close to the cure rate of MUI or UUI by medical treatment, which is only 49% (ICQ 35.6-58%) on the short term. The mechanical function of the uterosacral ligaments and its effects on urinary incontinence has not been well studied. However, it has been demonstrated that the content of collagen in the uterosacral ligaments of women with urinary incontinence is decreased in comparison to women without urinary incontinence.125 Also the Integral Theory states that urinary stress and urge symptoms may be, at least in part, the result of lax suspensory ligaments, mainly caused by an altered microstructure (collagen/elastin).13,102 The etiology of overactive bladder (OAB) is still unclear but is usually associated with detrusor activity and treated with anticholinergics, botulinum toxin or neuromodulation.126 According to the Integral Theory, repairing the pubourethral and uterosacral ligaments can cure urge incontinence, frequency and nocturia in 86% of cases.127 It is assumed that the repair restitutes the stretching of the vagina to support the bladder base stretch receptors, which in turn avoids premature activation of the micturition cycle. However, clinical data to support this is limited to this uncontrolled study and therefore the current level of evidence remains very low. The basic concept is that lax ligaments weaken the striated muscle that contracts against these ligaments. The secondary elongation of these muscle fibres weakens contractile strength and prevents appropriate closure of the urethral tube. So, damaged ligaments are considered ‘the cause’, reinforcement of these ligaments is therefore ‘the cure’. However, The increasing evidence for structural deficit in the uterosacral ligaments should encourage further exploration of the concept of replacing the uterosacral ligaments by a synthetic substitute. Our review results support this strategy. Although the included NRS and the single RCT showed a moderate to low level of evidence, these findings can partially be explained by the vague distinction and overlap between subtypes of urinary incontinence. First, women can present with challenging symptom profiles and clinical assessment is not always accurate. Second, not all included studies used urodynamics (or did not clearly report it) to assess patients preoperatively to distinguish between different subtypes of UI. Finally, between 29% and 36% of women have MUI, while many of them may have mild SUI and do not seek for
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