Treatment of Stress Urinary Incontinence—Midurethral Slings: Top-down, Bottom-up, “Outside-in,” or “Inside-out”ANDRE SILVA, WILLIAM MD, FRCSCClinical Obstetrics and Gynecology: June 2007 - Volume 50 - Issue 2 - p 362-375 doi: 10.1097/GRF.0b013e31804a840c Current Controversies in Gynecology Abstract Author Information Two randomized trials have reported no differences in efficacy between suprapubic arc and tension-free vaginal tape at 2 years. There are no long-term studies comparing the inside-out and outside-in transobturator (TOT) approach, although short-term data show no difference in cure rates or complications. The short-term efficacy of TOT midurethral slings is comparable with the retropubic slings; however, preliminary evidence suggests that TOT slings may have a lower success rate compared with retropubic slings for the treatment of intrinsic sphincter deficiency. The risk of bladder injury may be the least with the “inside-out” approach, whereas retropubic techniques have a higher risk of cystotomy as compared with the TOT approach. Four randomized controlled trials comparing the retropubic and TOT approaches show no differences in rate of de novo urgency, retention, frequency, nocturia, or incomplete voiding. Department of Obstetrics and Gynecology, St Francis Hospital, Federal Way, Washington Correspondence: William Andre Silva, MD, FRCSC, 34503 9th Ave S, Suite 330, Federal Way, WA 98003. E-mail: firstname.lastname@example.org © 2007 Lippincott Williams & Wilkins, Inc.