I appreciate the comments made by Wael Agur regarding colposuspension compared with slings. His argument against Fusco et al.’s conclusion that synthetic slings were superior to colposuspension is strong. However, Fusco and Novara [1] corrected their meta-analysis and placed the Valpas study in the laparoscopic colposuspension group. The corrected Forest plot did not change the odds ratio and p value compared with the original plot. The other problem with meta-analysis studies is the inclusion of nonhomogenous groups and different surgical techniques. Autologous slings from different body sites (e.g., fascia lata or vaginal wall) can show great variation in their viscoelastic properties and remodeling after grafting.

The largest, well-designed study [2], the Stress Incontinence Surgical Treatment Efficacy Trial (SISTEr) compared traditional pubovaginal sling (PVS) using autologous rectus fascia with colposuspension (modified Tanagho) using permanent sutures. At 24 months, Albo et al. [3] reported the results of this first randomized multicenter clinical trial (RCT) conducted by the National Institutes of Health's Urinary Incontinence Treatment Network (UITN) in which women (n = 655) underwent either colposuspension (n = 329) or pubovaginal sling (n = 326) procedures. Overall and specific stress urinary incontinence success rates were higher in the PVS group than in colposuspension group. The superiority of PVS over colposuspension [4] was maintained at 5 years in the extended study (E-SISTEr).

A recent Cochrane review [5] that analyzed 22 studies comparing colposuspension with slings (traditional and synthetic) found no significant difference in success rates. However, subgroup analysis of studies comparing traditional slings and open colposuspension showed better effectiveness with traditional slings in the medium and long term [relative risk (RR) 1.35; 95% confidence interval (CI) 1.11–1.64 from 1–5 years of follow-up; RR 1.19; 95% CI 1.03–1.37).

Training young pelvic floor reconstructive surgeons in traditional PVS is important and should be part of their curriculum. An open colposuspension should still be considered an option, especially in patients undergoing open surgery.