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Randomised trial comparing the upright and supine positions for the second stage of labour

participate and 68% of the cohort were followed up successfully. Four different surgical procedures were considered together which makes it impossible to interpret cure rates and the effect of surgery on the individual women. Previous continence surgery was not reported and can affect surgical outcome. The authors have shown no significant difference in outcome between women who had pre-operative urodynamic testing and those who did not. Assuming the objective cure rates reported in the literature?.? two groups of 220 women would be required to show that urodynamics did not make a difference to the outcome of surgery, assuming a power of 0.90 and a significance level of 0.05‘. The reported study is too small to demonstrate this. The women who underwent urodynamic investigation may have represented a selected group who had undergone previous continence surgery which is known to reduce the cure rate. The authors state that the improvement measured depended on the pre-operative symptom impact index scores so that women with worse scores initially had the worst scores after surgery. The women who had undergone urodynamics had higher scores than those women who did not. After surgery both groups had similar index scores. The women who had undergone urodynamics may have benefitted. The main reason for performing urodynamics is to determine who would benefit from treatments other than surgery and this was not addressed in the current survey. In this study only 32% of women had moderate or major improve ment one year after surgery; this contrasts with a symptomatic follow up study of women who had undergone incontinence surgery following pre-operative urodynamics. Two hundred and one women were assessed with a postal validated disease specific questionnaire’ before and after colposuspension. Only 39 women (19.4%) had any incontinence with 24 (12%) finding that this disturbed their lifestyle to some degree. Of a smaller number of women (n =28) who had undergone an anterior repair only 10 (35.7%) were dry. The greatest contrast between our data and this study were that 96.5% of our women would recommend investigation and treatment to their friends, compared with 68% in the reported study‘. In conclusion the effects of incontinence surgery should be studied with an understanding of the confounding variables which can affect the findings, otherwise the results are not meaningful. The data presented by Black and colleagues may be misleading to those who perform and those who undergo incontinence surgery.