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Surgical Management of Stress Urinary Incontinence

Author: Anitra D. Beasley MD, MPH

Mentor: Laurie S. Swaim MD
Editor: Sangini Sheth, MD

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Stress urinary incontinence (SUI), defined as involuntary leakage of urine during coughing, laughing, sneezing, or physical activity, affects greater than 16% of all women.  Bothersome SUI can be managed surgically or non-surgically.  Because SUI surgery is associated with operative morbidity, post-procedure voiding difficulty, and development of worsening urge incontinence, surgical intervention is traditionally reserved for patients whose symptoms persist despite conservative therapy.

Anti-incontinence procedures are classified as slings, retropubic urethropexy procedures, or artificial sphincters.  The National Institute for Health Care and Excellence considers synthetic midurethral slings, retropubic urethropexy (colposuspension), and autologous rectus fascial slings as first-line surgical therapy.  Selection of a surgical approach depends on many factors, including the need for an abdominal procedure for other pelvic disease, concomitant pelvic organ prolapse, and the health status of the patient.  The most current evidence supports using a vaginal approach when possible.  Artificial sphincters are procedures of last resort and should not be used unless the patient has failed previous surgical interventions due to the complex nature of the surgery and a high rate of postoperative infections.  

Before midurethral slings, the surgeries of choice were retropubic urethropexy procedures, with either the Marshall-Marchetti-Krantz (MMK) procedure, Burch procedure, or a pubovaginal bladder neck sling.  Both the MMK and Burch are performed via a suprapubic approach and are designed to limit the mobility of the pubocervical fascia.  Burch procedures achieve this support with periurethral sutures to the iliopectineal, or Cooper’s ligament and MMK procedures to the pubic periosteum.  Because of the rare but serious complication of osteitis pubis, the MMK procedure is rarely performed. 

Midurethral vaginal tape slings with permanent mesh are as effective as retropubic colposuspension and bladder neck slings but have a shorter operative time and a lower risk for most postoperative complications.  They are now the most commonly used surgical procedure for stress incontinence.  The retropubic tension-free vaginal tape (TVT) and transobturator tape (TOT) midurethral slings have similar success rates but different risk profiles.  In general, the most common complications are pain, vaginal mesh erosion, infection, recurrent incontinence, dyspareunia, bleeding, organ perforation, neuromuscular problems, and vaginal scarring.  When compared to the transobturator approach, a retropubic approach is associated with a higher risk of bladder and vaginal perforation, vascular injury, and voiding dysfunction, but TOT is associated with a higher risk of groin pain compared to the retropubic approach. Although controversy exists about the role of synthetic mesh used in the vaginal repair of pelvic organ prolapse, there are substantial safety and efficacy data that support the role of synthetic mesh midurethral slings as a primary surgical treatment option for stress urinary incontinence in women.

Autologous fascia slings may be considered in patients who decline synthetic materials, have severe SUI and a nonmobile, fixed urethra, are undergoing urethral reconstruction, or who have complications from prior mesh.  Rectus fascia or fascia lata slings perform as well or better than their mesh counterparts but also have higher complication rates.  Single incision mini-slings are gaining popularity and were developed to shorten operative time and move the midurethral sling procedure into the ambulatory setting.  They follow the basic procedure for a midurethral sling, but use an anchor system rather than tissue resistance for support.  Compared to midurethral slings, minislings have lower success rates, lower patient satisfaction, and higher reoperation rates.

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Initial approval: November 2015; Revised May 2017; Reaffirmed November 2018; Reaffirmed July 2020; Reaffirmed January 2022


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