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Surgical Management of Stress Urinary Incontinence

Author: Anitra D. Beasley MD, MPH

Mentor: Laurie S. Swaim MD
Editor: Daniel Martingano, DO

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Stress urinary incontinence (SUI), defined as involuntary leakage of urine in cases of increased intraabdominal pressure such as during coughing, laughing, sneezing, etc. The prevalence increases with age, reaching a peak of 50% among women 40 years of age and older, and is higher among White than among Black or Hispanic women.  SUI can be managed surgically or non-surgically, while surgical intervention is reserved for patients whose symptoms persist despite conservative therapy.

Surgical procedures in the treatment of SUI are classified into three categories: midurethral slings, retropubic urethropexy procedures, and 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 the need for a concurrent abdominal procedure (e.g. abnormal uterine bleeding due to uterine fibroids), concomitant pelvic organ prolapse, and the ability to tolerate perioperative conditions .  The vaginal approach is preferred when possible.  Artificial sphincters (AS) are procedures that should not be used unless the patient has failed previous surgical interventions since AS are surgical complex and carry a high rate of postoperative infections.  

Retropubic urethropexy procedures (RUP)include 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, and midurethral slings are preferred over RUP. 

Midurethral slings are the most commonly used surgical procedures for SUI. Slings with permanent mesh are as effective as retropubic colposuspension and bladder neck slings and have a shorter operative time and a lower risk for most postoperative complications seen with RUP.  .  There are two types of midurethral slings: the retropubic tension-free vaginal tape (TVT) and transobturator tape (TOT). These two types have similar success rates but different risk profiles which guide patient selection.  Overall, the most common complications are pain, vaginal mesh erosion, infection, recurrent incontinence, dyspareunia, bleeding, and organ perforation (e.g. bladder).  TVT is associated with a higher risk of bladder and vaginal perforation, vascular injury, and voiding dysfunction, with TOT associated with a higher risk of pelvic pain and dyspareunia. Thus, a TVT may be preferred in younger, more active patients whereas a TOT may be preferred in patients with prior pelvic surgery to avoid bladder injury...

Autologous fascia slings may be considered in patients who have severe SUI and a nonmobile, fixed urethra, are undergoing urethral reconstruction, or have complications from prior mesh.  Rectus fascia or fascia lata slings perform at least as their mesh counterparts but have higher complication rates. 


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Initial approval: November 2015; Revised May 2017; Reaffirmed November 2018; Reaffirmed July 2020; Reaffirmed January 2022. Revised November 2023


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