This document discusses stress urinary incontinence (SUI) and various treatment options. It begins by outlining some myths about SUI, noting that it is not simply a natural part of aging and can be treated. Conservative management options for SUI are discussed such as lifestyle changes and pelvic floor exercises. Surgical options for urodynamic stress incontinence (USI) are then summarized, including traditional approaches like Burch colposuspension as well as modern mid-urethral sling (MUS) procedures. Complications, outcomes, and long-term results are compared for different surgical techniques. Guidance from regulatory bodies on the appropriate use of MUS is also presented.

1. DATO‘ DR ARUKU NAIDU
MD(UKM), FRCOG(LONDON), CU(JCU), AM
CONSULTANT UROGYNAECOLOGIST
HRPB. ISH
www.aruku-naidu.blogspotcom
STRESS URINARY
INCONTINENCE

2. ― The involuntary loss of
urine so severe as to have a
significant cause of disability and
dependancy ‖
It affects quality of life
tremendously.
URINARY STRESS
INCONTINENCE

3.  Urinary incontinence/prolapse
is a natural part of aging
 Norm
 Nothing can be done about it
 Surgery is the only solution
 Knowledge limits lead to
patients accepting
 Shyness
MYTHS

6.  Impact on lifestyle and avoidance
of activities
 Fear of losing bladder control
Embarrassment
 Impact on relationships
 Increased dependence on
caregivers
 Discomfort and skin irritation
 Long run—cost & depression
QUALITY OF LIFE IMPACT

7. COST OF INCONTINENCE
• DIRECT, INDIRECT AND TOTAL COSTS
• 2% GDP IN US AND SWEDEN
• 1 BILLION IN AUSTRALIA
• 386 DOLLARS PER YEAR PER
• INCONTINENT PATIENT
• 710 MILLION DIRECT COSTS PER YEAR
• Malaysia ?? Started 2005, adhoc budget
• MORE SCHOLASHIPS & UROGYNAE UNITS
• IKN

8. CONSERVATIVE MANAGEMENT
FOR
URINARY STRESS INCONTINENCE

9. . Lifestyle interventions
. Avoid bladder irritants
. Bladder Diary
. Postural Techniques: perfect pee!!
. Physiotherapy & Pelvic Floor Exercise depending on PM
strength 60-70% improvement
(Effect of Kegel Exercises on the Management of Female Stress Urinary Incontinence: A
Systematic Review of Randomized Controlled Trials British Journal of Urology (1998), 82, 181–191)
. Topical estrogens for every woman over 45 years
CONSERVATIVE MANAGEMENT

11. STRESS URINARY INCONTINENCE
NON MEDICAL/SURGICAL MANAGEMENT
Don‘t forget adjuvant non medical treatment which can
greatly improve patient‘s quality of life
What is available?
 Pads and pants
 Devices (and appliances)
 Aides
 Indwelling catheters
 Intermittent catheterisation (CISC)

12. SURGERY
FOR
URODYNAMIC STRESS
INCONTINENCE (USI)

13. TRADITIONAL VS MODERN
URODYNAMIC STRESS INCONTINENCE
TRADITIONAL SURGICAL
APPROACH:
• Elevate bladder neck &
proximal urethra
• Support bladder neck &
prevent funneling
• Increase outflow
resistance
• Colposuspension
MODERN SURGICAL
APPROACH:
• ―Intergral Teory‖ of urinary
incontinence
• Proposes that urinary incontinence
are as a result of failure urethral
closure by pubourethral ligament,
suburethral hammock &
pubococcygeus muscles to support
the mid-urethra
• Mid-urethral slings

14. pubourethral
ligament
urethropelvic
ligament
RATIONALE FOR A
INCONTINECE SURGICAL APPROACH
Creating a hammock

15. PROCEDURE MEAN ( % )
FIRST
PROCEDURE
MEAN ( % )
RECURRENT
INCONTINENCE
BLADDER BUTTRESS 67.8 NA
MARSHALL-
MARCHETTI KRANTZ
89.5 NA
BURCH
COLPOSUSPENSION
89.8 82.5
BLADDER
NECK SUSPENSION
86.7 86.4
SLINGS 93.9 86.1
INJECTABLES 45.5 57.8
SURGICAL TECHNIQUES FOR
URODYNAMIC STRESS INCONTINENCE

16. CURE RATES FOR USI
(AMERICAN UROLOGICAL ASSOCIATION)
Duration Retropubic
suspension
Transvaginal
suspension
Anterior
repair
Sling
procedures
12-23
months
84% 79% 68% 82%
> 48
months
84% 67% 61% 83%

17. COLPOSUSPENSION

18. Historacilly colposuspension has been regarded as most
likely to produce a lasting cure and correction of
cystocoele
 Long term results; 85-90% cure at more than 10 years
 10% rectocele
 10% ‗de novo‘ overactive bladder(OAB)
SO WHY CHANGE TO NEW PROCEDURES;
 Surgical cure < 100%
 Complications: voiding dysfunction/OAB
 Recover time longer
 Expensive
URINARY STRESS INCONTINENCE

19. Nylon Tape IVS
Sparc Tape TVT
MID URETHRAL SLINGS (MUS)
Type 1, uncoated, monofilament mesh, macroporous( >75Um)

20. Biological slings/ Autologus facial sling (AFS)
TVT® (Gynecare) : Ulmsten et al. (1996)
SPARC (Suprapubic arc) (2001)
MONARC® TOT : Delorme (2001)
TVT – “O”® (Gynecare) : De Leval (2002)
TVT – Secur® (TVT-S)
Mini Arc®
HISTORY OF MUS

21. RETROPUBIC & TRANSOBTURATOR
PATHWAYS

22. SUBURETHRAL SLINGS (TVT)
Retropubic Approach

23. 90 women, TVT as primary
procedure for USI
Median follow up 11.5 years (69/90)
90.2% objectively cured
77% Subjectively cured (Pt
Impression scale)
4.7% considered failed
Of 25 with preoperatively urgency,
56% reported improvement
5.9% de novo urge symptoms
Nilsson et al (2001, 2008), Nordic multi-
centred prospective study
TVT MEDIUM TO LONG TERM RESULTS
TVT 17 years duration , high
satisfaction rate & no serious
long term complications

24. TOT APPROACH
Obturator
canal
Urethra
SAFE ENTRY
ZONE of MONARC
NEEDLE
Adductor longus

25. Mirror Mirror on the Wall,
who is the fairest of them ALL?
Oophyra
Zeppere
Boston Solyx
Bard AJust
Gynecare Secur
AMS MiniArc

26. Mini Slings

27. RATIONALE FOR TOT APPROACH
Palma, Sling tendineovaginal. J. Bras. Ginec 109:93, 1999.

28. Meatus
Midurethra
Bladder neck
1 cm
1 cm
1 cm
Vaginal Incision

29. Saline or
m/adr - local

30. Left paraurethral dissection

31. Right paraurethral dissection

32. Sling

33. SPARC AND MONARC
PLACEMENTS IN A CADAVER
RETROPUBIC
TOT

35. Ward, Hilton (BMJ 2002, 2007)
UK & Ireland TVT Trial Group
Multicentre RCT, 2 and 5 year outcome
175 patients with TVT, 169 patients with colposuspension
Objective cure rate 81% (MUS) vs 90% ( colposuspension)
TVT is associated with more operative complications than
colposuspension, but colposuspension is associated with more
postoperative complications and longer recovery
TVT shows promise for the treatment of USI b/c of minimal access &
rapid recovery
Cure rates at 6 months, 2 years and 5 years comparable btw 2 groups
MUS more cost effective
MUS VS COLPOSUSPENSION

36. Richter HE, Albo ME, Zyczynski HM, et al. Retropubic versus transobturator midurethral slings for stress
incontinence.
N Engl J Med 2010;362:2066-76
Trial Of Mid-Urethral Slings
TOMUS
RP vs TO – overall: objective SUI cure rates ( 81% vs 78%)

37. Ogah J, Cody JD, Rogerson L. Minimally invasive synthetic
suburethral sling operations for stress urinary incontinence in
women. Cochrane Database of Systematic Reviews 2011, 62 trials
( 7101 patients)
RP vs TO – overall: equivalent subjective SUI cure rates
TO – less voiding dysfx, blood loss, bladder perforation, shorter
op time
RP vs TO – overall: objective SUI cure rates ( 88% vs 84%)

38. Complications TVT TOT
Bladder perforation 2 0
Vaginal skin perforation 0 4
Groin pain 1 8
Removal of tape (pain) 0 1
Tape extrusion 2 3
Removal for extrusion 0 1
Voiding difficulty requiring
catheterization
5 5
Requiring ISC at 4/52 3 4
Requiring ISC at 1 year 1 2
UTI requiring antibiotics 7 2
De novo OAB symptoms 4 4
Wound infections 0 2
Vaginal infections 0 4
COMPLICATIONS

39. Management of mesh complication after SUI & POP repair: A review & analysis of current literatures. Barski &
Deng. BioMed Research International, volume 2015, Article ID 831285, 8 pages

40.  Market driven: see one & do culture
 Tips : stay away from the bladder neck, do
the sling that you are trained in
 If you want to change – LEARN IT properly
 MUS are unforgiving with a small margin for
error
 More ‗art‘ in the surgery? practice
 Need to be ‗tentioned‘ as comes with
experience
 Handle complication early & effectively
WHAT LEADS TO COMPLICATIONS

42. # 100. Gurol-Urganci I, Geary RS, Mamza JB, Duckett J, El-Hamamsy D, Dolan L, et al. Long-term
Rate of Mesh Sling Removal Following Midurethral Mesh Sling Insertion Among Women With Stress
Urinary Incontinence. JAMA. 2018 Oct 23. 320 (16):1659-1669.

43. Gurol-Urganci I, Geary RS, Mamza JB, Duckett J, El-Hamamsy D, Dolan L, et al. Long-term Rate of
Mesh Sling Removal Following Midurethral Mesh Sling Insertion Among Women With Stress
Urinary Incontinence. JAMA. 2018 Oct 23. 320 (16):1659-1669.

44. Surgeon
Training
Knowledge
Skills
Devices
Mesh Type
Route of application
Patient
LUTs ISD, DO, VD
POP, concurrent Ant Mesh
Age
Pregnancy
Obesity
Governing Body ??
Cochrane Reviews
College Guidance
Industry modification – laser cut,
detangled edges, handles, string,
adjustability
Efficacy
Complications / functional LUTs
Previous failed
Fistula radiation
Interactions of factors influencing choice/risk

45. IUGA supports MUS for USI
Restriction of MUS is
disservice to women

46. Mid-urethral mesh sling procedures
1.5.2 If non-surgical management for stress urinary incontinence has failed, and
the woman wishes to think about a surgical procedure, offer her the choice of:
colposuspension (open or laparoscopic) or an autologous rectus fascial sling.
Also include the option of a retropubic mid-urethral mesh sling in this choice
but see recommendations 1.5.7 to 1.5.11 for additional guidance on the use of
mid-urethral mesh sling procedures for stress urinary incontinence. [2019]
1.5.7 When offering a retropubic mid-urethral mesh sling, advise the woman
that it is a permanent implant and complete removal might not be possible.
[2019]
1.5.8 If a retropubic mid-urethral mesh sling is inserted, give the woman
written information about the implant, including its name, manufacturer, date
of insertion, and the implanting surgeon's name and contact details. [2019]
1.5.9 When planning a retropubic mid-urethral mesh sling procedure, surgeons
should: use a device manufactured from type 1 macroporous polypropylene mesh
consider using a retropubic mid-urethral mesh sling coloured for high visibility,
for ease of insertion and revision. [2013, amended 2019]
1.5.10 Do not offer a transobturator approach unless there are specific clinical
circumstances (for example, previous pelvic procedures) in which the
retropubic approach should be avoided. [2019]
1.5.11 Do not use the 'top-down' retropubic mid-urethral mesh sling approach or
single-incision sub-urethral short mesh sling insertion except as part of a
clinical trial. [2019]

47.  Careful selection of patient and pre-op optimization
 Appropriate & adequacy of training received prior to operating
 Treat UTI prior to surgery if present
 Urodynamic assessment pre-operatively as indicated
 Careful decision on choice of approach after thorough
evaluation of patient‘s LUTS
 Proper positioning of the patient before embarking on the
surgery
 Emptying of bladder before commencing the surgery
 Consider autologous sling which may be deemed a safer
alternative than a synthetic sling at the time of urethral injury
 Discuss all options & patients involved in decision making
REMEDIAL MEASURES TO
OVERCOME COMPLICATIONS?

49. BURCH
COLPOSUSPENSION

50. PUBO-VAGINAL SLING

52. TRANSOBTURATOR
APPROACH

53. BULKING AGENTS

54. CONSENT FOR SLINGS
2. Possible serious risks:
Damage to the bladder and/or Ureter, Urethra and/or long term disturbance to the bladder function in approximately 2% of cases
Damage to bowel ( anus, rectum small or large bowels) in approximately in 1% cases
Haemorrhage requiring blodd transfusion in about 2-3% cases
Return to the operating theatre for additional stitches or to control bleeding or for open surgery
Pelvic abscess/infection approximately in 1% cases
Venous thrombosis or pulmonary embolism approximately in 1% patients
Dyspareunia ( painful sexual intercourse)
Failure to achieve the desired results or recurrence of prolapse or urinary incontinence
Mesh Sling/MUS /tape: MESH SLING IS PERMANENT & IT IS NOT POSSIBLE TO REMOVE COMPLETELY IF NEED ARAISES
Complications- eg. Erosions, mesh protrusion in about (0.7%) , voiding dysfunction/difficulty in voiding ( 3%) , pelvic or groin pains, damage to urethra.
Others (please specify) ______________________________________________________________________________________________________
3.Possible frequently occurring risks:
Urinary retention in about 3% of patients, may need release or excision of the tape/ mesh sling
Vaginal bleeding, discharge or infection
Frequency of micturition, nocturia and urgency in about 7% of patients
Wound infection – up to 15% especially in patients with risk factors
Pain, may require analgesics- in particular Pelvic/groin pain is TOT mesh sling is applied, the pain can last for months to years in very few patients
Others (please specify) ______________________________________________________________________________________________________
4. Any extra emergency procedures which may become necessary during the procedure:
Blood transfusion – may be required in approximately 2 in every 1000 women undergoing this procedure
Removal of ovaries for unsuspected disease during the surgery
Conversion to abdominal approach due to anticipated difficulties or to undertake repair of any injury to bladder, ureter, bowel or major blood vessels in
approximately in 4% - 8% cases
Other procedures may be necessary to save live or to overcome complications (please specify) ____________________________________________
I have explained that in obese women, those with underlying medical problems or who have had previous surgery (ex: Caesarean section), the
quoted risks may be higher than average women.
I have also discussed the benefits and risks of any other available treatments including Physiotherapy, Conservative & Non Surgical options.
I have discussed other alternative surgeries to correct SUI/USI such as colposuspension, fascial slings, synthetic slings (MUS) & bulking
agents
Sling controversy discussed / Global statement supporting MUS for SUI 2018, discussed (https://www.augs.org/assets/1/6/AUGS-
SUFU_MUS_Position_Statement.pdf)

55. SUS IS GOLD STANDARD FOR NOW ??
• Mid urethral sling(MUS) operation is easy, simple and cost
effective operation
• MUS more cost effective than Burch colposuspension. SUS are
costly per tape.
• Subjective and Objective cure somewhat same. Ward et al
2002, 2004 and 2007.
• 17 years of TVT experience ( Nilssion et al 2013)
• Choice of RP or TO need individual assessment & preference
• Other options need to discussed with patients
• Obtain informed consent if doing MUS procedures
• Change of practice is inevitable
• May need to learn colposuspension back !!
• May need to explore newer modality ??
CONCLUSIONS

56. QUESTIONS …?