This document discusses stress urinary incontinence (SUI), including its definition, prevalence, clinical testing, investigation, and classification systems. It then covers both conservative and surgical treatment options for SUI, with an emphasis on the various surgical procedures. Key points discussed include midurethral sling procedures being the current first-line surgical approach, with transobturator tapes preferred over retropubic or transvaginal needle suspensions. Factors in choosing the appropriate procedure include the presence of other pelvic organ prolapse and the severity of incontinence.

1. DR KAWITA BAPAT
INDORE

2. 
 SUI is best defined by the International Continence
Society as “involuntary leakage of urine on exertion,
effort, coughing, or sneezing.
 The majority of published data suggest that around
50% of incontinent women will exhibit pure SUI with
a further 30% experiencing mixed incontinence.
 Thus potentially large numbers of adult women
with troublesome urine leakage will have a “stress
component” to their incontinence.
INTRODUCTION

3. 
 Urge incontinence
 Stress incontinence
 Mixed
 Overflow
 Functional
SUI

4. 
 Urinary stress test
 Cotton swab test
 Post void residual volume
 Perennial pad test
 Urodynamic testing
 Intrinsic sphincter deficiency test
Clinical testing

5. 
 Uroflowmetry
 Detrusor pressure
 Endoscopy
 Imaging
INVESTIGATION

6. 
 Video urodynamic
 Degree of urethral mobility
 Function of the urinary sphincter
 Weakness of the pelvic floor
Blaivas classification

7. 
 Type 0
 the vesical neck and proximal urethra are closed at rest
 being situated at or above the superior margin of the pubic
symphysis
 During stress (cough or strain) although the vesical neck and
proximal urethra open
 no leakage is observed.
 Type 1
 The vesical neck is closed at rest,
 situated at or above the inferior margin of the pubic symphysis.
 During stress maneuver with increased abdominal pressure, the
vesical neck and proximal urethra open and descend < 2 cm, with
urinary incontinence being demonstrated.

8. 
 Type 2a
 The vesical neck is closed at rest
 above the inferior margin of the pubic symphysis.
 During stress, the vesical neck and proximal urethra descend >2
cm
 urinary incontinence is demonstrated.
 Type 2b
 At rest, the vesical neck is closed
 but is situated below the inferior margin of the pubic symphysis.
 During stress, there is further descent, the proximal urethra opens
and urinary incontinence is demonstrated.

9. 
 Type 3
 At rest, the vesical neck and proximal urethra are
open,
 despite the absence of a detrusor contraction, there
is obvious leakage of urine,
 which is either gravitational or associated with a
minimal increase in intravesical pressure.

10. 
 “stress component” is made with confidence
 treatment modalities should be fully discussed
 behavioral therapy
 timed voiding
 fluid management
 smoking and caffeine reduction
 weight loss
 lifestyle modifications.
 use of pelvic floor muscle training (PFMT) as first line
therapy
 Biofeedback techniques use of vaginal cones
Conservative management

11. 
For women who fail or decline
conservative therapy, there are arrays of surgical
options.

12. 
 Delayed leak
 Especially if there is large volume leakage
 Difficult to stop
 Suggestive of cough-induced detrusor over activity.
Choosing the correct
procedure

13. 
Anterior colporrhaphy along with Kelly’s
aplication
38% treatment failure rate
Transabdominal paravaginal repair
20–57% failure rate reported.
Transvaginal needle suspensions like Peyera,
Stamey, Raz, or Gittes procedures, referred to as
needle urethropexy,
higher SUI recurrence (treatment failure) rate
even 1-year follow up
What is currently not preferred ?

14. 
 Education.
 informed decision
Choosing the Correct Procedure

15. 
 Based on route of approach,
 the surgical procedures for SUI can be divided into
either abdominal (open/laparoscopic/robotic) or
vaginal.
 revolutionary changes in the last decade
 new minimally invasive techniques safe and
effective.
Choosing the Correct
Procedure

16. 
 There are nearly 200 surgical procedures
 Designed to restore the bladder neck and urethra to their
anatomically correct positions
 The choice of surgical procedure depends on a
number of factors
 including the presence of bladder or uterine prolapse,
 severity of incontinence,
 surgeon’s experience in performing specific types of
surgery.
Choice of Surgery

17. 
 Peri-urethral bulking agent injection
 Retropubic suspension (colposuspension,
paravaginal repair)
 Sling and tape procedures (including sub-urethral
tapes and urethral/bladder neck slings)
 Artificial urinary sphincter devices
Surgical approach

18. 
PROCEDURE
 COLPOSUSPENSION
(BURCH ,MMK)
 VAGINAL
SUSPENSION
 SUBRETHRAL SLING
(TVT,TOT,MINI SLINGS)
GOALS
 ELEVATES AND STABILIZE
UTRTHRA BY
SUSPENDING ANTERIOR
VAGINAL WALL TO
ILIOPECTINEAL COOPERS
LIGAMENT
 STABILISES URETHRA BY
SUPORTING
PARAURTHRAL TISSUE
AND ANTERIOR VAGINAL
WALL
 STABILIZING URETHRA BY
PLACING SUB URETHRAL
SLING ATTACHED TO
RECTUS FASCIA OR PUBIC
BONE

19. 
 sub-mucosaly
 apposition of the urethral wall.
 local anesthetia
 low associated morbidity
 autologous fat
 collagen to manufactured polymers (Teflon, Durasphere,
Macroplastique).
 Both subjective and objective short-term improvement
 Longer term studies are necessary before injection
therapy
 Urgency urinary retention, hematuria and particle
migration leading to granuloma
PERI-URETHRAL
BULKING AGENTS

20. 
(sometimes called colpo cysto urethropexy)
standard approach.
wide abdominal incision
often performed during abdominal surgeries
such as hysterectomy or hernia operations
along with sacrocolpopexy into the vagina.
Burch Colposuspension

22. 
 principle of elevating and fixing the bladder neck
and proximal urethra in a retropubic position to
enhance support.
 The most widely used technique is the Burch
colposuspension and this procedure has been used
as a gold standard with which to compare newer
surgical treatments for SUI.
RETROPUBIC SUSPENSION
PROCEDURES

23. 

24. 
 The MMK approach requires a wide abdominal
incision.
 The surgeon then elevates the urethra and bladder
neck using sutures.
 These structures are then secured and anchored to
underneath the pelvic bone.
Marshall-Marchetti-
Krantz (MMK).

25. 
 long-term performance of this procedure is uncertain.
 higher complication rates
 longer operating time
 less intraoperative blood loss
 less postoperative pain
 shorter hospital stay
 quicker return to normal activities
 shorter duration of catheterization
 Direct comparison studies of laparoscopic versus open
colposuspension are surprisingly few and far between.
Laparoscopic
colposuspension

26. 
“smaller is better” concept
Management an ongoing quest
for perfected treatment options
more efficacious outcomes
minimal patient morbidity
Next needleless, single small vaginal incision technique
could perhaps be the total elimination of any incision at
all
Mini slings

27. 
Retropubic MUS more suppression efficiency
Trans obturater approach less suppression
efficiency
Apical prolapse abdominal approach
 simultaneous burch colposuspension
Mild urethral sling is choice

28. 
 High quality trials
 Newer outpatient procedures
 No abdominal incisions
 small incision in the vagina.
 two small tacks are placed in the pubic bone.
 A sling is inserted into the vagina and is attached to the tack.
 The tension-free vaginal tape (TVT) procedure uses a special gauze
tape covered by a polypropylene coating,
 which is attached on each side of the urethrawith
 stress incontinence cure rates of 84 - 100%.
 The benefits of TVT may last for up to 8 years for women with stress
incontinence.
 However, women with mixed incontinence (a combination of stress
and urge) may not do as well with the TVT procedure.
first-line surgical
approach SLING
PROCEDURE

29. 
 minimal possible
 inflammation
 fibrosis
 shrinkage
 a non Current absorbable polymer
which mesh to choose

30. 
 Type 1 monofilament
 No sharp leaving fibers or edges
 Low elasticity
 High dimensional stability
 Large pores
 Better tissue integration
 Prevent bridging
 Development of a firm scar plate over the mesh.

31. 
TVT

34. 
TOT

35. 
 significantly shorter operative time for MUS
procedures compared to bladder neck slings

36. 
Surgical view

37. 
SUI REPAIR

38. 
 Periurethral bulking
 Retropubic suspension
 Colposuspension
 Burch - open-colposuspension
 laprascopic colposuspension
 Sling or tape procedure
 TVT (Transvaginal tape )
 TOT (Transobturator tape )

39. 
A type of retropubic colposuspension in which the
endopelvic fascia next to the bladder neck is attached
to the periosteum of the posterior pubic symphysis,
is also presently not recommended.
MMK has been used as an alternative to Burch’s
colposuspension, but Burch emerges as more
effective (lesser treatment failure rate) and with
lesser morbidity than MMK.
Key points

40. 
 Women who have symptoms suggestive of SUI and
confirmed by clinical examination require treatment,
and may be offered a trial of conservative therapy
initially.
 Women with uncomplicated SUI can be offered
corrective surgery by a vaginal or abdominal route, with
vaginal routeas route of choice except in patients of POP
(apical prolapse) being corrected by abdominal
sacrohysteropexy/sacrocolpopexy.
 For most women with uncomplicated SUI who require
and desire surgical treatment, midurethral
transobturator sling remains the procedure of choice, in
the light of currently available evidence.
Key points

41.  urinary incontinence and it is a problem, which requires
treatment, and can be treated
 Cotton swab test, perineal pad test, urodynamic testing
are not required for diagnosis or management of
uncomplicated SUI.
 PVR urine may be measured by a simple office
ultrasound before performing a MUS surgery in women
with SUI.
 uncomplicated SUI who require and desire surgical
treatment, midurethral transobturator sling remains the
procedure of choice.
Keypoints

42. 
 A retropubic approach may have superior efficacy
 Higher risk of complications
 Single vaginal incision minislings new promising
 Presently available evidence favoring minislings
 Not conclusive recommendation between minislings
and full-length midurethral tapes.
 Minislings have a potential to relieve, groin pain the
only itch full length transobturator tapes
 Maiden data suggests using a U-shaped minisling
rather than H-positioned sling.
Key points

43. 
 Currently, evidence in favor of the use of sub-
urethral tapes especially tension-free vaginal tapes
suggests that a new standard of low morbidity and
high efficacy surgical treatment for SUI has been set.
Key points

44. 
 Surgical management –Revolutionary
 Retropubic MUS –offered distinct advantage
 Trans obturator sling – safer means tension free
 Mini sling – smaller is better concept
Conclusion