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JO.Quantitative analysis of uterosacral ligament origin and insertion points by magnetic resonance imaging. Obstet Gynecol. 2004;103:447–51.
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Operations forStress Urinary
Incontinence
LaurenM.Conroy andO.LenaineWestney
8
Introduction
Stress urinary incontinence (SUI) is a common
condition affecting up to 50% of women at some
point in their lives [1]. It is characterized by the
involuntary loss of urine with increased abdominal pressure or physical exertion and is caused by
urethral hypermobility and/or intrinsic sphincter
deciency (ISD) [2].
While the initial treatments for SUI are conservative, such as pelvic oor exercises, many
women seek surgical intervention for persistently
bothersome symptoms. Surgeries aim to support
the urethra and bladder neck, improving urethral
coaptation. They include urethral injections,
slings (synthetic or autologous), and retropubic
suspensions. The optimal procedure selection
depends on several patient factors, such as the
characterization and severity of their incontinence and their ability to tolerate invasive
procedures.
In addition, each procedure is associated with
complications, with the most prevalent being
transient urinary retention and new-onset irrita-
L. M. Conroy
Department of Urology, University of Texas Health
Science Center at Houston, Houston, TX, USA
e-mail: lauren.m.conroy@uth.tmc.edu
O. L. Westney (*)
Department of Urology, University of Texas—MD
Anderson Cancer Center, Houston, TX, USA
e-mail: owestney@mdanderson.org
tive voiding symptoms, such as urgency and frequency. Complications vary between techniques,
and clinicians must weigh these risks when counseling patients on optimal surgical management.
Injectable Therapy
An Overview
Urethral injection therapy represents a minimally
invasive option to treat SUI, ideal for patients who
may not tolerate or desire surgical interventions or
who have SUI primarily driven by suboptimal
sphincter activity [3]. A urethral bulking agent
(UBA) is injected into the submucosa of the proximal urethra using endoscopy (Fig. 8.1). The
agent is injected with a needle, either transurethrally through a scope or periurethrally. These
techniques are reported to be similarly effective.
However, the periurethral route is associated with
higher rates of early complications [4].
There are two prevailing types of UBAs. The
rst are gels with suspended macroparticles (e.g.,
Macroplastique), and the second group is homogeneous gels that provide a bulking effect through
volume alone (e.g., Bulkamid) [5]. There are limited data to support any one agent over another
[6]. The agents are believed to increase the central lling volume of the urethra, thus increasing
the power of the urethral sphincter with contraction and decreasing urinary leakage [7].
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Hoffman et al. (eds.), Major Complications of Female Pelvic Surgery,
https://doi.org/10.1007/978-3-031-66772-5_8
83
84
Fig. 8.1 Picture of transurethral injection
L. M. Conroy and O. L. Westney
UBAs, occurring in 10% of patients postoperatively and presenting with similar urinary symptoms [11].
Mid-Urethral Slings (MUS)
An Overview
Mid-urethral slings (MUS) are the current gold
standard surgical treatment for SUI in women
[6]. In an MUS procedure, a sling is placed under
the urethra at the level of the mid-urethra. The
sling works by compressing and securing the
posterior wall of the urethra with increased intraabdominal pressure, thus preventing urinary
leakage [1, 12]. The slings are made of a polypropylene monolament, macroporous mesh [12].
Complications
Retention
One of the most common postoperative complications associated with UBAs is urinary retention. A review of 117 articles, including case
reports, found that amongst 6462 patients, 542
incidents of retention were reported [8]. The
retention duration needed to be claried in this
with extended follow-up periods have shown this
retention to be primarily transient [9, 10]. Hoe
etal. reported that of ve incidents of acute urinary retention requiring catheterization, four
spontaneously resolved the following day [10].
Postoperative transient urinary retention rates are
higher when injecting via the periurethral route
[4].
De Novo Irritative Voiding Symptoms
UBAs are also associated with new-onset
urgency, frequency, and urge incontinence. de
Vries etal. found that amongst 6462 patients, 452
reported urinary issues such as these [8]. While
symptom duration was not reported in this review,
another study noted that 3years postinjection of
Macroplastique, the rate of de novo irritative
voiding symptoms was 1.2% [9]. Notably, urinary tract infections (UTIs) are common with
Tension-Free Vaginal Tape (TVT)
One of the initial MUS procedures developed
was a tension-free vaginal tape (TVT), also
known as a retropubic mid-urethral sling. In this
procedure, a tape is inserted through the retropubic space. Two techniques are utilized: a bottom up approach and a top-down approach. In the
bottom-up technique, a trocar with an attached
sling is inserted through the vagina on one side of
the urethra, elevated through the retropubic
space, and out the suprapubic skin. This is performed contralaterally, leaving the tape suspended beneath the urethra. In the top-down
technique, trocars are inserted into the suprapubic skin and exit in the vagina [12, 13]. The bottom- up approach is more effective and associated
with fewer adverse effects [1].
Transobturator Tape (TOT)
The transobturator tape (TOT) procedure was
developed to minimize the morbidity associated
with TVT and the risk of injury to local structures. In this procedure, a tape is inserted horizontally between the bilateral obturator foramens,
avoiding the retropubic space [12] (Fig.8.2). Two
techniques are utilized: outside-to-inside and
inside-to-outside. Using the outside-to-inside
method, a trocar is placed through the adductor
longus tendon and rotated inward through the
8 Operations forStress Urinary Incontinence
Fig. 8.2 Pelvic diagram with TOT in place
vagina bilaterally. A tape is then attached to the
trocars and withdrawn with them through the
thigh incisions, remaining suspended beneath the
urethra. In the inside-to-outside technique, trocars are inserted into the vagina and exit through
the adductor longus tendon [12–14]. These techniques have similar effectiveness; however, the
outside-to-inside approach is associated with a
higher risk of vaginal perforation and erosion
[15].
Single-Incision Slings (SIS)
The most recently developed mid-urethral slings
are single-incision slings (SIS) or mini-slings.
These were designed to reduce further morbidity
associated with slings and provide a less invasive,
potentially outpatient option to treat SUI [16]. In
this procedure, the sling consists of a piece of
mesh positioned between two anchoring ends. A
single incision is made in the vaginal epithelium,
and the device is pushed under the mid-urethra
[12]. Different SIS are associated with other
anchoring mechanisms [17].
Complications
Mesh Erosion
In 2011, the Food and Drug Administration
(FDA) released a safety communication reporting severe complications associated with transvaginal placement of mesh for pelvic organ
prolapse (POP) repair. While MUS were not
included in this communication, media attention
85
and increased litigation raised concerns surrounding the use of synthetic mesh in the treatment of incontinence [18]. Since then, several
studies have investigated the risk of mesh eroding
into the urethra and vagina in patients who have
undergone an MUS procedure. Overall, mesh
erosion is uncommon and not more common in
one type of MUS over another, as seen in two
recent meta-analyses. A Cochrane review found
that mesh erosion occurred in 2.0% of TVT procedures vs. 2.2% of TOT procedures (Table8.1)
[1]. These results were supported by Brazzelli
et al., who found similar erosion rates [19].
Notably, most of the studies reviewed in these
meta-analyses had short follow-up periods. One
study, which followed patients for more than
10 years, found that the rates of sling erosion
with TOT increased after 10years; however, the
rate of erosion at this time was 2.4% [20]. The
limited studies comparing MUS and SIS indicate
that the erosion rates are similar [19].
Risk factors associated with mesh erosion
include age, current smoking status, diabetes
mellitus, vaginal incision >2cm, and a history of
prior surgery for incontinence or POP. Studies
have shown that older age is associated with erosion, likely secondary to increased urogenital
atrophy and resulting thinner tissue. However,
other studies have shown that younger age and
increased sexual activity may also be associated
with an increased erosion risk. Increased incision
size and a history of a prior surgery with scar tissue are related to vascular damage and diminished tissue perfusion [9].
Bladder Injury
Blind passage of trocars through the retropubic
space with TVT puts patients at risk of bladder
perforation and vascular, nerve, and bowel injuries [21]. As a result, bladder perforation is signicantly more common with TVT than with
TOT. A Cochrane review found that the risk of
bladder or urethral injury was 4.9% with TVT vs.
0.6% with TOT [1].
Pain
Groin pain is a common complication associated
with TOT, as the exit point of the trocars is the
86
L. M. Conroy and O. L. Westney
Comments
1
Quality of the evidence (GRADE)
No of participants
(studies)
⊕⊕⊕⊝ MODERATE
CI)
(95% CI) Relative effect (95%
*
2,3
⊕⊕⊝⊝ LOW
4
⊕⊕⊕⊝MODERATE
5
⊕⊕⊕⊝ MODERATE
6
⊕⊕⊕⊝ MODERATE
7
⊕⊕⊕⊝ MODERATE
Illustrative comparative risks
Assumed risk Corresponding risk
Table 8.1 TOT compared to TVT for SUI in women
(810–844)
Retropubic (RPR)
route Transobturator (TOR)
Study population RR 0.98 (0.96–1.00) 5514 (36 RCTs)
844 per 1000 827 per 1000
Mean control group risk across studies
Outcomes
Subjective cure (Short term
<1 year)
(800–833)
833 per 1000 816 per 1000
Study population RR 0.97 (0.92–1.03) 683 (5 RCTs)
881 per 1000 854 per 1000
Subjective cure (medium
term, 1–5years)
(810–907)
(799–895)
Mean control group risk across studies
869 per 1000 843 per 1000
(615–735)
Study population RR 0.95 (0.87–1.04) 714 (4 RCTS)
707 per 1000 671 per 1000
Mean control group risk across studies
843 per 1000 801 per 1000
Subjective cure (long term,
>5 years)
(733–877)
Study population RR 0.13 (0.08–0.20) 6372 (40 RCTs)
Bladder or urethral
49 per 1000 6 per 1000 (4–10)
Mean control group risk across studies
25 per 1000 3 per 1000 (2–5)
Study population RR 0.53 (0.43–0.65) 6217 (37 RCTs)
72 per 1000 38 per 1000 (31–47)
Mean control group risk across studies
55 per 1000 29 per 1000 (24–36)
Study population RR 0.98 (0.82–1.17) 4923 (31 RCTs)
82 per 1000 80 per 1000 (67–96)
Mean control group risk across studies
perforation
Voiding dysfunction (short
and medium term, up to 5
years)
De novo urgency or urgency
incontinence (short term, up
to 12 months)
83 per 1000 81 per 1000 (68–97)
8 Operations forStress Urinary Incontinence
87
8
⊕⊕⊕⊝ MODERATE
9
⊕⊕⊕⊝ MODERATE
10
⊕⊕⊕⊝ MODERATE
11
⊕⊕⊕⊝ MODERATE
12,13
⊕⊕⊝⊝LOW
695 (4 RCTs)
(3.36–23.00)
(139–311)
14 per 1000 66 per 1000 (44–99)
Mean control group risk across studies
45 per 1000 208 per 1000
Groin pain Study population RR 4.62 (3.09–6.92) 3226 (18 RCTs)
29 per 1000 8 per 1000 (3–23)
Mean control group risk across studies
18 per 1000 6 per 1000 (2–14)
Suprapubic pain Study population RR 0.29 (0.11–0.78) 1105 (4 RCTs)
Study population RR 1.13 (0.78–1.65) 4743 (31 RCTs)
20 per 1000 22 per 1000 (15–32)
Mean control group risk across studies
21 per 1000 24 per 1000 (16–34)
Study population RR 1.64 (0.85–3.16) 1402 (9 RCTs)
19 per 1000 31 per 1000 (16–60)
mean control group across studies
24 per 1000 39 per 1000 (20–76)
Study population RR 8.79
Vaginal tape erosion (short
and medium term, up to 5
years)
Repeat incontinence surgery
(short term, within 12
months)
Repeat incontinence surgery
(38–262)
11 per 1000 100 per 1000
(225–1000)
Mean control group across studies
67 per 1000 589 per 1000
(long term, > 5 years)
Modied from a Cochrane review
88
L. M. Conroy and O. L. Westney
medial thigh. The pain is often transient and
resolves in the post-op period [22]; however, in
rare cases, it can persist and become chronic [22].
This chronic pain is associated with damage to
the obturator nerve as the trocar traverses the
obturator foramen [12]. Not surprisingly, groin
pain is signicantly more common with TOT
than with TVT. A recent meta-analysis has
reported the rate of groin pain to be 6.3% with
TOT versus 1.3% with TVT [19]. These ndings
are primarily based on studies conducted within
1-year post-op. One study, which evaluated outcomes after 13years, found 1 of 168 patients to
have persistent groin pain, not requiring analgesics [20].
SIS was developed in part to reduce the risk of
developing postoperative pain. A meta-analysis
of 14 studies found the immediate post-operative
pain rate to be 6.8% with SIS versus 19.2% with
TVT [19]. There is limited data to show the longterm comparison of pain with SIS and standard
MUS.
Voiding Dysfunction
While an MUS functions to compress the urethra,
patients risk obstruction and resulting voiding
dysfunction if the tape is placed with too much
tension around the urethra or too close to the
bladder neck [12]. This is more commonly found
with TVT, where the tape is placed at a more vertical angle, resulting in increased obstruction
[23]. Within the rst 5years postoperatively, the
risk of voiding dysfunction is 7.2% with TVT vs.
3.8% with TOT [1]. This is often transient, however, as long-term dysfunction necessitating surgery or permanent catheterization is rare. One
randomized controlled trial (RCT) found that the
risk of requiring these measures was 2.7% with
TVT vs. 0% with TOT [23].
De Novo Irritative Voiding Symptoms
One of the most common complications after an
MUS surgery is new-onset irritative bladder
symptoms, such as increased urinary urgency or
detrusor overactivity (DO). Meta-analyses
revealed no signicant difference in these symptoms between TVT and TOT (8.2% vs. 8%) [1] or
TVT and SIS (9.2% vs. 9.5%) (Brazzelli 2019) in
the rst 12months post-operation [1].
Recurrent Incontinence
It is not uncommon for patients to require multiple procedures to manage their SUI adequately.
At 12 months post-operation, 3.6% of patients
with TOT vs. 2.2% with TVT will require repeat
continence surgery. After 1–5 years, 18.3% of
patients with TOT will require repeat surgery (vs.
0.5% with TVT) [1]. Limited data demonstrate
the long-term need for repeat surgery following
an SIS surgery. However, current data indicate
that in the short term, the need is greater than for
standard MUS [1, 17].
Recurrent or persistent SUI following an MUS
surgery may also be due to various factors,
including the wrong choice of the initial procedure, patient characteristics, and the natural history of incontinence. When deciding between
TVT and TOT, many factors must be considered.
Some evidence indicates that TOT is less effective
in patients with SUI, primarily caused by intrinsic sphincter deciency or more severe initial
SUI [23, 24]. Other factors, such as patient
weight and age, may also impact surgery success
[12]. Finally, with time, the pelvic oor weakens,
and the intrinsic sphincter function declines,
worsening SUI naturally [3].
Pubovaginal Slings (PVS)
An Overview
Before the widespread use of synthetic slings, the
traditional slings used to treat SUI were pubovaginal slings (PVS) composed of autologous
fascia. Today, this type of sling is still widely
used for patients when synthetic materials are not
desired or contraindicated, such as with patients
at risk of poor wound healing, immunocompromise, or regularly require clean intermittent catheterization (CIC) [6, 25, 26]. Furthermore, there
is a belief that these slings are more compressive
and, thus, are more appropriate for patients with
worse incontinence [26].
PVS are placed at the bladder neck, compressing the proximal urethra and bladder neck
with increased abdominal stress, providing bladder outlet resistance and thus preventing urinary
leakage [26] (Fig.8.3). Fascial slings are most
8 Operations forStress Urinary Incontinence
Fig. 8.3 Diagram with an implanted pubovaginal sling
89
Fig. 8.4 Diagram demonstrating passage of sling sutures
using a Sarot clamp
commonly composed of rectus abdominis fascia
from the abdominal wall or fascia lata from the
lateral thigh [27]. In a PVS procedure, following
the harvesting of fascia, the vaginal epithelium is
dissected under the mid-urethra and bladder
neck. The endopelvic fascia is perforated using
this dissection, and the retropubic space is developed on either side of the urethra. Clamps or
needles are then passed from the abdomen,
through the previously developed plane, into the
vaginal incision, where they grasp a suture tied
to the harvested fascial sling (Fig.8.4). The ends
of the graft suture are then brought out of the
abdominal incision bilaterally, leaving the fascia
suspended beneath the bladder neck. Finally, the
suture is tied down over the rectus fascia to
secure the sling and provide adequate tensioning
[12, 26].
Complications
Bladder Perforation
The PVS procedure requires blind passage of
instruments through the retropubic space, putting
patients at risk of bladder perforation. The
American Urological Association (AUA) guideline meta-analysis reported a perforation rate of
4% [28]. Patients with previous pelvic surgeries
are at an increased risk of perforation [26].
Urinary Retention
The placement of a PVS at the bladder neck, as
well as the tensioning of the sling, puts patients at
risk of bladder outlet obstruction, resulting in urinary retention [27]. Studies have shown a voiding
dysfunction rate of up to 14% [26]. Several studies investigated the duration of urinary retention.
Mock et al. found that 4.4% of patients who
received a PVS developed voiding dysfunction,
1.1% required long-term CIC, and 3.3% resolved
spontaneously within 1 month of surgery [25].
Athanasopoulos et al. found that 10.6% of
patients developed voiding dysfunction, with
most of these cases resolving within 2 months
and 1.9% eventually requiring surgical resolution
[29].
De Novo Irritative Voiding Symptoms
One of the most common complications of
PVS is postoperative irritative voiding symptoms, possibly related to a degree of bladder
outlet obstruction created by the sling [29].
Studies have shown a rate of de novo urgency
of up to 18.5% [25, 26, 29]. Kim etal. found an
increase in irritative voiding symptoms with
90
increased time from sling placement, likely
secondary to worsening detrusor function with
age rather than a long-term consequence of the
sling [30].
Recurrent Incontinence
The need for repeat continence surgery following
primary or secondary PVS placement is minimal.
However, only some studies have investigated the
long-term efcacy of PVS.Khan etal. found that
of 61 patients who received PVS, after 10years,
none required reoperation, and Kim etal. found
that of 83 patients, after 14.5 years, 2 required
reoperation [30, 31]. Other studies have indicated
up to an 84% absence of SUI symptoms 10years
following a PVS surgery [32]; however, after this
extended period, it is unclear whether repeat
symptoms are due to operation failure or agerelated changes [30, 32].
L. M. Conroy and O. L. Westney
Retropubic Suspensions
An Overview
Retropubic suspensions involve lifting the tissue
surrounding the bladder neck and proximal urethra into the pelvis behind the anterior pubic
bones [33]. These procedures have largely been
replaced by less invasive procedures, such as
slings. They are now mostly reserved for patients
for whom synthetic materials are contraindicated
or who are undergoing concomitant pelvic surgery [6]. They are used to treat patients with SUI
primarily caused by urethral hypermobility [33].
There are several variations of retropubic suspensions, with Burch colposuspension being the
most common. In a Burch procedure, the anterior
vaginal wall at the bladder neck level is elevated
and sutured to the iliopectineal ligament [34]
(Fig.8.5). This is believed to aid in continence by
stabilizing the bladder, neck, and urethra and
restoring them to their original retropubic position [33]. This procedure can be performed either
open or laparoscopically, with similar efcacy
[35].
Another common variation is the Marshall–
Marchetti–Krantz (MMK) procedure, where the
Fig. 8.5 Diagram demonstrating the location of Burch
suspension sutures
bladder neck is suspended onto the periosteum of
the pubic symphysis. Minimal data favor Burch
to MMK in effectively treating SUI [36].
Complications
Voiding Dysfunction
Voiding dysfunction or urinary retention is rare
following retropubic suspension, especially compared to slings, the gold standard SUI treatment.
Data show almost no risk of developing voiding
dysfunction following retropubic suspension
[36–38].
Recurrent Incontinence
Compared to slings, the trade-off associated with
reduced morbidity of retropubic suspensions is at
a lesser degree of treatment “success.” Brubaker
etal. found that 5years following Burch, 12% of
patients required surgical retreatment, and Albo
etal. found that 2 years following Burch, 11%
needed surgical retreatment [37, 38].
8 Operations forStress Urinary Incontinence
91
Conclusions
Several procedures are available to treat SUI,
each with varying risk proles. Clinicians should
consider these risks and counsel patients based
on their unique needs when making recommendations regarding the optimal procedure.
References
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2. Ford AA, Ogah JA. Retropubic or transobturator
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s00192- 015- 2797- 3.
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Klarskov N.Patient characteristics that may inuence
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https://doi.org/10.1097/JU.0000000000000176.
4. Kirchin V, Page T, Keegan PE, Atiemo KO, Cody
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