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234 Challenging Concepts in Urological Surgery
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patient’s symptoms point towards idiopathic OAB syndrome or another condition which could
cause similar symptoms such as recurrent UTIs, bladder pain syndrome, bladder cancer, bladder
stones, pelvic malignancy, sexually transmitted diseases, or previous pelvic radiotherapy.
Initial investigations should include a 3- day bladder diary, post- void bladder scan, and urine
dipstick. Conservative management strategies can often reduce the bother patients experience
from their symptoms— these include weight loss, fluid management (including cutting out
caffeine), and pelvic floor exercises. Medical therapy such as topical vaginal oestrogen therapy,
anticholinergics, and beta- 3 agonists have reasonable efficacy although compliance is an issue.
The role of UDS is controversial; it is usually only indicated if symptoms are refractory to medical
treatment and there is no compelling evidence that it helps to select a treatment modality or
predict response. It is generally helpful if a patient presents with mixed symptoms, there is an
unclear diagnosis, poor history, associated voiding symptoms, or a background neurological
condition.
Intravesical BTX is a very effective treatment although patients will need repeated treatments.
PTNS offers similar efficacy to pharmacotherapy but requires a regular time commitment
from the patient at the start as well as for maintenance sessions. It is not widely offered.
SNS is a reasonably safe and minimally invasive treatment option but does require intensive
commitment on behalf of the patient. Revision rates can be high. Augmentation cystoplasty
should be reserved for the most refractory cases and in patients who are fit to undergo
major surgery. They should be appropriately counselled about the high risk of ISC and other
associated risks and complications. Invasive treatment modalities should be discussed within a
multidisciplinary setting and all treatment options explored with the patient.
References
1. Bo K, Frawley HC, Haylen BT, et al. An International Urogynecological Association (IUGA)/
International Continence Society (ICS) joint report on the terminology for the conservative and nonpharmacological management of female pelvic floor dysfunction. Neurourol
Urodyn. 2017;36(2):221– 244.
2. Avery K, Donovan J, Peters TJ, Shaw C, Gotoh M, Abrams P. ICIQ: a brief and robust
measure for evaluating the symptoms and impact of urinary incontinence. Neurourol
Urodyn. 2004;23(4):322– 330.
3. Coyne KS, Sexton CC, Kopp ZS, Ebel- Bitoun C, Milsom I, Chapple C. The impact of overactive bladder on mental health, work productivity and health- related quality of life in the
UK and Sweden: results from EpiLUTS. BJU Int. 2011;108(9):1459– 1471.
4. Willis- Gray MG, Dieter AA, Geller EJ. Evaluation and management of overactive
bladder: strategies for optimizing care. Res Rep Urol. 2016;8:113– 122.
5. Robinson D, Hanna- Mitchell A, Rantell A, Thiagamoorthy G, Cardozo L. Are we justified in
suggesting change to caffeine, alcohol, and carbonated drink intake in lower urinary tract
disease? Report from the ICI- RS 2015. Neurourol Urodyn. 2017;36(4):876– 881.
6. Cody JD, Jacobs ML, Richardson K, Moehrer B, Hextall A. Oestrogen therapy for urinary
incontinence in post- menopausal women. Cochrane Database Syst Rev. 2012;10:CD001405.
7. Shamliyan T, Wyman JF, Ramakrishnan R, Sainfort F, Kane RL. Benefits and harms of
pharmacologic treatment for urinary incontinence in women: a systematic review. Ann
Intern Med. 2012;156(12):861– 874.
8. Chapple CR, Nazir J, Hakimi Z, et al. Persistence and adherence with mirabegron versus
antimuscarinic agents in patients with overactive bladder: a retrospective observational
study in UK clinical practice. Eur Urol. 2017;72(3):389– 399.
9. Allison SJ, Gibson W. Mirabegron, alone and in combination, in the treatment of overactive
bladder: real- world evidence and experience. Ther Adv Urol. 2018;10(12):411– 419.
10. Gray SL, Anderson ML, Dublin S, et al. Cumulative use of strong anticholinergics and inci-
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dent dementia: a prospective cohort study. JAMA Intern Med. 2015;175(3):401– 407.
11. Nambiar AK, Bosch R, Cruz F, et al. EAU guidelines on assessment and nonsurgical management of urinary incontinence. Eur Urol. 2018;73(4):596– 609.
12. Malone- Lee JG, Al- Buheissi S. Does urodynamic verification of overactive bladder determine treatment success? Results from a randomized placebo- controlled study. BJU Int.
2009;103(7):931– 937.
13. Brazzelli M, Murray A, Fraser C. Efficacy and safety of sacral nerve stimulation for urinary
urge incontinence: a systematic review. J Urol. 2006;175(3):835– 841.
14. Jackson BL, Burge F, Bronjewski E, Parkinson RJ. Intravesical botulinum toxin for
overactive bladder syndrome without detrusor overactivity. Br J Med Surg Urol.
2012;5(4):169– 173.
15. Colli E, Artibani W, Goka J, Parazzini F, Wein AJ. Are urodynamic tests useful tools for the
initial conservative management of non- neurogenic urinary incontinence? A review of the
literature. Eur Urol. 2003;43(1):63– 69.
16. Rovner E, Kennelly M, Schulte- Baukloh H, Zhou J, Haag- Molkenteller C, Dasgupta
P. Urodynamic results and clinical outcomes with intradetrusor injections of
onabotulinumtoxinA in a randomized, placebo- controlled dose- finding study in idiopathic
overactive bladder. Neurourol Urodyn. 2011;30(4):556– 562.
17. Schurch B, de Seze M, Denys P, et al. Botulinum toxin type a is a safe and effective treatment for neurogenic urinary incontinence: results of a single treatment, randomized, placebo controlled 6- month study. J Urol. 2005;174(1):196– 200.
18. Chapple C, Sievert KD, MacDiarmid S, et al. OnabotulinumtoxinA 100 U significantly improves all idiopathic overactive bladder symptoms and quality of life in patients with overactive bladder and urinary incontinence: a randomised, double- blind, placebo- controlled
trial. Eur Urol. 2013;64(2):249– 256.
19. Peters KM, Carrico DJ, Wooldridge LS, Miller CJ, MacDiarmid SA. Percutaneous tibial nerve
stimulation for the long- term treatment of overactive bladder: 3- year results of the STEP
study. J Urol. 2013;189(6):2194– 2201.
20. Awad SA, Al- Zahrani HM, Gajewski JB, Bourque- Kehoe AA. Long- term results and complications of augmentation ileocystoplasty for idiopathic urge incontinence in women.
Br J Urol. 1998;81(4):569– 573.
21. van Kerrebroeck PE, van Voskuilen AC, Heesakkers JP, et al. Results of sacral
neuromodulation therapy for urinary voiding dysfunction: outcomes of a prospective,
worldwide clinical study. J Urol. 2007;178(5):2029– 2034.
22. Amundsen CL, Richter HE, Menefee SA, et al. OnabotulinumtoxinA vs sacral
neuromodulation on refractory urgency urinary incontinence in women: a randomized
clinical Trial. JAMA. 2016;316(13):1366– 1374.
23. Agarwal A, Eryuzlu LN, Cartwright R, et al. What is the most bothersome lower urinary
tract symptom? Individual- and population- level perspectives for both men and women.
Eur Urol. 2014;65(6):1211– 1217.
235Case 23 Urge urinary incontinence
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24
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CASE
Stress urinary incontinence
Rachel Barratt
Expert commentary Suzanne Biers
Case history
A 52- year- old woman presented with long- standing urinary incontinence (UI), progressively worsening over the last 18 months. Urinary leak while running had meant she
had stopped exercising and had put on weight as a result, with a raised body mass index
(BMI) of 34 kg/ m2. She also leaked on coughing, laughing, and occasionally without
any obvious cause, and required three large pads per day which were often saturated.
She denied associated lower urinary tract symptoms (LUTS). She had two children by
normal vaginal delivery, and was now perimenopausal. Urinalysis was negative, postvoid residual (PVR) was negligible, and 24- hour pad weight was significant at 70 g.
Examination revealed mild vaginal atrophy, a demonstrable stress leak on cough, but
no pelvic organ prolapse (POP), and pelvic floor power was 3 out of 5 (Table 24.1).
Expert comment Assessment of UI
Be vigilant and seek out ‘red flag’ symptoms when assessing patients with UI. These include
haematuria, pain, recurrent urinary tract infections (UTIs), previous pelvic radiotherapy or surgery,
and symptomatic POP. There is a small subset of women with ‘complete’ UI, with new or worsening
incontinence who are ‘never dry’. Maintain a high level of suspicion for vesicovaginal fistula in
these cases. Congenital causes of persistent lifelong UI include duplex kidney with an ectopic ureter
inserting into the distal urethra or vagina.
Pad weight tests are not routinely recommended, but 24- hour pad weights can be helpful in
quantifying the severity of SUI1; >4.0 g is considered significant.2 The International Consultation on
Continence Questionnaire for Urinary Incontinence (ICIQ- UI) short form is a useful, validated, succinct
questionnaire assessing frequency, volume, and bother from and triggers for UI, and is helpful in
objectively recording symptoms at baseline and after intervention.
3
Table 24.1 The Medical Research Council grading and Laycock’s Modified Oxford Scale
(adapted) are examples of systems utilized by pelvic floor physiotherapists to manually assess
muscle strength, and both are graded on a scale from 0 to 5
MRC grading of muscle strength Oxford grading system Score
No contraction No contraction 0
Flicker of movement Flicker 1
Active movement with gravity eliminated Weak 2
Active movement against gravity Moderate 3
Active movement against gravity and resistance Good (with lift) 4
Active movement against strong resistance Strong 5
Adapted and used with the permission of the Medical Research Council (MRC), https:// mrc.ukri.org/ resea rch/ fac ilit iesand- resour ces- for- rese arch ers/ mrc- sca les/ mrc- mus cle- scale/ ; Laycock J. Incontinence. Pelvic floor re- education. Nursing
(Lond). 1991 Jul 25– Aug 21;4(39):15– 7. PMID: 1881640.
238 Challenging Concepts in Urological Surgery
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The starting point for any patient with SUI is a trial of conservative measures.
Weight loss
For patients with a BMI >30 kg/ m2, weight loss programmes achieving a loss of 5– 10% body weight in
overweight individuals result in symptom improvement in 47– 65%.
4
Oestrogen therapy
● Treatment with topical oestrogen therapy has been shown to be of use in postmenopausal patients.
● Conversely, systemic oestrogen therapy (with conjugate equine oestrogens) can worsen pre- existing
SUI or cause new SUI.
6
5
Duloxetine medication
● Inhibits presynaptic reuptake of serotonin and norepinephrine in the sacral spinal cord, increasing
the availability of these neurotransmitters to the postsynaptic pudendal motor neurons, and thus
increasing the resting tone of the urethral striated sphincter.
Learning point Conservative options for SUI
● Systematic review has shown it is efficacious when compared to placebo, but has a high rate of
gastrointestinal and nervous system side effects resulting in a high discontinuation rate.
7
● Both National Institute of Health and Care Excellence (NICE) and European Association of Urology
(EAU) guidelines do not recommend the use of duloxetine as a primary treatment, but it can be
used in those who do not wish to embark on surgical therapy.
Pelvic floor muscle training
8,9
Supervised pelvic floor muscle training (PFMT) has been shown to improve SUI by 20– 87%, but there
is a lack of evidence for sustained long- term benefit.10 PFMT consists of supervision from a trained
pelvic floor healthcare professional in identifying pelvic floor contraction and then performing eight
to ten fast- twitch fibre exercises (quick hold and release) and eight to ten slow- twitch fibre recruiting
exercises (hold for 10 seconds and release) performed three times per day.
Expert comment Topical oestrogen
Topical oestrogen therapies are available in pessary tablet, cream, and oestradiol- releasing vaginal ring
pessary (Estring®) forms. Pelvic floor, urethral, and bladder tissues are sensitive to the effects of local
oestrogen, and oestrogen receptors enhance the support mechanism of the pelvis through effects on
synthesis and breakdown of collagen. Although topical oestrogens have minimal systemic absorption,
advice should be taken from haematology and oncology experts if its use is considered in patients
with prothrombotic conditions or a history of breast or endometrial cancer.
Evidence base Cochrane systematic review comparing the outcomes of PFMT versus no
treatment on UI
A Cochrane review included 31 randomized or quasi- randomized trials, and involved 1817 women
from 14 countries11:
● Symptomatic ‘cure’ of SUI was eight times more likely for patients receiving PFMT compared to no
treatment (56% vs 6%).
● Symptomatic ‘cure or improvement’ of SUI was six times more likely for patients receiving PFMT
compared to no treatment (74% vs 11%).
● PFMT were associated with significant improvement in both UI symptoms, quality of life scores and
satisfaction, and reduced UI episodes by one per day.
(now 32 kg/ m2) alongside a trial of topical oestrogen therapy, the patient’s symptoms
failed to improve. As the patient reported primary pure SUI, the decision was taken
to not proceed with twin- channel urodynamic studies (UDS). She wished to pursue
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active treatment and was counselled on all (surgical) options, and provided with a
patient decision aid and patient information leaflets.
239Case 24 Stress urinary incontinence
Both NICE and EAU guidelines
8,9
do not recommend UDS for the patient with primary ‘pure’ SUI. Of note,
this represents a very small number of patients (5.2%).12 If there is any doubt in the diagnosis, voiding
dysfunction, POP, urge- predominant mixed UI, or recurrent SUI, UDS should be offered.
Two randomized controlled trials have looked at the use of UDS for predominant SUI symptoms and
the resulting surgical outcomes:
Evidence base The role of urodynamics in uncomplicated primary SUI
The Value of Urodynamic Evaluation (VALUE) study
This evaluated differences in treatment outcomes at 12 months in 630 women between standard
‘office’ evaluation and twin- channel UDS assessment13:
● Treatment success was 76.9% in the UDS group and 77.2% in the office evaluation group (non-
inferior outcomes).
● Ninety- seven per cent with a clinical diagnosis of SUI had confirmed UDS SUI. UDS identified
voiding dysfunction which had not been detected clinically in 10%, and excluded detrusor
overactivity when it had been reported clinically in around 10– 20% of patients.
The Value of Urodynamics Prior to Stress Incontinence Surgery 2 (VUSIS 2) study
This evaluated the strategy of immediate surgery for SUI versus tailoring therapy according to UDS
findings in 578 women, and found no difference at 12 months follow- up.
14
Clinical tip Options for primary SUI
For patients who wish to undergo surgery for primary SUI, all options can be offered after
discussion in a specialist local pelvic floor multidisciplinary team (MDT) meeting. Alongside
efficacy, the most important factor when counselling patients is the side effect profile of each
procedure. Please note, mid-urethral synthetic tapes have not been in UK use since 2018.
Urethral bulking agents (i.e. Bulkamid®, Macroplastique®, Coaptite™)
● Success rates up to 50% cure (dry) and 70– 80% improvement in SUI at 12 months.
15
● Repeat treatment is required in 30– 60% of patients.
● Risks include infection (UTI), bleeding, retention of urine <2%, urethral pain, de novo overactive
bladder symptoms <1%.
● Benefits are that it is a ‘minimally invasive’ day- case procedure that can be performed under local
anaesthetic.
Mid- urethral (synthetic) tapes
● Subjective success rates are 62– 98% within 12 months, with no differences in success rates between
retropubic and transobturator tapes16; longer- term success rates are 43– 92%.
● Side effect profile, however, does differ:
- Retropubic mid- urethral tape (MUT) is associated with a higher rate of bladder perforation (<5%),
voiding dysfunction, and suprapubic pain (2%).
- Transobturator MUT is associated with higher rates of groin pain (6%) but has a decreased risk of
voiding dysfunction and visceral or vascular injury (<1%).
- General risks include infection; bleeding; pain (suprapubic, pelvic, vaginal, thigh or groin pain,
which can be chronic); injury to or extrusion of mesh into the bladder, urethra, or vagina; voiding
dysfunction; and de novo overactive bladder symptoms. Vaginal mesh extrusion is <3% for both.
Autologous fascial sling
● Success rates for autologous fascial sling (AFS) are around 82%.
17
240 Challenging Concepts in Urological Surgery
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● Specific risks include urinary retention and voiding dysfunction— this is more common as compared
to MUT and colposuspension.
Colposuspension
● Aims to reposition the urethra and bladder neck in a normal anatomical position, and is helpful for
type 2 (hypermobility) SUI.
● Subjective success rates at <12 months are 85– 90%, deteriorating slightly to 79% after 5- year follow- up.
● Specific risks include middle and posterior compartment POP in around 15%.
Evidence base Review of the comparative data on colposuspension, pubovaginal slings, and
MUTs in the surgical treatment of female SUI
This systematic review and meta- analysis reports the findings of all comparative trials
involving MUT for the surgical management of primary female SUI up until 2016, and
includes 28 randomized controlled trials.
Colposuspension versus MUT
● MUT had significantly higher cure rates compared to colposuspension (when laparoscopic
colposuspension was included).
● Subjective success rates were 82% versus 74% for MUT and colposuspension respectively, and
objective success rates 79.7% versus 67.8%.
MUT versus AFS
● Both techniques had similar efficacy and prevalence of complications.
● There was a trend towards a higher risk of bladder perforation with MUT and a higher incidence of
reoperation with AFS.
● Patients treated with MUT had a statistically significant lower incidence of storage LUTs.
Retropubic versus transobturator MUT
● Retropubic MUT had statistically significant higher objective and subjective success rates compared
to transobturator MUT (86% vs 84% and 78% vs 74%, respectively), although when any definition of
cure was used, overall continence rates were not significantly different.
● Retropubic MUT had higher rates of bladder and vaginal perforation (4.8% vs 1.6%), UTI (10% vs
7.9%), and voiding symptoms (9.2% vs 5.6%).
● Vaginal erosion rates were reported to be higher in transobturator MUT (2.8% vs 1.8%).
● Other complications including storage symptoms, reoperation rates, and requirement for clean
intermittent self- catheterization were found to be equivalent.
18
19
The case was discussed at the local hospital MDT meeting, and the patient elected
to proceed with a retropubic MUT (tension- free vaginal tape). Postoperative recovery
was uneventful, but she failed to attend follow- up, and was re- referred by her general
practitioner 18 months later for persisting UI. The patient reported occasional urgency, but symptoms were still predominantly SUI. Her BMI had risen to 37 kg/ m2.
She reported improvement from her retropubic MUT, but still required two pads per
day and wanted to be dry. She had not experienced UTI, pelvic pain, or dyspareunia,
and had no evidence of POP or mesh erosion on vaginal examination in clinic.
Clinical tip Surgery for primary SUI in women
NICE clinical guidelines on female UI management (NG123)9 advise that women with primary SUI
should be discussed at the local MDT meeting prior to offering surgery, and should be counselled
on all options with the assistance of a patient decision aid. First- line surgical options include
colposuspension, AFS, and MUT (retropubic route, bottom- to- top). For all indwelling synthetic
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products, a comprehensive database should be kept (on a national registry) including information on
date and detail of the procedure, mesh, bulking agent or suture material used, manufacturer, product
unique identification code, date, and detail of complications, and women should be given a copy
of their data. Mesh complications should be reported to the Medicines and Healthcare products
Regulatory Agency (MHRA). For women considering repeat continence surgery, their case should be
discussed at a regional MDT meeting with specialists who deal with complex pelvic floor dysfunction
(and mesh- related problems).
Expert comment Vaginal mesh surgery
This case predates the ‘pause’ on vaginal mesh surgery which was introduced in the UK in July
2018, and extended in March 2019, following the NHS England Independent Medicines and
Medical Devices Safety Review. Recommendations that should be established for practice to
resume include:
● Only undertake operations if appropriately trained and operating regularly
● Report every procedure to a national database
● Register of operations maintained
● Report complications via the MHRA
● Accreditation of specialist centres for SUI mesh procedures
● NICE guidelines on the use of mesh for SUI (published 2 April 2019).
Clinical tip Key points in the clinical history for recurrent UI after surgery
For patients with recurrent UI following previous surgery for SUI, the following additional pertinent
symptom information should be gathered:
● Urgency: approximately 10– 15% of women will develop de novo detrusor overactivity, with or
without incontinence.
● Incomplete bladder emptying and poor flow is suggestive of voiding dysfunction.
● Recurrent UTIs may be indicative of voiding dysfunction, retention of urine, or can be a feature of
mesh or suture exposure in the urinary tract.
● Vaginal pain and dyspareunia may be early signs of mesh extrusion into the vagina.
9
241Case 24 Stress urinary incontinence
Expert comment Investigation of recurrent UI
Investigation of recurrent UI should include urinalysis, PVR, a 3- day bladder diary, and UDS.
This helps to rule out associated voiding dysfunction or detrusor overactivity, and allows accurate
determination of the type of SUI, whether this is predominantly intrinsic sphincter deficiency or
urethral hypermobility in nature. Video UDS can be used to classify SUI (Table 24.2). An abdominal
(Valsalva) leak point pressure <60 cmH2O on UDS and a mean urethral closure pressure <30 cmH2O
on urethral pressure profile testing, both suggest intrinsic sphincter deficiency.
Table 24.2 Blaivas classification of SUI from video urodynamic studies
Type Description
Type 0 Clinical report of SUI, but without clinical signs
Type I Leakage that occurs during stress with <2 cm descent of the bladder base below
Type 2 Leakage on stress accompanied by marked bladder base descent (>2 cm) that
Type 3 Bladder neck and proximal urethra are already open at rest (with or without
the inferior margin of the symphysis pubis
occurs only during stress (IIa) or is permanently present (IIb)
descent), also known as intrinsic sphincter deficiency
8,9
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Evidence base Surgical options for recurrent SUI
Approximately 8– 17% of women will require further surgery after primary SUI treatment.
A systematic review and meta- analysis of randomized controlled trials for recurrent SUI by Agur
et al. failed to show any difference in outcomes or complications for MUT (either retropubic or
transobturator), AFS, or colposuspension.21 Another systematic review by Nikilopoulous et al.
looked at all studies on recurrent SUI, and reported pooled success rates of 68% for MUT (this
decreased to 62% if the primary procedure had also been MUT), 76% for colposuspension, and
79% for AFS.22 In comparison, urethral bulking agents had pooled success rates of 38%, and
adjustable slings and other continence devices pooled success rates of 53%.22 Bladder neck
artificial urinary sphincters (AUS) can also be used in recurrent SUI setting, with success rates
of 42– 86%.
After case discussion at a specialist (regional) MDT meeting, and after counselling,
the patient opted for an AFS, which she underwent along with removal of the vaginal
component of her tape concurrently. At the 4- week postoperative review, she reported
problems with one UTI and sensation of incomplete bladder emptying despite initially
passing her trial without catheter as an inpatient. In clinic, uroflowmetry showed a
Qmax of 11 mL/ s for a voided volume of 180 mL, with a PVR of 250 mL. The patient was
happy with her continence and agreed to manage the elevated residuals with clean intermittent self- catheterization twice daily, and subsequently UTIs resolved. She remained
continent and happy with her result.
23
Video UDS demonstrated SUI with a stable bladder and normal voiding (Figure 24.1).
20
Figure 24.1 Twin- channel urodynamic trace demonstrating a stable detrusor during bladder filling, but
SUI leaking on provocation with cough at bladder capacity. MC, micturition command.
243Case 24 Stress urinary incontinence
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Options for complex SUI cases, when primary or secondary surgical procedures have failed, include
bladder neck AUS insertion. The AMS 800™ is the only US Food and Drug Administration- approved
AUS, although newer devices are available. The AUS can be inserted via an open abdominal or vaginal
approach, laparoscopically or robotically, and has three components consisting of an inflatable cuff,
a pump placed in the labia majora, and a pressure- regulating balloon placed in the extravesical
space. Continence rates are 80% (ranging from 61% to 100%), but there is a recognized long- term
deterioration in this with subsequent failure over time.
Learning point Options for complex SUI cases
Complications
These include24:
● Infection of the device requiring explantation (up to 45%)
● Bleeding— requiring transfusion, embolization, or return to theatre in <2%
● Injury to bladder neck (44%) and vagina (25%)
● Erosion of device into urethra or vagina requiring explantation (up to 22%)
● Urethral atrophy resulting in recurrent incontinence
● Device failure requiring revision or replacement (up to 44%)
● Limited life expectancy of device— no long- term evidence in non- neuropathic women but
estimated at 8– 10 years in men.
‘Last resort’ surgical alternatives include urinary diversion with an ileal conduit formation or continent
urinary diversion— either bladder neck closure or heterotopic neobladder formation combined with a
continent catheterizable channel (Mitrofanoff or Monti).
A final word from the expert
Public concern regarding synthetic MUT
Following prominent patient group campaigns and Food and Drug Administration investigations
from 2008 onwards, concerns have been raised over the complications and safety of
synthetic MUT. Although current evidence suggests that synthetic MUTs are efficacious, when
complications occur, they can significantly impair quality of life for patients. During a review into
adverse events for primary SUI treated with synthetic MUT, the rate of complications in 92,000
patients was 9.8%, which is higher than previously recorded.25 Currently, mesh procedures are
not being offered in the UK, and specialist mesh centres are being commissioned, which as part
of their role will offer specialist management of mesh complications.
Minimally invasive procedures
Advances in laparoscopic and robotic technology have led to the development of minimally
invasive access for colposuspension as well as AUS insertion. Minimally invasive access has been
shown to reduce intraoperative blood loss and decrease length of stay, but may also improve
complication rates in other domains as experience in this area increases. Routine use of these
techniques (in particular robotics) is hampered by the high cost of hardware and consumables
required, and often render them economically unjustifiable.
Tissue engineering
Given the recent concerns regarding synthetic MUT and the inherent increased risk of harvesting
autologous fascia, research is ongoing into producing biological materials to make slings.
Research into electrospun poly- L- lactic acid and porcine small intestine submucosa shows they
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