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The treatment of the SUI should be carefully selected for each patient by evaluat-
ing the type of disorder, the severity of the symptomatology and concomitant fac-
tors that may preclude the use of surgery even with the mini-invasive techniques
available today. The preoperative counselling should evaluate patient and surgeon
satisfaction with treatment by having a discussion during the planning phase of
surgery about individual patient’s goals and expectations for their treatment and
awareness of potential adverse events [20, 21].
9.8.1 Midurethral Slings
The most effective therapy, after the attempt with conservative therapies in case of
their failure, is the surgical therapy, which has undergone a breakthrough in the year
1990, thanks to the introduction of the midurethral sling (MUSs), ensuring equal
results, in terms of corrective efcacy of the disorder, both compared to the laparo-
tomic Burch colposuspension and the laparoscopic one, but had the undoubted
advantage of a lower hospitalization and fewer postoperative complications [22].
NICE 2013 [5] guideline counsels to not offer laparoscopic colposuspension as
a routine procedure for the treatment of SUI in women; in fact, only an experienced
laparoscopic surgeon working in a multidisciplinary team (MDT) with expertise in
the assessment and treatment of UI should perform the procedure [5].
The slings can be made of autologous material, formed by tissue taken from the
fascia lata or from the rectus abdominis fascia, or articial meshes, usually polypro-
pylene monolament macroporous type 1; in both cases they are introduced by a
small vaginal incision and placed “tension-free” in order to guarantee support to the
middle urethra. The current trend is aimed at the use of articial meshes, having
been shown the lowest rate of reaction and lowest postoperative complications [23].
The two most used techniques today are the tension-free vaginal tape (TVT),
experimented in the year 1990 by Petros and Ulmsten [24, 25], in which the mesh is
introduced by the vaginal incision and then directed towards the retropubic space,
then coming out from the abdominal wall in the suprapubic area, and the most
recent transobturator tension-free vaginal tape (TVT-O), in which the mesh passes
through the obturator foramen. Depending on how the needles are inserted during
the placement of the sling, we can dene the TVT-O (transobturator) technique
inside-out (when the needle, bilaterally, goes from the vaginal incision through the
obturator membrane and then comes out laterally to the genitocrural fold) and the
TOT technique out-inside (when the needles go from an incision a few centimetres
from the genitocrural fold and come out in the vaginal incision).
The use of the retropubic midurethral sling (RP-MUS) such as TVT has a higher
risk of bladder injury than the TVT-O [
26]. Other possible complications of TVT
are urinary tract lesions, urinary tract infections and abnormal bladder voiding,
which is dened as a post-voiding bladder residual of more than 150mL.Occasionally,
vascular lesions may occur during the placement of the sling due to the passage of
the guide trocar in the retropubic space, or intestinal lesions, with risk that increases
in case of previous abdominal-pelvic surgery. An indication to the use of retropubic
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way is the form of SUI due not to urethral hypermobility but to intrinsic sphincter
deciency (ISD) with xed urethra: in such cases its use was found to be more
effective than that of transobturator way [27].
An evolution of the MUS is represented by the passage of the sling through the
obturator foramen, as in the TVT-O, developed precisely to avoid some of the major
complications of the retropubic pathway, such as urinary tract and vascular lesions
[28]; complications related to non-complete bladder voiding are also reduced.
Another advantage of TVT-O compared to the retropubic technique is the reduction
of the duration of the operation, only 15min on average, and a reduction of hospi-
talization; on the other hand, patients may report pain, more frequently, especially
in the inguinal site compared to the TVT [29].
A modied form of the TVT-O procedure is the TVT-Abbrevo
®
in which a mesh
of lesser length, only 12cm, is used with inside-out technique, from the vaginal
incision, coming out laterally to the genitocrural fold. Moreover, in the TVT-
Abbrevo
®
, the obturator membrane [30] is not perforated with the guide scissors.
Capobianco etal. [31] studied a sample of 56 patients submitted to SUI correction
by TVT-Abbrevo
®
technique and followed controls in the postoperative period at 12
and 24months, demonstrating the high level of success of the procedure with 76.6%
of patients who showed a regular urodynamic function at 12months, 17.86% who
had a signicant improvement in the symptoms and only 1.78% of the patients
examined who showed a “de novo” overactive bladder. The benets obtained were
classied both in terms of patient’s subjective well-being and objective measured by
urodynamic studies, Q-tip test and stress test with cough, with excellent results also
in the long term and high safety prole [31].
Both TVT and TVT-O are associated with high long-term success rates [32],
with similar results between the two techniques, as demonstrated by a recent Italian
meta-analysis on the basis of data concerning 49 examined studies [33].
However, in the UK and across the world, there has been a lot of publicity and
legal action relating to a small percentage of women undergoing TVT procedures
who have complications such as erosion and pain. However there are differences in
complications between TOT and TVT; in fact RP-MUS showed a higher rate of
bladder perforations in comparison to TVT-O [26, 33].
9.8.2 Single-Incision Mini Sling
The mini slings represent the third generation of midurethral slings and are differ-
entiated by the use of a single vaginal incision approach as entry and by the less
amount of mesh used. It has debated whether or not to submit obese patients to this
type of treatment, and a recent study showed that BMI did not affect the outcome
(efcacy) of treatment with mini slings [34]. The procedure aims to minimize the
risk of major adverse events such as bladder, vaginal, urethral and vascular perfora-
tions or erosions and chronic pain that are associated with minimally invasive sling
procedures. The SIMSs have shorter tape lengths and different xation systems to
transobturator minimally invasive slings and do not enter the retropubic space
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(reducing the risk of major vessel or visceral injury) or the lateral half of the obtura-
tor foramen (reducing the risk of groin pain), but they are anchored in the obturator
membrane or in the obturator muscles. A special tip anchors the sling in place
behind the midurethra. SIMS systems may differ in the length of the sling, the xa-
tion method, the xation location and the method of tension adjustment or control.
The mesh implant is permanent, but, if removal is needed because of infrequent
complications, the anchoring system can make the device very difcult or impos-
sible to remove. Furthermore, the evidence on efcacy in the long term is inade-
quate in quality and quantity [5].
9.8.3 Urethral Bulking Agents
A further alternative to sling surgery (even less invasive) is now represented by the
possibility of using injections of “urethral bulking agents” (UBAs), the use of which
is recommended in elderly patients, patients with high anaesthesiological risk or
patients reluctant to undergo surgery [35, 36]. UBAs act in thickening the urethral
walls by injecting them into the submucosa and elevating the urethral mucosa by
restoring the natural continence and urethral resistance [36, 37]. The ideal bulking
agent should be easily injectable, with good cost-benet ratio, and biocompatible
and should not migrate from the injection site and cause low inammatory reaction
of the affected tissues [38]. It is also indicated in patients who have already under-
gone surgery without benet or with recurrence of symptoms. The American
Urological Association recommended the use of UBAs in elderly patients, in
patients with increased anaesthesiological risk and in patients who refused a more
invasive procedure [39]. In addition, the National Institute for Health and Clinical
Excellence (NICE) [40] suggests that UBAs are indicated in patients with signi-
cant reduction in urethral mobility and in patients who have a history of failure with
the conservative therapy of the SUI [39]. Over the years, several materials have been
tested, including parafn, autologous grease, polytetrauoroethylene, glutaralde-
hyde combined with bovine collagen, porcine dermis and hyaluronic acid plants.
These substances were then abandoned due to health problems, adverse events and
marked hypersensitization reactions and because of migration from the injection
site [41]. Among the substances used today, as UBAs, the most used are the
polydimethylsiloxane (Macroplastique
®
) and polyacrylamide gel (Bulkamid
®
). In
both cases these are materials that are implanted in the urethral submucosa exerting
a mass effect and thus increasing the urethral sphincter pressure and consequently
urinary continence. The main advantage of using these agents is the possibility of
providing the patient with a less invasive treatment in the care of SUI compared to
traditional surgery [42]. For example, polydimethylsiloxane (Macroplastique
®
) is
indicated in the treatment of SUI due to intrinsic sphincter deciency (ISD). The
substance is implanted, during cystoscopy, so as to have direct vision of the area,
about 1cm away from the urethral origin thus going to restore the urethral sphinc-
teric function [43]. There are subjective and objective benets through urodynamic
studies, pad test 24h and number of incontinence episodes during the day [44]. It is
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also possible to repeat the treatment at a distance of time both to consolidate the
benets obtained with the rst injection and in case of persistence of the symptoms
after the rst treatment. Bulking agents are, ultimately, a safe agent in the treatment
of SUI, and because of low side effects, they are indicated in case of patients with
comorbidities that preclude surgical therapy [45]. Recently, a new silicone-derived
elastomer, Urolastic
®
, was introduced into the medical practice; once injected into
the paraurethral tissue in a few minutes, it undergoes a change from the liquid state
to solid state thereby supporting the urethra. It has proven to be a material that has
a good biocompatibility without risks of migration from the injection site and with
an excellent duration in terms of improvement of clinical symptomatology precisely
for its physical chemical characteristics, which could make it in the future a new
option for the treatment of SUI [46, 47].
Women should be made aware regarding UBAs that repeat injections may be
needed to achieve efcacy, efcacy diminishes with time and efcacy is inferior to
that of synthetic tapes [5].
9.9 Recurrent Stress Urinary Incontinence
Women whose primary surgical procedures for SUI has failed (including women
whose symptoms has returned) should be referred to tertiary care for assessment (such
as repeat urodynamic testing including additional tests such as imaging and urethral
function studies) and discussion of treatment option by a multidisciplinary team [5].
The prevalence of voiding dysfunction, including urinary retention, following
MUS procedures, ranges from 2 to 25% with a surgical intervention required to
resolve the problem in 0–5% of patients [48].
The rate of a second surgical treatment for recurrent stress urinary incontinence
(RSI) after the initial surgery varies according to the studies [49, 50]. In fact, Jonsson
Kunk etal. [49] reported a cumulative recurrence of 14.5% with over 155,000 patients
examined 9years after a primary surgery; the type of repeat surgery performed was sling
(70.5%), followed by bulking agents (20.1%), Burch (6.5%), laparoscopic (1.5%), nee-
dle (0.8%), total vaginal hysterectomy (0.5%) and Kelly (0.2%) [49]. Fialkow etal. [50]
had 8.6% recurrence over 40,000 US women who underwent either a sling or retropubic
colposuspension (Burch) for surgical treatment of SUI.In a third recent retrospective
study [51], the rate decreased at 6% of women retreated within 5years following their
initial standard anti-incontinence procedures (Burch and sling procedures).
Risk factors for recurrent or persistent urinary incontinence after surgical treatment
include ageing; obesity; medical comorbidities, such as diabetes mellitus; previous
high-grade incontinence; mixed urinary incontinence; and previous failed surgery [52].
The debate in literature at the moment is still open about which of the operative
techniques for female recurrent stress urinary incontinence is the most efcient and
safest, but there isn’t still a consensus, and there are few data regarding the choice
of type of surgery for persistent/recurrent SUI.
The choice of the procedure in case of RSI should be individualized and carefully
chosen considering the severity and type of symptoms, medical comorbidities and the
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type of previous surgery. A second anti-incontinence procedure is effective in many
women with persistent/recurrent SUI, at least in those women candidate to surgery.
MUS surgery appears to be a good choice in case of recurrent SUI.A meta-
analysis of 12 prospective studies with a total of 430 women reported good results
both in case of previous sling procedure and other procedures such as Burch colpo-
suspension with cure rate of 79% after any previous surgery and 73% after a prior
midurethral sling [52, 53]. Results in terms of cure rates seemed to be higher for
TVT compared with TOT midurethral sling (80% versus 54% after any prior sur-
gery); however, data about TOT procedures were too few [53].
The previous procedure to which the patient was submitted seemed to play a role in
the following choice of treatment demonstrating that a repeated retropubic TVT seems
to offer better results than using a TOT following a failed primary TVT [54, 55].
A retrospective study by Cerniauskiene etal. [56] compared 45 women with
recurrent SUI after a rst surgery procedure of Burch colposuspension, TVT and
TOT.As second surgery Burch colposuspension operation, TOT or TVT procedures
were performed. According to this study [56], no differences were shown in the
outcomes with the different techniques. Nevertheless, minimally invasive tech-
niques undoubtedly had many advantages compared to the Burch colposuspension
operation, and nowadays TVT and TOT procedures are the rst choice procedures
for recurrent stress urinary incontinence treatment. Repeat surgery seemed also to
be associated with a higher risk of intraoperative complications and lower success
rate than initial surgery [57].
Regarding medical treatments there is no current evidence about the efcacy of
conservative management of SUI for women with persistent/recurrent symptoms
after surgical therapy. In general, however, conservative measures are not as effec-
tive for treatment of SUI as surgery and should be mainly considered in women who
decline or are not candidates to surgery.
Urethral injections of UBAs are an option for women with persistent SUI.They
are normally reserved to women who wish to avoid or cannot tolerate an invasive
procedure. In a retrospective review of 165 women who had recurrent SUI, after
undergoing a synthetic midurethral sling procedure, the use of UBAs showed a
higher risk of failure in comparison to a repeated sling procedure [
58]. In fact, of
this group of women, UBAs were used in the treatment of 67 patients, while the
other 98 underwent a repeat sling procedure. The group who underwent a urethral
bulking procedure had a worst outcome (38.8% of failure) compared with those
who underwent a repeated midurethral sling (11.2%) [58]. Injections often need to
be repeated to maintain continence.
9.10 Stress Urinary Incontince andExperimental Therapies
There are, nowadays, insufcient clinical data about the use of stem cells (autolo-
gous myoblasts, muscle-derived stem cells and autologous broblasts) injected in
the urethra to treat the intrinsic sphincter deciency [59].
The articial urinary sphincter [60] in women has not yet been extensively tested
or evaluated with controlled randomized clinical trials. This technique is not recom-
mended as a rst-line surgical therapy of SUI [60–62].
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9.11 Conclusions
Currently, according to the guidelines 2016 of the European Society of Urology
and the Position Statement of 2017 of the European Urogynaecological Association,
the synthetic midurethral slings are the gold standard for the surgical treatment of
SUI [63, 64]. A recent systematic review and meta-analysis on 28 controlled clini-
cal trials on 15,855 patients showed that midurethral slings are more effective than
Burch colposuspension and that the comparison studies between the retropubic and
transobturator slings have shown a higher rate of subjective and objective care of
the retropubic technique but with greater risk of complications such as intraopera-
tive bladder and vaginal perforation (OR 2.4, p=0.0002), pelvic hematoma (OR
2.61, p = 0.002) and urinary tract infections (OR 1.31, p= 0.04). There was no
statistically signicant difference in efcacy between the transobturator inside-out
technique and that of outside-in though the risks of vaginal perforation were lower
in the inside-out [65]. A recent Cochrane Database Systematic Review of Ford
etal. [29] concluded that midurethral slings are as effective as retropubic colposus-
pension but have a shorter operation time and a lower risk of postoperative
complications.
Surgical therapy should be indicated only after conservative (rehabilitative, local
oestrogenic) therapies have failed. Lifestyle changes such as weight loss and pelvic
oor muscle training should always precede surgery.
The current trend is aimed at the continuous research of new therapeutic strate-
gies in order to achieve an ever better balance between high efcacy and maximum
reduction of adverse events.
Table 9.2 shows recommendations on management of female SUI [66].
Current data on new therapies such as laser therapy are still limited in their long-
term efcacy while showing results that appear to be good in immediacy and that
could have a potential role in the future routine medical therapy of the IUS.
Table 9.2 Recommendation on management of female stress urinary incontinence
Grade of
recommendation
For morbidly and moderately obese women, weight loss helps to reduce
UI symptoms
A
6
Medical therapy and rehabilitation should be the rst step of treatment A
6
Midurethral slings (MUSs) are the gold standard for surgical treatment A
6, 29, 63,64
TVT and TVT-O have high long-term success rates A
6
Urethral bulking agents are recommended in elderly patients, in patients
with increased anaesthesiological risk and in patients who refuse a more
invasive procedure
B
6,39
The best therapeutic approach for recurrent stress incontinence (RSI)
after a sling failure should be individualized. The best choice could be to
counsel a repeat MUS (retropubic or transobturator) or bulking agents to
women with RSI
C
66
A: Based on clinical studies of good quality and consistency addressing the specic recommenda-
tions and including at least one randomized trial
B: Based on well-conducted clinical studies but without randomized clinical trials
C: Made despite the absence of directly applicable clinical studies of good quality
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Practice Points
• SUI is highly prevalent in postmenopausal women.
• Surgical therapy should be indicated only after conservative (rehabilitative, local
oestrogenic) therapies have failed.
• The synthetic midurethral slings (TVT and TVT-O) are the gold standard for the
surgical treatment of SUI.
• Urethral bulking agents are recommended in elderly patients, in patients with
increased anaesthesiological risk and in patients who refuse a more invasive
procedure.
Future Research
• Preventive measures of SUI.
• Dene new therapeutic strategies of SUI in order to achieve an ever better bal-
ance between high efcacy and maximum reduction of adverse events.
• To taste newer and lighter midurethral slings.
• Dene stem cell (autologous myoblasts, muscle-derived stem cells and autolo-
gous broblasts) role whether injected in the urethra to treat the intrinsic sphinc-
ter deciency.
Conict of Interest Disclosure The authors report no conicts of interest. The authors alone are
responsible for the content and writing of the paper.
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9 Management ofFemale Stress Urinary Incontinence
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