Review Articles

Surgical Management of Stress Urinary Incontinence 

Farzaneh Sharifi-Aghdas*

Department of Urology, Shaheed Labbafinejad Hospital, Shaheed Beheshti University of

Medical Sciences, Tehran, Iran

ABSTRACT

Introduction: This review evaluates the most recent knowledge regarding surgical

management of stress urinary incontinence.

Materials and Methods: A comprehensive MEDLINE search was performed, limited

to those articles published from 1995 to 2005. In total, 470 articles were reviewed—the

most relevant of which were considered, and additional ones were selected by

reviewing these studies' bibliographies. Overall, 53 articles were selected and used in

this study.

Results: Few randomized controlled trials have been performed. The best results of

retropubic procedures are seen when the intrinsic urethral sphincter is competent and

its effectiveness is sustained in the long term. A laparoscopic approach, although less

popular and with a lower short-term cure rate, is an alternative. Sling surgeries can

be the first-line treatment for all types of stress urinary incontinence. Autologous

grafts are still considered the gold standard, but synthetic materials such as tension-

free tape have comparable results with standard open retropubic procedures. Still,

long-term cure and complication rates have not yet been elucidated. Using urethral

bulking agents is the least invasive approach, applicable in both intrinsic sphincter

deficiency and urethral hypermobility. However, it has a poor long-term outcome and

necessitates repeat injections.

Conclusion: Long-term data suggest that Burch colposuspension and sling

procedures produce similar objective cure rates. New synthetic suburethral slings such

as tension-free vaginal tape have gained popularity in recent years. Complications of

traditional and newer suburethral slings are declining but still occur and often are

associated with serious morbidity. New therapies must be studied in randomized

clinical trials. 

KEY WORDS: stress urinary incontinence, pubovaginal sling, retropubic procedure, tension-

free vaginal tape

175

Urology Journal

UNRC/IUA

Vol. 2, No. 4, 175-182 Autumn 2005

Printed in IRAN

Introduction

Stress urinary incontinence (SUI) is the most

common type of incontinence in women, with

86% of incontinent women presenting with

symptoms of SUI in either pure (50%) or mixed

(36%) forms.(1) Stress urinary incontinence, the

complaint of involuntary leakage during exertion,

occurs at least weekly in one third of adult

women. Although SUI is not life-threatening, it

may have considerable impact on a woman's

quality of life. However, no considerable research

on the prevention of urinary incontinence has

been done. Initial treatment includes nonsurgical

*Corresponding author: Department of Urology,

Shaheed Labbafinejad Medical Center, 9th Boustan,

Pasdaran, Tehran 1666679951, Iran.

Tel: ++98 912 175 8340

E-mail: fsharifiaghdas@yahoo.com



Surgical Management of Stress Urinary Incontinence

management,(2) and although surgical procedures

are more likely to cure SUI, they are associated

with more adverse events. Nearly, 300 procedures

have been proposed for SUI, but only a few have

survived with enough supportive evidence to be

recommended. Currently, less-invasive modifica-

tions of these procedures are being done, and

studies on their efficacy are ongoing. 

Pathophysiological concepts and theories on the

clinical staging of SUI have changed in recent

years. For decades, the physiological concepts of

urinary incontinence were a summation of

factors and forces. The urethral closure

mechanism is composed of the urethral mucosal

seal, the submucosal vascular plexus, and

competence of the bladder neck, as well as

intrinsic and extrinsic sphincters. This closure

mechanism is supported by the pelvic floor

muscles and their fascial coverings, which

function as a hammock.(3) The normal position of

the bladder base and urethra provides pressure

transmission, so that pressure from the intra-

abdominal cavity is exerted equally on the

bladder dome and the proximal urethra.(4) The

logical extension of these ideas is that SUI is

caused by a loss of pressure transmission and

hammock-like support due to urethral

hypermobility and prolapse and impaired

intrinsic sphincter function.(3,5) The foregoing is

known as integral theory.

First introduced by Petros and Ulmsten,(6,7) this

theory initiated crucial changes in the way

clinicians view the management of SUI. Integral

theory emphasizes the importance of fixation of

the midurethra to the pubic bone by pubourethral

ligaments and suggests that opening and closing

of the urethra and bladder neck are regulated by

a "battery of surrounding structures."(7) This

theory has led to a novel anti-incontinence

support therapy known as tension-free vaginal

tape (TVT).(8) Tension-free vaginal tape is placed

in the midportion of the urethra instead of at the

level of the bladder neck, and it should be loose

enough to ensure that the urethra is compressed

as little as possible at rest. 

Surgical treatment of SUI can be divided into 3

basic types: colposuspension, suburethral sling

procedures, and injection of urethral bulking

agents. It is recommended that women who plan

for future pregnancies postpone colposuspension

and sling procedures until they have completed

their family. Although not documented, it has

been suggested that postmenopausal women with

urogenital atrophy receive vaginal estrogen prior

to surgery.(9) The question that confronts the

clinician is which procedure to use for which

patient—TVT, or one of its modifications,

colposuspension, or conventional slings. 

Few studies compare these procedures. And

unfortunately, many postoperative patients

experience continued incontinence, despite

improvement of SUI. Although surgical

procedures have been adopted based on "expert"

opinion, the fact remains that untested

techniques and materials frequently have been

introduced without careful human subject testing.

When choosing surgical management then, the

surgeon must weigh the chance of cure against

the chance of severe complications. Less

common, but still serious complications, such as

vascular and bowel injuries, require further

studies with large samples of patients that

compare the different surgical approaches. 

Diagnostic and Treatment

Managements

To diagnose SUI, clinical and urodynamic

(simple or complex) examinations must be

performed to evaluate the bladder filling and

emptying phases. Loss of urine through the

urethra with a simultaneous increase in intra-

abdominal pressure can be seen visually. The role

of radiology such as cystography, sonography,

and magnetic resonance imaging is controversial.

Thirty percent of stress incontinent patients may

show some forms of detrusor overactivity during

urodynamic study, which may be associated with

a decrease in the cure rate after surgery.

Nonetheless, there have been no randomized

trials on the influence of a comprehensive

preoperative evaluation (including urodynamic

study) compared with a basic preoperative clinical

evaluation on the treatment outcome in women

with SUI symptoms. In a cohort study of 442

women, Black and coworkers(10) reported

improvement of the severity of SUI in 87% of

patients and cure (continence) in only 28% after

surgical operation. These improvements persisted

for at least 12 months. The likelihood ratio of

improvement was similar regardless of whether

urodynamic studies had been conducted before

operation or not. 

Generally, conservative therapy should be

attempted initially in women with SUI.

Conservative treatments include pelvic muscle

exercises, bladder retraining, pharmacologic

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Sharifi-Aghdas

therapy, functional electrical or magnetic

stimulation, and the use of mechanical devices

such as pessaries. Although not documented, it is

suggested that postmenopausal women with

urogenital atrophy receive topical estrogen. 

In the past decade, surgeons have put their

efforts into differentiating intrinsic sphincter

deficiency from hypermobility, choosing a

pubovaginal sling or bulking agents for the

former and colposuspension for the latter. This

was based initially on a preliminary report in

which women younger than 50 years with

urethral closure pressure less than 20 cm H2O

had a higher failure rate after a Burch

colposuspension than did women with a closure

pressure greater than 20 cm H2O.(11) Recently,

however, this dichotomy has been called into

question, substituted by the idea that all women

with SUI have some degree of sphincter

weakness. To date, it is not clear from which

surgeries women with hypermobility and degrees

of sphincter weakness benefit. As SUI is

considered a degenerative tissue disorder, the

outcomes of different surgical procedures are

relatively similar at short-term follow-up;

however, the cure rate dramatically declines at

long-term follow-up for the majority of

procedures. 

Retropubic Procedures

These procedures are indicated for women with

the diagnosis of urodynamic SUI and

hypermobility of the proximal urethra and

bladder neck. The best results are seen when the

urethral sphincter (intrinsic sphincter or bladder

neck) is competent. Marshall and colleagues,(12) in

1949, first described retropubic urethrovesical

suspension for the treatment of SUI. In 1961,

Burch introduced his technique.(13)

Although numerous terms and variations of

retropubic repair have been described, the goal is

the same: to stabilize the urethra by lifting

tissues near the bladder neck and proximal

urethra in the area of the pelvis behind the pubic

symphysis to prevent their descent, and to allow

urethral compression against a stable suburethral

layer. The approach may be either abdominal

(open or laparoscopic) or vaginal. The 3 most

popular retropubic procedures are the Burch

colposuspension, the Marshall-Marchetti-Krantz

vesicourethropexy, and the paravaginal defect

repair. Of these 3, the Burch colposuspension has

been studied most extensively. The surgical

technique in most studies on the Burch

colposuspension is a modification described by

Tanagho in 1976.(14) Two to 3 permanent or

delayed absorbable sutures are passed through

the endopelvic fascia lateral to the midurethra

and bladder neck and then through the ipsilateral

Cooper's ligament and tied with gentle tension.

Many studies have reported their results with the

Burch technique, mostly with methodologic

limitations. A few randomized trials have been or

are being conducted. A short-term cure rate

(defined as the percentage with complete

continence) of 73% to 92%, and a success rate

(defined as the percentage with cure or

improvement) of 81% to 96% have been

reported.(15) This technique's effectiveness

continues for the long term; after 5 to 10 years,

approximately 70% of patients are still

continent.(15,16)

Several studies have assessed the long-term

outcome of the Burch procedure. Alcaly and

coworkers have studied 109 women with the

Burch colposuspension for a mean follow-up of

13.8 years.(17) The cure rate in this population is

69%. This rate has been significantly lower in

women who had had pervious bladder neck

surgery. Results from a Cochrane review indicate

that open colposuspension is the most effective

treatment for SUI, especially for long-term

outcomes. Patient satisfaction has been reported

high (82% in 146 patients with colpo-

suspension).(18)

Voiding dysfunction (in 2% to 27% of patients)

and de novo detrusor overactivity (in 8% to 27%

of patients) are the most frequently reported

complications of the Burch method.(18-20) It has

been reported that 5% to 13.6% of women with a

history of Burch colposuspension may develop an

enterocele,(13,17,21) although all do not require

surgical correction. In an evaluation of pelvic

organ prolapse following isolated Burch

colposuspension, Kwon and colleagues(22)

concluded that the majority of patients

undergoing an isolated Tanagho modification of

the Burch procedure without preoperative

prolapse did not appear to be at increased risk

for subsequent operative intervention. 

A recent systematic review(23) evaluating the

effectiveness of laparoscopic colposuspension

compared 5 trials of laparoscopic with open

colposuspension. The objective cure rate

(assessed as leakage on clinical stress and

urodynamically) was lower for laparoscopic than

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Surgical Management of Stress Urinary Incontinence

for open colposuspension. However, the subjective

cure rate was comparable between the 2 groups

at 6-month to 18-month follow-up. Trends were

shown toward higher complication rates, less

postoperative pain, shorter hospital stays, and

less time to return to normal function for

laparoscopic compared with open colposuspension.

Ankardal and colleagues have reported a higher

cure rate (subjective and objective) at 1-year

follow-up for open colposuspension (120 patients)

compared with the laparoscopic (120 patients)

approach.(24) Further well-designed and

adequately powered randomized trials are

required to definitively compare these 2

approaches.

Suburethral Slings

Aldridge(25) introduced the fascial suburethral

sling in 1942. A suburethral sling procedure is

used mainly as a treatment of intrinsic sphincter

deficiency (ISD) or failed previous SUI surgery.

However, few studies have been performed that

evaluate the suburethral sling as a first-line

procedure.(26) The materials used as a sling can

be categorized as autologous, cadaveric,

xenograft, and synthetic. These categories can be

further subdivided into rectus fascia, fascia lata,

and vaginal wall for autologous materials; freeze-

dried irradiated cadaveric fascia lata, solvent-

dehydrated cadaveric fascia lata, fresh-frozen

cadaveric fascia lata, and cadaveric dermis for

cadaveric materials; and porcine dermis, porcine

subintestinal mucosa, and porcine pericardium

for xenograft; and polypropylene, polyester,

Silastic, and expanded polytetrafluoroethylene for

synthetic materials. 

The advantages of using allografts or synthetic

slings include a reduction in the morbidity of

harvesting from a second surgical site, decreased

operative time, early postoperative recovery, and

an unlimited supply of artificial material.

Nonetheless, autologous rectus fascia and fascia

lata are the most common materials used.

Additionally, they are considered the gold

standard for slings to which the outcomes of all

other materials are compared.(27) It has been said

that failure of sling procedures—especially those

of autografts and allografts—become apparent in

the first 6 months after surgery. This is related

to degeneration of the fascia or breakdown of

anchoring sutures; however, after this phase,

surgical results remain stable. Allografts carry a

theoretical risk of unwanted transmission of

infections. Experimental studies have shown no

difference in mechanical strength between

autografts and cadaveric allografts.(28,29) However,

the long-term durability of allograft fascia

continues to be studied.

Morgan and associates,(30) in 247 women,

reported an 88% overall cure rate (91% for type-2

and 84% for type-3 SUI) using autologous rectus

fascia at a mean follow-up of 51 months.

Chaikin(31) has reported a 92% objective cure rate

in 25 patients followed for an average of more

than 1 year. The overall reported cure rates

(defined as the percentage with complete

continence) vary between 73% and 95%, and

success rates (defined as the percentage with

cure or improvement) vary between 64% and

100%.(19,32) Outcomes might be better in primary

as opposed to repeat surgery.

Synthetic materials have the disadvantage of

potentially generating an inflammatory reaction

to a foreign body. This may result in a higher risk

of erosion and fistula formation compared with

autologous materials, although this has not been

proved in a comparative trial. In the short term,

objective cure rates using polyester and

polypropylene mesh are reported as being 73% to

93%.(27) Many conventional synthetic materials—

including polytetrafluoroethylene or Teflon,(33-37)

expanded polytetrafluoroethylene (Gore-Tex; WL

Gore & Associates, Inc, Newark, Del, USA),

silicone, and polyester (ProteGen; Boston

Scientific, Natick, Mass, USA)—have been

withdrawn owing to erosion and infection. The

most frequently reported complications of sling

procedures are postoperative voiding dysfunction

in an average of 12.8% of patients (range, 2% to

37%),(26) urinary retention and self-

catheterization in 2% to 7.8%,(26,27,31) de novo urge

incontinence in 6% to 14% of patients,(19,38,39) and

erosion of the sling in the bladder, urethra, and

vagina, mostly after synthetic slings, in up to 5%

of patients.(19,38,39) Misplacement of the

suburethral sling to the distal urethra or

proximal to the bladder neck also can be a

problem. In general, synthetic materials seem to

be associated with lower cure rates and higher

complication rates than autologous materials.(27)

Tension-Free Vaginal Tape

Tension-free vaginal tape procedure is based on

a theory of SUI pathophysiology by Petros and

Ulmsten.(6) The concept behind the TVT is that

SUI is the result of inadequate urethral support

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Sharifi-Aghdas

due to weak pubourethral ligaments in the

midurethra. Tension-free vaginal tape aims at

reinforcing the functional pubourethral ligaments

and secure proper fixation of the midurethra to

the pubic bone to maintain continence. Under

local or regional anesthesia, a strip of

polypropylene tape is inserted via a small

incision. The patient is asked to cough frequently

to adjust the position of the tape and to lie in a

resting position to exert sufficient pressure on

the urethra only during stress, not at rest.(6,7,39)

Cure rates (complete dryness) of 66% to 91% have

been reported.(18,40,41,42) The long-term objective

results of the TVT procedure have been

demonstrated by Nilsson and colleagues,(43) who

found an 85% cure, 10.6% improvement, and a

4.7% failure rate at a median follow-up of 56

months.

The operative time of TVT is relatively short

and is performed mainly under local or regional

anesthesia, with a short hospitalization (ie,

outpatient or overnight). The success of TVT has

encouraged the introduction of similar products

with modified methods of midurethral sling

placement (ie, retropublic top-down, prepubic,

and transobturator approaches). Ward and

colleagues have reported the 2-year follow-up of

344 women with SUI in a multicenter,

randomized, controlled trial comparing TVT and

open Burch colposuspension. The objective cure

rate (defined as the percentage of patients with a

negative 1-hour pad test) ranged from 63% to 85%

for the TVT procedure and 51% to 87% for open

colposuspension.(18) However, with regard to

subjective assessment, only 43% of the women in

the TVT group and 37% in the open

colposuspension group reported having a cure.

Women undergoing TVT are more likely to have

a cystocele after surgery; whereas, those

undergoing Burch colposuspension are more

likely to have apical prolapse. 

Since its description, it is estimated that more

than 800 000 TVT procedures have been

performed worldwide, and there has been

increasing interest in the transobturator tape

(TOT) approach. Tension-free vaginal tape mainly

suits patients with urethral hypermobility and

mild degrees of intrinsic sphincter deficiency

(known as "good urethra"), and we should rely on

the old concepts of urethral compression to treat

SUI with a "bad (scarred, open) urethra."(10)

Complications. Adverse events are related to

entry into the retropubic space and include

bleeding, retropubic hematoma, and injury to

adjacent structures such as the bladder, urethra,

and vagina. Bladder perforation is the most

frequent intraoperative complication, occurring

in between 0% to 25% of patients.(44-46) There is a

higher risk in patients who have previously

undergone surgery for incontinence. Voiding

difficulties occur in 3% to 5%,(17,47) and de novo

urgency is reported in 6% to 15% of

patients.(44,48,49) Urinary tract infection occurs in

6% to 22% of patients, and retropubic hematoma

in 0% to 5%.(50) Other complications such as bowel

injury, erosion to the vagina or urethra, and

injury to the greater and lesser vessels (epigastric

arteries) and obturator nerve are rare, but may

occur.(50) For the first time, Johnson and

associates have reported necroticizing fascitis as

a very rare complication after TVT, resulting in

exploration and wide debridement of the anterior

rectus fascia.(51) According to the unpublished

data, there have been 7 deaths reported after

TVT, 6 associated with bowel perforation, and 1

of vascular injury.(52) No such data are available

for other techniques. 

Within the last 2 years, numerous other

surgical devices for stress incontinence have been

introduced worldwide. One example is TOT,

which was designed in 1998. Theoretically, this

procedure avoids the risk of bladder, bowel, or

vascular injury, because the procedure passes the

polypropylene midurethral sling through the

obturator membrane along its ischiorectal fossa

path, bypassing the pelvic cavity altogether.

However, the surgical effectiveness and

complication rates of this procedure remain to be

established.

Urethral Bulking Agents

Several bulking agents have been used to treat

SUI in women. The rationale for their use arises

from the need for a washer effect on the tissues

at the proximal urethra and the bladder

neck.(53,54)

This approach is the least invasive surgical

procedure, originally described for patients with

SUI caused by intrinsic sphincter deficiency,

although it might be effective in patients with

urethral hypermobility. It can be done under local

anesthesia on an outpatient basis. Various

bulking agents are available including autologous

fat, glutaraldehyde cross-linked bovine dermal

(GAX) collagen, silicone microparticles, carbon-

coated zirconium beads, and dextranomer/

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Surgical Management of Stress Urinary Incontinence

hyaluronic acid copolymer.(53,54) The challenges of

these bulking agents (eg, carbon-coated zirconium

beads, calcium hydroxylapatite and dextranomer/

hyaluronic acid [Dx/HA] copolymer, silicone,

polytetrafluoroethylene and bovine collagenase)

are their durability, cost-effectiveness, safety

(concerns regarding migration, foreign-body

reaction, and immunologic reaction), and long-

term results. Organic substances may be

reabsorbed, while synthetic and biocompatible

products seem to have a better stability.(54)

The agent is injected transurethrally or

transvaginally into the periurethral tissue around

the bladder neck, proximal to midurethra, to

increase outlet resistance. Many reports have

studied GAX collagen as a bulking agent.

Dmochowski and colleagues(55) have summarized

the literature on GAX collagen for SUIs caused

by intrinsic sphincter deficiency. They also found

that most patients had a history of failed anti-

incontinence surgeries with a fixed bladder neck

or "bad urethra." The cure rate was 7% to 83% in

17 studies. Only 8 studies had defined intrinsic

sphincter deficiency (either as Valsalva leak point

pressure lower than 60 cm H2O or stress

videourodynamic to assess bladder neck opening).

In general, short-term cure rates of GAX collagen

(defined as complete dryness) are 30% to 78%.

Success rates (defined as leakage of less than 1

pad per day) are 40% to 86%.(53,54) Long-term

results (up to 2 years) suggest a continuous

decline in cure and success rates.(19) In a

randomized controlled trial, GAX collagen and

Durasphere (Advanced Uroscience, St Paul, Minn,

USA) have had similar results for SUIs due to

intrinsic sphincter deficiency.(56) The

disadvantages of bulking agents include the need

for repeat injections, their costs, and the

occurrence of adverse effects (eg, migration,

introduction of a foreign body, and generalized

immunologic reaction) of using nonautologous

materials. In addition, the surgeon is unable to

precisely determine the quantity of materials

needed for an individual patient.(57) Complications

such as urgency, urinary retention, and urinary

tract infections are rare; thus, this therapy might

be more suitable for women who wish to avoid

complications associated with more invasive

surgery.(58) Several new bulking agents and

techniques are in various stages of development,

including microballoons, human collagen,

autologous cartilage, bioglass, cross-linked

hyaluronic acid, calcium hydroxylapatite,

hyaluronic acid, dextranomer microspheres,

silicone, and ethylene vinyl alcohol polymers.(55)

At present, use of bulking agents is not widely

accepted, since data are limited.(58) The

recommended indications for injection are

previous surgical failure, high risk of surgical

operation, and patient preference. 

Conclusion

Stress urinary incontinence is common in

women and may impact their activity and quality

of life. After a basic evaluation, most women can

receive treatment. Conservative management

should precede surgery. However, surgical

management is the most effective treatment,

albeit it has more adverse events. Long-term data

suggest that Burch colposuspension and sling

procedures produce similar objective cure rates.

These results are supported by several

randomized trials as well as a large number of

case series. It has been shown that laparoscopic

Burch technique has a lower cure rate; however,

better-designed studies are ongoing. New

synthetic suburethral slings such as TVT have

gained popularity in recent years. Short-term

results of TVT demonstrate success rates similar

to those of Burch colposuspension. Long-term

complications after Burch colposuspension,

pubovaginal slings, and TVT are mostly related to

voiding dysfunction and urgency. The

complications of traditional and newer

suburethral slings are declining but still occur

and often are associated with serious morbidities.

Despite the advantages of synthetic materials,

the lack of an ideal material and treatment for

incontinence persists. Bulking agents have poor

long-term results, necessitating repeat injections.

Further research is needed to study the factors

that impact treatment success and durability of

various techniques. New therapies must be

studied in randomized clinical trials preceding

general clinical use, determining the efficacy as

well as the safety of new surgical techniques.

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