What we recommend surgically for our patients who have SUI—and why
| Clinical problem and patient characteristics | Surgery | Rationale |
|---|---|---|
| Primary SUI with urethral hypermobility—young patient | TVT | TVT has similar effectiveness and more long-term data than TOT; TVT may result in less sexual pain than TOT |
| Primary SUI with urethral hypermobility—older patient; leak point pressure >60 cmH20 | TOT | Similar effectiveness, fewer complications with TOT |
| Recurrent SUI with urethral hypermobility—any age; leak point pressure >60 cmH20 | TVT | Limited data suggest effectiveness of TVT after TOT failure |
| Recurrent SUI with urethral hypermobility—leak point pressure <60 cmH20 (ISD) | TVT or pubovaginal fascial sling | Some but not all data indicate that TVT is more effective for ISD; fascial slings in expert hands are effective, based on cohort studies |
| Recurrent SUI with nonmobile bladder neck; any leak point pressure | Urethral bulking | All sling procedures have lowered effectiveness when the bladder neck is immobile |
| SUI mixed with dominant urgency or voiding dysfunction | TOT | TOT improves or does not exacerbate mixed urinary symptoms to the extent that TVT may |
| SUI with prolapse and planned vaginal prolapse repair | TVT or TOT | Limited data support similar effectiveness for either approach |
| “Occult” SUI with prolapse reduced and planned vaginal prolapse repair | TOT or “wait and see” | TOT has a lower chance of creating new irritative voiding symptoms; “wait-and-see” approach allows treatment of SUI if it develops after prolapse repair |
| Recurrent SUI with previous synthetic sling mesh complication (or patients who desire treatment without mesh) | Pubovaginal fascial sling or Burch colposuspension | These nonmesh options are effective for recurrent SUI, but have higher surgical morbidity |
| ISD = intrinsic sphincter deficiency; SUI = stress urinary incontinence; TVT = tension-free vaginal tape or similar retropubic midurethral sling; TOT = transobturator sling placed either by outside-in or inside-out variations | ||
Patients who have recurrent SUI: Retropubic sling. Comparative data are limited regarding the retropubic and TOT approaches for recurrent SUI that does not involve ISD. One case series reported good results with the use of retropubic TVT for recurrent SUI after an initial TOT approach.23
Patients who have ISD: Retropubic sling (synthetic midurethral sling or fascial sling placed at the bladder neck). A few studies suggest that patients with ISD have better outcomes with the retropubic approach.19,20 However, with differing definitions of ISD and relatively few patients with ISD included in these trials, it is not possible to conclude definitively that the retropubic approach is more effective than the TOT approach for patients who have SUI and ISD. However, the retropubic approach has longer-term data to support its effectiveness; therefore, with some but not all evidence suggesting its superiority for ISD, it is reasonable to choose the retropubic midurethral approach.
A pubovaginal fascial sling placed at the proximal urethra is also an effective option, based on numerous cohort studies.12
Patients who have recurrent SUI or ISD, or both, with a non-mobile bladder neck: Urethral bulking. Although data are scant, urethral injection therapy is beneficial for SUI in the short-term, but long-term studies are lacking. Bulking agents include silicone particles, calcium hydroxylapatite, and carbon spheres; studies have not shown one to be more or less efficacious than the others.24
It is reasonable to use urethral bulking first in these patients as the morbidity is very low and some patients become continent. A retropubic sling can be performed if urethral bulking fails to adequately improve symptoms, although the effectiveness is lower in this population than in women with SUI and urethral hypermobility.
Patients who have mixed stress and urge incontinence or voiding dysfunction: TOT sling. Limited data suggest that the TOT approach improves symptoms of mixed incontinence—or, at least, exacerbates them to a lesser degree than the retropubic approach. Rarely is a sling release needed to treat obstructive urinary symptoms after the TOT approach.
Patients who have prolapse and SUI: Retropubic or TOT sling. When a sling procedure is performed at the same time as reconstructive surgery for prolapse, it has similar effectiveness, regardless of whether the retropubic or TOT approach is selected.8,11 A sling placed during prolapse surgery (placed through a separate midurethral incision) appears to be as effective as a sling placed as a sole procedure.
Patients who have prolapse and occult SUI: TOT sling. If you recommend a sling to prevent SUI after prolapse surgery by any route, pick the sling with acceptable efficacy and the lowest rates of complications and voiding dysfunction. Patients are especially intolerant of complications from a sling to prevent SUI. Given the ease of placement and low morbidity of a later outpatient sling procedure, it is also reasonable to offer patients the “wait-and-see” alternative to see if SUI develops after prolapse surgery and only then proceeding with sling surgery. In this way, overtreatment is avoided, and any complications that occur after sling surgery for SUI treatment may be better tolerated by the patient. The preferences of an informed patient may guide decisions in this setting.