RCOG Guideline No. 35

Stress Incontinence:
An evidence-based management approach
Prof. Hesham Salem. M.D.
Ob. Gyn
Alexandria University
•USI as recently defined by the International Continence
Society, is the complaint of involuntary leakage of urine
during effort or exertion or during sneezing or coughing.
•More than 200 operative procedures have been described
for the treatment of USI. Many of these are modifications of
the same procedure; but there is not one single
definitive operation.
•Surgery is recommended if conservative treatment fails
i.e. cure rates of around 50% have been reported with
Anterior repair
Evidence level Ia
RCOG Guideline No. 35
Anterior repair is less successful as an
operation for continence than retropubic
procedures and has been superseded by
sling procedures.
Anterior repair still has a role in the
Anterior repair
The Cochrane Collaboration.
Anterior vaginal repair was found to be less
effective than open abdominal retropubic
This was based on woman-reported continence
rates in eight trials both in the short and long
term These findings held irrespective of the
coexistence of prolapse.
The correct operation for the woman with stress
incontinence in the presence of anterior wall
prolapse is currently unclear.
Burch colposuspension
Evidence level Ia
RCOG Guideline No. 35
Burch colposuspension is the most effective
surgical procedure for stress incontinence,
with a continence rate of 85–90% at one
The continence rate falls to 70% at five
years; this shows better longevity than other
methods of treatment.
Burch colposuspension
The Cochrane Collaboration.
 A Cochrane review concluded that open
colposuspension is the most effective surgical
treatment for stress incontinence, especially in
the long term.
 There was no evidence of increased morbidity or
complication rate with open colposuspension
compared with other techniques, although
posterior pelvic-organ prolapse is more common
than after anterior colporrhaphy and sling
Burch colposuspension
To do
• It is sometimes easier to dissect the bladder from the
vagina with 50 or 100 cm3 of water or urine in the
bladder, because the bladder’s boundaries are easier to
• Let the assistant tie the sutures while the surgeon’s left
hand remains intravaginally to control the ‘tension’ of the
sutures, or vice versa.
Not to do
• Excessive mobilization causes denervation.
• Sutures tied too tightly cause urge and residual urine.
Alternative suprapubic surgery
Evidence level Ia
RCOG Guideline No. 35
The role of other suprapubic operations such as
Marshall–Marchetti–Krantz (MMK), paravaginal
repair and laparoscopic colposuspension, is
The operation was less successful than Burch
colposuspension at correcting a cystocele.
In a Cochrane review,MMK was more likely to
fail at five years than Burch colposuspension.
Alternative suprapubic surgery
Evidence level III
RCOG Guideline No. 35
• Paravaginal repair was first described by White
in 1909.
• Randomised comparison of colposuspension
with paravaginal repair; at six months follow-up,
there was an objective continence rate of 100%
for those patients undergoing colposuspension
but only 72% for those undergoing paravaginal
• Currently, the importance of recognition or repair
of paravaginal defects is uncertain.
Laparoscopic colposuspension
Evidence level Ia
RCOG Guideline No. 35
• Laparoscopic colposuspension has been
the subject of several case series and
continence rates between laparoscopic
and open Burch colposuspension.
Laparoscopic colposuspension
the Cochrane collaboration
• A Cochrane review published in 2002 examined eight
eligible trials, of women receiving laparoscopic Vs. open
• Subjective continence rates were similar at 6 –18
months (85–100%) but there was some evidence of
poorer objective outcomes for the laparoscopic operation
• There were no significant differences for postoperative
detrusor overactivity or voiding difficulty.
• There were trends towards a higher complication rate
and longer operative times, shorter hospital stay and
earlier return to normal activities for the laparoscopic
Needle suspension procedures
Evidence level Ia
RCOG Guideline No. 35
• Needle suspension procedures should not be
• initial success rates are not maintained with time and the
risk of failure is higher than for retropubic suspension
• The first procedure was described by Peyrera and
numerous procedures have subsequently evolved from
this, including the Gittes and the Stamey procedure,
using suspending sutures and patch materials.
• Procedures have evolved to include the percutaneous
bladder-neck suspension using bone anchors and a
suspending system.
Needle suspension procedures
Cochrane review
• Needle suspensions were more likely to
fail than open retropubic procedures and
there were more perioperative
complications in the needle suspension
• Needle suspensions may be as effective
as anterior repair but carry a higher
Sling procedures
Evidence level III
RCOG Guideline No. 35
 Sling procedures, using autologous or synthetic
materials, produce a continence rate of
approximately 80% and an improvement rate of
90%, with little reduction in continence over time.
 Only one synthetic sling procedure (tension-free
vaginal tape) has been subjected to randomised
study to date.
Conclusion 1
American Urological Association
• The American Urological Association considered that ‘Retropubic
suspensions and slings are the most efficacious procedures for
long-term success based upon cure/dry rate.
• However, in the panel’s opinion, retropubic suspensions and sling
procedures are associated with slightly higher complication rates.
• In patients who are willing to accept a slightly higher complication
rate for the sake of long-term cure, retropubic suspensions and
slings are appropriate choices.
• The Second International Consultation on Incontinence concluded
that suburethral slings represented ‘an effective procedure for
genuine stress incontinence in the presence of previous failed
Tension-free vaginal tape (TVT)
 The Prolene® (Ethicon) tension-free vaginal
tape (TVT) is relatively new, although increasing
numbers of cohort studies of its use are being
 The six-month subjective and objective results of
a randomized trial between TVT and Burch
colposuspension showed a similar continence
rate from both procedures.
 Complete dryneness in both groups was 38%
and 40% respectively (based on a rigorous
definition of cure).
Suburethral slings
Cochrane review
 A Cochrane review compared suburethral
slings with open abdominal retropubic
 For short-term cure, overall rates are
similar to open abdominal retropubic
 About 1/11 had a complication during TVT,
most commonly bladder perforation,
although serious consequences are rare.
TVT-O procedure
A new TVT-O procedure (Gynecare, Ethicon) using an
inside-out approach to minimize urethral and bladder injury
has been proposed.
But, at this time, there is no objective evidence that it is any
safer than the out-inside type sling procedure.
Neuman compared two anti-incontinence operations: the
TVT and the TVT-O for the first two 75 patients groups.
In this studies, the TVT-obturator patients seem to have
complications than the TVT patients with the same early
therapeutic failure rates, respectively 1.3% and 2.7% with
one year follow-up.
Transobturator Tension-Free Sling
To do
• Whenever you are not sure about the bladder’s integrity, do a
• Be as cautious with transobturator systems as you would be
• with retropubic systems.
• If you think you will have to do an anterior colporrhaphy at the same
time, use a transobturator system; this cannot shift towards the
bladder neck because of its different fixations on both sides.
Not to do
• Do not apply tension to the tape.
• Do not use a hook-shaped instrument to go from the inside out—you
may lose your way and end up in the obturator vessels.
Injectable agents
Evidence level III
RCOG Guideline No. 35
o Injectable agents have a lower success
rate than other procedures: a short-term
continence rate of 48% and an
improvement rate of 76%.
o Long term, there is a continued decline in
o However, the procedure has a low
morbidity and may have a role after other
procedures have failed,
Artificial sphincters
Evidence level III
RCOG Guideline No. 35
• Artificial sphincters can be successfully
used after previous failed continence
surgery but have a high morbidity and
need for further surgery (17%)
Preoperative management
Evidence level Ia
RCOG Guideline No. 35
It is recommended that women undergoing
surgery for urodynamic stress incontinence
should have urodynamic investigations prior
to treatment (including cystometry).
The Burch colposuspension has been considered as the
gold standard, as a result of long-term objective
incontinence cure rates.
Since 1996, when TVT was first introduced, it has been
used extensively with high success rates, equivalent with
Burch colposuspension and with less morbidity.
In 2001, the transobturator vaginal tape was introduced,
using either the out-in or the in-out approach for the
placement of the tape.
The TOR is appealing because of its simplicity, safety,
and the lower risk of bladder perforation.
The RCTs showed no difference in outcomes between
out-in and in-out approaches.
Experience showed a shorter learning curve with the inout route,
Thank you

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