What are the surgical management options for urinary incontinence?

Surgical Management Options for Urinary Incontinence

For patients with stress urinary incontinence, mid-urethral synthetic slings (MUS) are the preferred first-line surgical treatment option due to their high efficacy, minimal invasiveness, and lower complication rates compared to other surgical approaches. 1

Types of Urinary Incontinence and Initial Assessment

Before selecting a surgical approach, it's important to determine the type of urinary incontinence:

• Stress urinary incontinence (SUI): Leakage with increased abdominal pressure (coughing, sneezing, exercise)
• Urge urinary incontinence: Leakage preceded by sudden urge to urinate
• Mixed urinary incontinence: Combination of stress and urge components

Primary Surgical Options for Stress Urinary Incontinence

1. Mid-Urethral Synthetic Slings (MUS)

• Types:

  • Retropubic MUS (RMUS): Success rates 84-95% with long-term durability 1, 2
  • Transobturator MUS (TMUS): Similar efficacy to RMUS with different complication profile 1

• Comparison:

  • RMUS: Higher risk of bladder perforation (6%), vascular/visceral injuries, voiding dysfunction
  • TMUS: Lower risk of bladder perforation, higher risk of groin pain 1, 3
  • Selection between RMUS vs TMUS should be based on surgeon experience and patient-specific factors 1

2. Autologous Fascial Pubovaginal Sling (PVS)

• Uses patient's own fascia (rectus or fascia lata)
• 85-92% success rates with 3-15 years follow-up 1
• Preferred for patients concerned about mesh complications or with contraindications to synthetic mesh 1

3. Burch Colposuspension

• Traditional gold standard before MUS development
• Still relevant for patients concerned about mesh or undergoing concomitant abdominal surgery 1
• Can be performed open, laparoscopically, or robotically

4. Bulking Agents

• Injectable materials to increase urethral resistance
• Lower efficacy (32-48%) and durability compared to other surgical options 1
• Best suited for:
  • Elderly patients
  • High anesthetic risk patients
  • Those preferring less invasive options with understanding of lower success rates 1

5. Artificial Urinary Sphincter (AUS)

• Limited role in female SUI
• Consider in cases of severe intrinsic sphincter deficiency after other procedures have failed
• Higher complication rates including erosion (28%), infection, and device malfunction 1

Contraindications for Synthetic Mesh Slings

Synthetic sling surgery is contraindicated in patients with:

• Urethrovaginal fistula
• Urethral erosion
• Intraoperative urethral injury
• Urethral diverticulum 1

Complications to Monitor

Mid-Urethral Slings

• Bladder perforation: 4-8% (higher with RMUS)
• Urinary tract infections: 10-15%
• Mesh erosion/extrusion: 5-8%
• Voiding dysfunction: 5-10%
• Major vascular/bowel injuries (rare but serious): <0.1% 2, 4

Autologous Slings

• UTI: 11%
• Bladder injury: 4%
• Wound complications: 8% 1

Special Considerations

Mixed Urinary Incontinence

• Surgical procedures may be considered for patients with mixed incontinence when the stress component is significant 1
• Approximately 14% of patients with pre-existing urge incontinence may continue to experience symptoms after stress incontinence surgery 1

Concomitant Prolapse

• Surgical procedures for SUI and pelvic organ prolapse may be safely performed together
• Important: Tensioning of any sling should not be performed until prolapse surgery is completed 1

Clinical Decision Algorithm

1. For first-line treatment in most patients with SUI:

   • Mid-urethral synthetic sling (RMUS or TMUS)

2. For patients concerned about mesh or with contraindications to synthetic mesh:

   • Autologous fascial pubovaginal sling
   • Burch colposuspension

3. For elderly, high-risk, or minimally symptomatic patients:

   • Bulking agents

4. For recurrent/complex cases after failed procedures:

   • Consider artificial urinary sphincter
   • Revision surgery with autologous materials

Important Caveats

• All patients should be thoroughly counseled regarding surgical and non-surgical options
• Success rates for surgical procedures range from 51-88% with long-term follow-up 1
• FDA has issued warnings about mesh complications in stress incontinence and pelvic organ prolapse surgeries 1
• Cystoscopy should be performed during sling procedures to detect potential bladder or urethral injuries 1