Female Stress Incontinence Procedures

Female stress urinary incontinence (SUI) — leakage with raised abdominal pressure — is treated surgically when conservative measures fail or are declined. The options run from least to more invasive: periurethral bulking agents, the midurethral sling (MUS), the autologous pubovaginal sling (PVS), and Burch colposuspension. The sling is the workhorse, and autologous fascia is the gold-standard graft for all forms of SUI. The disease, evaluation, and trial evidence are covered in the Reconstruction topic; this page is the operative reference.

Indications and Evaluation

• Mandatory work-up — history with bother assessment, objective demonstration of SUI (a positive stress test, repeated standing if not seen supine), urinalysis, and post-void residual.
• Assess urethral mobility (Q-tip) — slings support and compress the urethra during stress, so women without urethral mobility respond less well.
• Urodynamics are not needed in the index patient (the VALUE trial showed office evaluation non-inferior to UDS for 12-month success); reserve them for non-index cases (neurogenic disease, unconfirmed SUI, elevated PVR, significant voiding dysfunction, urgency-predominant mixed incontinence, or prior anti-incontinence/POP surgery). ISD can be confirmed on UDS.
• Counsel that surgery targets the stress component — urge symptoms may persist or arise de novo (≈ 33% persistent urge after a PVS), and women at risk of retention (poor detrusor contractility, high PVR) should be taught clean intermittent catheterisation (CIC) beforehand.

Surgical Options

• Periurethral bulking (Bulkamid) — for women wishing to avoid more invasive surgery, or with insufficient improvement after a prior procedure; counsel on the expected need for repeat injections.
• Burch colposuspension — largely replaced by the MUS (equivalent to TVT in trials); reserved for women avoiding both mesh and a fascial harvest, or having a simultaneous abdominal procedure.
• Slings — the midurethral sling (mid-urethra, synthetic) and the pubovaginal sling (bladder neck, autologous), detailed below.

Feature	Midurethral sling	Pubovaginal sling
Position	Mid-urethra	Bladder neck
Material	Predominantly synthetic	Predominantly autologous
Donor morbidity	None	Yes
Corrects	Hypermobility	ISD + hypermobility
With urethral diverticulum repair	Cannot	Can
Postoperative voiding dysfunction	Lower	Higher

Midurethral Sling

A strip of soft macroporous polypropylene monofilament mesh (pore size > 75 μm, which allows tissue ingrowth and resists infection) placed tension-free at the mid-urethra. It is best for mild-to-moderate SUI with urethral hypermobility, with a low erosion risk when correctly and loosely placed. The two routes — retropubic and transobturator — give similar overall continence.

Retropubic (TVT) Technique

1. Vaginal incision — in lithotomy with a weighted speculum and catheter, make a 2–3 cm vertical vaginal incision starting 1 cm below the meatus (the mid-urethra is midway between the bladder neck and meatus); hydrodissect and develop paravaginal flaps toward the inferior pubic ramus without piercing the endopelvic fascia.
2. Needle pass — make paired 1 cm suprapubic incisions over the symphysis, 2 cm from midline; with the bladder drained and a finger deflecting the urethra, pass the needle hugging the bone (resistance order: rectus fascia → retropubic space → endopelvic fascia) and out through the vaginal incision.
3. Cystoscopy is mandatory — distend with ≥ 300 mL and inspect with the 30- and 70-degree lenses; if perforated, withdraw and re-pass, and leave the catheter 5–7 days after a perforation.
4. Tension-free positioning — pull the sling under the mid-urethra with the plastic sheath still on, set it tension-free with a spacer (right-angle/Kelly clamp or 9-mm Hegar) between sling and urethra, remove the sheaths, and trim the ends below skin level before closing.

Transobturator Technique

• Placed through the obturator foramen (outside-in or inside-out — equivalent outcomes), avoiding the retropubic space, so it is favoured in obesity, a lower ventral hernia, or prior retropubic/bladder surgery.
• Through the same midurethral vaginal incision, the needle passes between it and the inner-thigh notch where the adductor longus tendon meets the inferior pubic ramus, at the level of the clitoris, traversing gracilis/adductor brevis → obturator externus, membrane, and internus → endopelvic fascia. Stay close to the bone and medial to avoid the obturator nerve and vessels, and never engage the adductor longus tendon (chronic pain). Flexing the hip 100–110° aids the inside-out pass.
• Cystoscopy (≥ 300 mL, 30/70-degree lenses) then tension-free positioning as above — a clamp must slide freely under the urethra with no waisting.

Route selection — continence is similar, but the transobturator route has less bladder perforation and voiding dysfunction yet causes thigh/groin pain in 10–15% and is less durable long-term, while the retropubic route gives higher dry rates in severe SUI/ISD and is more durable (with more bladder perforation).

Autologous Pubovaginal Sling

A free graft of rectus fascia (or fascia lata) placed at the bladder neck under mild tension — the gold standard for all SUI (minimal inflammation, negligible erosion). It is indicated for ISD ± hypermobility, recurrent SUI after a failed MUS or suspension, SUI with a concomitant urethral diverticulum or fistula (where synthetic mesh is contraindicated), and neurogenic urethral loss.

Technique

1. Harvest the graft — through a 6–8 cm transverse suprapubic incision, mark and sharply excise a 2 cm × 8 cm strip of rectus fascia with preplaced figure-of-eight size-0 polypropylene sutures at the corners (these become the suspension handles); close the fascial defect with running 0-polydioxanone. (Fascia lata harvested with a fascial stripper is the alternative.)
2. Vaginal exposure — an inverted-U or longitudinal incision over the bladder neck/proximal urethra; develop the plane laterally and perforate the endopelvic fascia aimed toward the ipsilateral shoulder to enter the space of Retzius, then dissect the bladder neck medially off the pelvic wall up to the rectus fascia.
3. Transfer the sling — pass a Stamey needle from the suprapubic incision through the retropubic space under finger guidance (minimising bladder injury); perform cystoscopy with the needles in place to exclude injury; thread the sling sutures, pull the sling up to sit at the bladder neck, and anchor it to the periurethral tissue.
4. Tension — tie the sutures over the rectus fascia with minimal or no tension for SUI (one or two fingers should fit between the knot and fascia). An occlusive (tighter) sling is reserved for refractory SUI, urethral erosion, or an incompetent outlet — the patient then performs CIC.

Outcomes

Continence is 61–97%, and it is particularly effective for ISD and recurrent SUI. SISTEr (NEJM 2007) — autologous rectus-fascia PVS beat Burch on success but with more voiding dysfunction (63% vs 47%) and urge incontinence. Return to normal voiding is slower than after a MUS, so sling incision or urethrolysis is delayed (by weeks) if needed.

Complications

• Voiding dysfunction / retention — higher after the PVS than the MUS; transient retention usually resolves (~10 days). Manage with CIC, loosen the sling in the OR within ~6 weeks (not for synthetic slings), then proceed to sling incision or urethrolysis (comparable success, less morbidity). De novo urgency reaches up to 12% after a MUS but ~33% persist after a PVS.
• Mesh complications (synthetic MUS only) — vaginal exposure 0.5–8.1% (small, < 1 cm, asymptomatic → topical estrogen; larger → excise), urethral or bladder perforation (never observe — excise and reconstruct with non-overlapping suture lines ± interposition), and pain (groin pain higher with the transobturator route — treat with sling incision/excision). Bladder trocar injury occurs in 2.7–3.8% (higher with the retropubic route). The autologous PVS has very low erosion — a key advantage.
• General — bleeding, infection, and persistent SUI; the fascial harvest adds incisional hernia (~1.2%) and seroma/hematoma (~4%, mostly needing no intervention). Avoid heavy lifting for 6 weeks.