4th Annual Jefferson Urology Symposium: Focus on Urinary Incontinence

© The Canadian Journal of Urology TM : International Supplement, August 2021 31 Evaluation and management of female urinary incontinence to the abdomen or from the abdomen to the vagina (top down and bottom up) and has a success rate between 51%-81%. 14 There is no difference in outcomes between the approaches. The transobturator approach avoids entering Retzius’ space and was introduced in response to the complication profile associated with the retropubic approach. In this approach, the sling is inserted into a horizontal plane underneath the middle of the urethra between the two obturator foramina. 48 The transobturator approach has a success rate between 43%-95% in follow up studies of up to 5 years. 14 In long term analysis of these two approaches, patients treated with the transobturator approach experience less urinary urgency, negative quality of life impact, and sexual dysfunction compared to the retropubic approach. However, the transobturator approach resulted in a lower 5-year success rate compared to the retropubic approach. 49 While complication rates for MUS placement are low, they must be considered as with any surgery. Some of the more common complications included bladder perforation with a retropubic MUS, reoperation for persistent SUI, urinary retention requiring sling incision, pelvic hematoma, infection, vaginal mesh erosion, and postoperative groin pain. The retropubic approach and the transobturator approach have differing adverse event profiles, with the retropubic approach having a higher rate of bladder perforation and problems with voiding, while the transobturator approach having lower long-term efficacy and increased groin pain. 48 Autologous fascial pubovaginal sling An autologous pubovaginal sling procedure utilizes autologous fascia lata or rectus fascial tissue to recreated the periurethral support. 14 This procedure has been shown tobe an effective anddurable long termtreatment option, with a success rate between 85%-92%. 50-52 Because of this, AFPS may be an attractive option in patients who had a previous mesh complication or placement failure, prefer to avoidmesh, or are high-risk for poor wound healing. 14 The SISTEr trial compared AFPS to a Burch colposuspension and found that an autologous pubovaginal sling was a more effective treatment overall and had a lower retreatment rate. 53 A systematic review by Fusco et al reported that patients undergoing anautologous pubovaginal slinghad similar short term cure rates when compared to patients who had MUS, though pubovaginal sling patients were more likely to have postoperative storage lower urinary tract symptoms. Complication profiles were otherwise similar between pubovaginal slings and MUS. 54 Conclusions UI is a prevalent condition that affects nearly half the female population in the United States. While not a life-threatening condition, it can significantly reduce patient quality of life. Determining the type of UI and level of bother to the patient are critical. The work up must always include a thorough history and physical, UA, and PVR. Appropriate adjunct tests can be utilized if the diagnosis is still not certain. Advanced therapies should only be used when needed. Education and advocacy remain cornerstones of treatment since it can they establish treatment expectations, improve adherence, and increase patient satisfaction. References 1. Danforth KN, Townsend MK, Lifford K, Curhan GC, Resnick NM, Grodstein F. Risk factors for urinary incontinence among middle-aged women. Am J Obstet Gynecol 2006;194(2):339-345. 2. Dooley Y, Kenton K, Cao G et al. 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