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Citation: C˘alinescu, B.C.; Neacs
,u, A.;
Martiniuc, A.E.; Dumitrescu, D.;
St˘anic˘a, C.D.; Ros
,u, G.-A.; Chivu, L.I.;
Ioan, R.G. Surgical Treatments for
Women with Stress Urinary
Incontinence: A Systematic Review.
Life 2023,13, 1480. https://doi.org/
10.3390/life13071480
Academic Editor: Kok Min Seow
Received: 18 May 2023
Revised: 7 June 2023
Accepted: 26 June 2023
Published: 30 June 2023
Copyright: © 2023 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license (https://
creativecommons.org/licenses/by/
4.0/).
life
Systematic Review
Surgical Treatments for Women with Stress Urinary Incontinence:
A Systematic Review
Bogdan Cristian Călinescu 1, Adrian Neacs
,u2, Ana Elena Martiniuc 2, Dan Dumitrescu 3, Catalina Diana Stănică2,
George-Alexandru Ros
,u4, Laura Ioana Chivu 5, * and Raluca Gabriela Ioan 1
1Department of Obstetrics-Gynecology, INSMC Alessandrescu Russescu, 38-52 Gheorghe Polizu Str.,
127715 Bucharest, Romania; bogdan-cristian.calinescu@drd.umfcd.ro (B.C.C.); raluca.ioan@umfcd.ro (R.G.I.)
2Department of Obstetrics-Gynecology and Neonatology, University of Medicine and Pharmacy “Carol Davila”,
37 Dionisie Lupu Str., 020021 Bucharest, Romania; adrianneacsu2006@yahoo.com (A.N.);
anilenac@yahoo.com (A.E.M.); catalina.stanica@umfcd.ro (C.D.S.)
3Department of General Surgery, Emergency University Hospital, University of Medicine and Pharmacy
“Carol Davila”, 168 Splaiul Independentei Str., 050098 Bucharest, Romania; dan.dumitrescu@umfcd.ro
4Department of Obstetrics-Gynecology and Neonatology, Saint Pantelimon Emergency Hospital,
University of Medicine and Pharmacy “Carol Davila”, 340-342 Pantelimon Str., 021659 Bucharest, Romania;
george.rosu@umfcd.ro
5Department of Pathophysiology, University of Medicine and Pharmacy “Carol Davila”,
050474 Bucharest, Romania
*Correspondence: laura.chivu@umfcd.ro
Abstract:
Stress urinary incontinence affects a large proportion of women in their lifetime. The objec-
tive of this review was to describe and compare the latest surgical trends in urinary incontinence and
focus on the literature advantages, disadvantages, complications and efficacy of surgical procedures
regarding this pathology. Using network meta-analysis, we have identified the most frequently
used procedures (Burch surgery, midurethral sling and pubovaginal sling), and we have described
and characterized them in terms of effectiveness and safety. Midurethral procedures remain the
gold standard for surgical treatment of stress urinary incontinence, although the potential of serious
complications following this procedure should be taken into consideration always. There is a clear
need for a much more unified evaluation of possible complications and postoperative evolution. This
process will help practitioners to adapt and individualize their strategy for each patient.
Keywords: stress urinary incontinence; Burch surgery; midurethral sling; pubovaginal sling
1. Introduction
Urinary incontinence is defined by the International Continence Association as any
involuntary leakage of urine. Most of the time, it occurs due to physical activity that
puts pressure on the bladder, such as exercise, sneezing, coughing, laughing or bending
over [1,2].
All over the world, it is a worrying condition that can reduce the quality of life in
women. Furthermore, the economic burden is considered to be high. The prevalence varies
from 20% to 50% throughout life but is seen more often in women who have had children,
and it becomes higher with age [
1
,
2
]. There are several types of urinary incontinence,
including stress incontinence, urge incontinence, overflow incontinence (chronic urinary
retention) or total incontinence. Each of these types has its own causes, but most of the
time, the causes may be common. Some of the possible causes lead to short-term urinary
incontinence, while others may cause long-term problems [3].
In Europe, the prevalence of SUI was estimated in 2022 at 14.5% according to a study
carried out in 2022 in the population group of 30–60 years, and in Romania, it is evaluated
to be 18%, maybe even higher due to the poor addressability of the patient regarding this
pathology [4].
Life 2023,13, 1480. https://doi.org/10.3390/life13071480 https://www.mdpi.com/journal/life
Life 2023,13, 1480 2 of 10
Stress incontinence appears when the pressure inside the bladder, as it fills with urine,
becomes greater than the strength of the urethra to stay closed [3].
If the muscles that keep the urethra closed are damaged, the urethra may not be able
to stay continent. Problems with the pelvic floor muscles may be caused by childbirth,
increased pressure in the abdomen, surgery in the pelvic area, connective tissue disorders
or neurological conditions [3].
Although urinary incontinence is a non-life-threatening condition, it is known to have
a significant health impact on the aging female population and leads to low quality of life
in many ways. When conservative treatments have failed to control the condition, surgical
treatment is necessary.
Surgical treatment for stress urinary incontinence was described with a lot of proce-
dures, each new procedure was developed to overcome the previous ones, but this situation
led to a lot of ambiguities [5].
In 1998, a prospective study was conducted on the comparison between the medium-
and long-term effects of various surgical treatment procedures in female stress urinary
incontinence. Basically, at that time, three types of surgical interventions were performed:
the Kelly suburethral plication, transvaginal needle suspension (or its variants) and Burch
colposuspension [5–7].
In the beginning, the indications for one of the procedures depended on the surgeon’s
choice, the Kelly plication procedure being predominant due to its technical simplicity
and simple postoperative evolution. This approach seemed to be easy and a little time-
consuming from the technical perspective than the other two procedures and, for a long
time, was the standard surgical procedure for stress urinary incontinence [7,8].
These interventions were surpassed by midurethral sling surgery developed in the
1990s, described as a minimaly invasive surgery that used a strip of synthetic mesh (sling)
that was placed with no fixation (tension-free) on the structures that needed to be sus-
pended [6,8].
Until the development of urodynamic investigation equipment (1998), the selection
criteria for the procedures were exclusively clinical and limited to the recurrent form,
especially after the Kelly operation, or to certain forms considered to be more complicated.
The introduction of a urodynamic investigation managed, first of all, to objectify the
type of incontinence preoperatively and objectively analyze a segment of the operated
patients. Many patients did not find themselves in a subsequent segment because of the
high subjectivity regarding self-evaluation. Moreover, a large number of recurrences were
not found in the computerized statistics of the urodynamic apparatus [8,9].
Currently, there are different types of surgical treatments for this condition, including
the following:
•Anterior vaginal repair colporrhaphy (anterior repair);
•Bladder neck needle suspensions;
•Open retropubic abdominal colposuspension;
•Retrosuspension made laparoscopic;
•Traditional sub-urethral retropubic sling;
•Midurethral retropubic sling (retro-MUS);
•Transobturator midurethral sling (transob-MUS);
•Single-incision slings small procedures;
•Peri-urethral injectable bulking agents.
Each of these operations can be performed with different techniques, and each has
its own advantages and disadvantages. Because of the lack of consensus and the different
types and techniques used to perform this surgical operation, it is difficult to determine
which procedure should be better used [
10
]. Comparative safety profile of these surgical
procedures is still unclear because of the lack of long-term evidence in most of the stud-
ies [
10
]. There is a clear need to declare adverse events after surgery for stress urinary
incontinence and a personalized strategy based on women’s symptomology, medical co-
Life 2023,13, 1480 3 of 10
morbidities, and intra-operative risk factors. A personalized strategy should always be the
best strategy in the treatment of each of the cases [11].
In this paper, we describe the latest trends in SUI with a focus on the literature
advantages, disadvantages, complications and efficacy. Besides the description of the
techniques, their analysis and comparison are extremely useful for refining the selection
process of an individualized technique for each patient.
The motivation for this review comes from the need to increase the addressability of
this pathology with multiple personal, social and economic implications. At this moment,
there is a multitude of surgical techniques described, each with its advantages and dis-
advantages, but there is a clear need for a much more unified and anatomically adapted
approach to this problem. The multitude of techniques described leads to a non-unitary
evaluation of possible complications and postoperative evolution. The purpose of the
review was to draw attention to these ambiguities and to establish the clear need for
collaboration in order to standardize procedures and declare complications.
Standardization of interventions, as well as a more accurate declaration of existing post-
operative complications, would help practitioners to adapt and individualize their strategy.
1.1. Search Strategy and Data Synthesis
We conducted a search of the literature limited to the last 10 years. We included
systematic reviews and meta-analyses, retrospective cohort studies and large prospective
cohort studies in our data synthesis. We hand-searched conference proceedings, journals
and reference lists of relevant articles. Case series and case reports were not included in
our data synthesis (Figure 1). The following databases were searched during the review
process: Medical Literature Analysis and Retrieval System Online (MEDLINE), Web of
Science, Pubmed and Cochrane Central Register of Controlled Trials.
Life 2023, 13, x FOR PEER REVIEW 4 of 11
Figure 1. Flowchart of the study selection process.
1.2. Data Collection and Analysis
Cochrane Incontinence published eight systematic reviews of randomized controlled
trials that analyzed nine surgical interventions used for the treatment of stress urinary
incontinence in women. These reviews represent an excellent literature base of evidence
for surgical interventions in this domain, published in the last 5 years. The multitude of
possible comparisons makes it difficult for both women and health professionals to inter-
pret the current evidence because of the lack of consensus [12,13].
All data they collected are systemized into a meta-analysis comparing the clinical
benefit of surgical procedures, and they also described adverse events and complications
in this type of surgery [1,12,13].
They screened using inclusion criteria, such as randomized controlled trials or quasi-
randomized controlled trials, women with urinary stress incontinence or mixed urinary
incontinence with predominant symptoms of stress urinary incontinence and comparing
two or more surgeries [13–16].
They included eight surgical methods in the analysis [12,16–19].
The results were impressive, which was the first extensive aempt to estimate the
clinical effects and safety of surgical interventions for the treatment of stress urinary in-
continence based on clinical trial evidence.
The conclusions of the study are that, in the short- to medium-term (one year), ret-
ropubic MUS, transobturator MUS, traditional sling and open colposuspension seem to
be more effective for the treatment of this type of incontinence. Evidence was insufficient
to describe the long-term effectiveness and safety of surgical treatments [15,16].
Figure 1. Flowchart of the study selection process.
Life 2023,13, 1480 4 of 10
A search of the literature was most commonly centered on the three most common
surgical methods, including the midurethral sling, Burch colposuspension and autologous
pubovaginal sling [Table 1].
Table 1. Inclusion/Exclusion criteria.
Criteria Inclusion Criteria Exclusion Criteria
Study population female
Written in English language
Studies made on established techniques.
Systematic reviews and meta analyses.
Large prospective cohort studies and
retrospective cohort studies.
Stress urinary incontinence.
Letters to the editors.
Case reports.
Clinical trials.
Studies made on small study groups.
Comparison between technical variation of the
same procedure.
Studies written in any other language
then English.
This review was registered to PROSPERO with the ID NR. CRD42023409430/10.04.2023.
1.2. Data Collection and Analysis
Cochrane Incontinence published eight systematic reviews of randomized controlled
trials that analyzed nine surgical interventions used for the treatment of stress urinary
incontinence in women. These reviews represent an excellent literature base of evidence
for surgical interventions in this domain, published in the last 5 years. The multitude
of possible comparisons makes it difficult for both women and health professionals to
interpret the current evidence because of the lack of consensus [12,13].
All data they collected are systemized into a meta-analysis comparing the clinical
benefit of surgical procedures, and they also described adverse events and complications
in this type of surgery [1,12,13].
They screened using inclusion criteria, such as randomized controlled trials or quasi-
randomized controlled trials, women with urinary stress incontinence or mixed urinary
incontinence with predominant symptoms of stress urinary incontinence and comparing
two or more surgeries [13–16].
They included eight surgical methods in the analysis [12,16–19].
The results were impressive, which was the first extensive attempt to estimate the
clinical effects and safety of surgical interventions for the treatment of stress urinary
incontinence based on clinical trial evidence.
The conclusions of the study are that, in the short- to medium-term (one year), retrop-
ubic MUS, transobturator MUS, traditional sling and open colposuspension seem to be
more effective for the treatment of this type of incontinence. Evidence was insufficient to
describe the long-term effectiveness and safety of surgical treatments [15,16].
Careful consideration of all surgical options and a better understanding of their associated
risks is a must before choosing a different, potentially less effective, non-MUS procedure. Each
case must be personalized and adapted to the need and desires of the patient.
A search of the literature was centered on the three most common surgical methods,
including the midurethral sling, Burch colposuspension and autologous pubovaginal sling.
The reason why the literature is centered on these three techniques is due to the fact that
although there is a multitude of complex techniques described, the research groups are very
small and inconsistent, and the techniques are non-standardized. Each surgeon can imagine
a personalized technique, but this leads to deficient anticipation of the postoperative
evolution and to a low safety profile, so we can only take into consideration established and
intensively studied techniques for which we have reported results, analyzed techniques
and large study groups.
1.3. Midurethral Sling
A midurethral sling system is designed to provide a strip of support under the urethra
to prevent it from falling during physical activity. It is considered that this procedure has a
symptom cure rate of 80–95% and an objective cure rate of 57–92% [15].
Life 2023,13, 1480 5 of 10
Midurethral sling, as a surgical procedure for SUI, was the most extensively studied
regarding the efficacy and the safety profile, so most of the reviews have the highest
evidence-based results on this procedure.
Midurethral sling involves inserting a strip of synthetic mesh through the retropubic
space or obturator foramen. Transobturator (TOT) was developed to minimize the potential
risk for bladder injuries and is considered to be the safer of the two options because, unlike
TVT, it avoids a surgical approach between the pubic bone and the bladder. TOT and TVT
are both made of polypropylene mesh [15,19].
In 2009, Cochrane’s review of 12,113 women described the efficacy between the
two procedures as similar, with a lower risk of vascular injuries and urinary retention
in the transobturator approach. The most recent reviews update reconfirmed the data.
Furthermore, they were also described to be more cost-effective. Fusco et al. performed an
updated systematic review to compare the efficacy and safety of MUS compared to Burch
colposuspension and pubovaginal slings and found that MUS was appreciably superior
for overall cure rates. They had a comparable risk of further incontinence surgery and late
complications [20].
Morling et al. described a study performed on 16,660 women who had undergone
a first single procedure with mesh compared with colposuspension, a mesh method that
was found to be more effective regarding immediate complications and with low second
interventions for relapse [21,22].
In 2017 in an updated systematic review, the advantage of TVT against retropubic
urethropexy and autologous fascia sling was reconfirmed [20].
In 2018 a multi-center study compared the tension-free vaginal tape and Burch colpo-
suspension showed a higher rate of continence in the TVT Arm at 2 years [23].
A 2013 Nordic multi-center cohort study demonstrated an objective cure over 90% at
17 years after TVT with only one mesh complication [24].
Regarding mesh safety, concerns about complications such as erosion, pain, dyspareu-
nia and infections were described. These complications can result in disabling symptoms
requiring major surgery and can sometimes reduce the quality of life. Additional questions
regarding polypropylene carcinogenic properties were raised, but a nationwide Swedish
cohort study including over five million women showed no association with increased
cancer risk following MUS surgery [25].
In general, the complications after MUS surgery appear to be lower than alternative
non-mesh-based SUI surgeries [26].
A Scottish independent review was reported in March 2017 and deduced that a
retropubic mesh tape is a good option with good safety and efficacy profile [27].
It is important to know that some of the women will suffer serious complications
that can affect their quality of life and are not easy to correct, but in most cases, they will
describe an improvement in SUI after treatment by a surgeon with high experience.
In 2022, a single-center prospective study that evaluated the functional outcome at
20 years after the vaginal sling procedure showed that the functional outcomes decline
after 20 years post-correction, so the cure rate after 5 years of TOT implantation was 80%,
and the follow-up showed that they dramatically decreased over the years. The limitation
of this study is that it is a single-center study, and the strengths are that it is one of the few
studies that evaluate the patient’s long-term satisfaction, but we all need to evaluate more
carefully the long-term outcomes in our patients, not only in 5 years but longer [28].
All of these studies have a general and common idea that, when used in appropriate
patients by appropriately trained surgeons, mesh procedures have a good safety and
efficacy profile [27].
1.4. Autologous Pubovaginal Sling
The autologous fascial pubovaginal sling was first described in 1978 and involves
collecting a piece of rectus fascia or sometimes tensor fascia lata which is placed under
the urethra after making a small vaginal incision. This procedure is described as taking
Life 2023,13, 1480 6 of 10
longer operative time because of the dissection and harvesting operative time, higher blood
loss involving dissection and postoperative morbidities such as seroma, so nowadays, it
is reserved for women with recurrent SUI, severe SUI or previous complications of MUS
surgery [29,30].
The pubovaginal sling is also indicated in the case of a urethral fistula or diverticulum
repair because of its obstructive effect and concomitant urethral reinforcement [30,31].
The low risk of complications, such as erosion due to foreign bodies associated with
synthetic mesh, is the principal advantage of this technique.
A contemporary large systematic review from the UK that described comparative the
pubovaginal sling with colpourethro suspensions and MUS showed similar success rates
regarding efficacy profile [12].
In 2007, a trial called the Stress Incontinence Surgical Efficacy trial made at 24 months
from the procedure described that the rate of success was higher for autologous pubovaginal
sling compared with colposuspension, although side effects and need for reintervention
was higher in the autologous pubovaginal sling [31].
Schimpf et al. found in their study that autologous pubovaginal sling was superior,
comparing subjective cure rates, to Burch colposuspension; however, MUS was found to
be superior to the pubovaginal sling regarding cure rates and had a lower incidence of
overactive bladder symptoms [32].
The pubovaginal sling is an effective procedure with high satisfaction rates but with
additional morbidity of harvesting of fascia. Concerns regarding mesh-related complications
increased interest in the pubovaginal sling technique because of the few pain-related compli-
cations and lack of mesh erosions reinterventions. However, the described surgical morbidity
and low surgeon expertise may be obstacles to wider use of this procedure [32,33].
1.5. Burch Urethropexy
This procedure consists of a suspension of the anterior vaginal wall to the iliopectineal
ligament and has been the main surgical procedure for many years and can be performed
open or by laparoscopic approach. Complications of this intervention include bladder
perforation, overactive bladder syndrome, prolapse and hemorrhagic incidents.
Because of its use for more than 50 years, the Burch procedure has data on long-term
outcomes, with cure rates up to 82% at 5- to 10-year follow-up. A large review found
similar results, and the continence rates for open Burch procedures were noted to be 85% at
1 year postoperatively and approximately 70% after 5 years [31].
Cohrane’s review from 2017, which included almost 5500 women, reviewed 55 trials
and demonstrated Burch urethropexy’s continued efficacy, especially for long-term urinary
management.
The procedure can also be laparoscopically performed. A study conducted at 2 years
postoperation was shown to be as effective as an open Burch procedure, however, with a
significantly longer operative time but a shorter length of hospitalization [16,31].
EAU guidelines suggest that any type of approach, open or laparoscopic, has compa-
rable cure rates, and it has to be offered as an alternative when a midurethral sling cannot
be considered [33].
NICE guidelines suggest that laparoscopic colposuspension should be made only by
an experienced laparoscopic surgeon who is part of a multidisciplinary team [34].
Burch and robotic Burch, which are minimally invasive options for treating this
condition, have similar outcomes but lack comparison data [35].
The robotic Burch urethropexy was first reported by Francis and colleagues in 2015.
The cost of robotic surgery procedures is known to be significant, and the authors propose
that a robotic approach in this pathology is particularly useful in patients that benefit from
other concomitant robotic surgeries, especially in the pelvic area [36,37].
Another minimally invasive variant of the Burch colposuspension is the “Mini-Incisional
Burch”. This procedure was proposed by Lind and colleagues in 2004, with the desire to
Life 2023,13, 1480 7 of 10
allow through a smaller incision the same surgical correction. The authors of the study
reported a complete cure in 97% of patients at short-term follow-up [35].
Due to the intensive use of sling operation, the use of the Burch colposuspension has
decreased nowadays but still has a significant role in the treatment of stress incontinence.
Specifically, this strategy has to be considered when we have limited space access, intra-
abdominal concurrent surgery or contraindications in the use of mesh.
2. Discussion
SUI generates a lower quality of life, having an effect on emotional well-being, de-
pression and anxiety, alternating relationship activities, low self-esteem and sometimes
associated comorbidities. Given the impact of the clinical manifestation, it also implies an
economic impact for both the individual and society, especially in our country, where the
patient is much less compliant with intermediate therapies and early investigation of the
health problem [38].
Milson and Coyne (2014), in a systematic review of economic costs, report that in
multinational studies, the annual estimated cost of disease for UI was billion-wise in five
European countries in 2010. In terms of cost efficacy, in recent years, health economics
has been a very important area in decision-making because, with their studies, they make
plans for the development of medical strategies by considering the costs involved in
different medical approaches. Regarding SUI, there are involved high direct economic
costs expressed in a decrease in labor productivity that leads to a second economic loss for
society in all areas [39].
In addition to the economic and social implications, the implications in the sexual
sphere are not to be neglected. Due to the pelvic anatomy and the proximity of the urinary
tract to the genital tract, sexual problems can occur. Women who suffer from this pathology
may associate anxiety with the possibility of losing urine during sexual intercourse. Such
a dysfunction involving low predictability of the event and poor control can determine
the woman not wanting sexual intercourse or being anxious during it, something that
leads to couple and trust problems. Studies on female sexual dysfunction estimate sexual
disturbances in 39–45% of sexually active women. Several papers studied the relationship
between urinary incontinence and sexuality, and they concluded that urgency symptoms
or even urine loss were associated with anxiety, mood disturbances and low quality of life
of SUI in the context of sexual life, sometimes leading to depression [40].
The pathophysiology of stress urinary incontinence in complex and the unitary action
of all pelvic anatomical structures, such as urethral support, vesical neck function and
urethral muscles, is important in maintaining balance. Stress incontinence appears when
the pressure inside the bladder, as it fills with urine, becomes higher than the strength of
the urethra to stay closed [3].
Slow-contractile muscle fibers from the urethra generate tension and maintain the
closed urethra [
3
]. The mechanism prevents urine leakage and keeps urethral pressure
during stress periods. If the urethra has trauma, such as radiotherapy or surgery, the
urethral wall will lose elasticity and secondary closure capability [3].
Perhaps one of the most important aspects of continence control concerns the balance
between all of these systems. The anatomical pathogenesis of SUI facilitates a better
understanding of the mechanism of SUI and provides new ideas for surgical treatment.
There are several theories that explain the dysfunctions in SUI at the level of each system
as well as imbalances in the whole system. There are various anatomical factors, but the
majority of the studies pay much attention to the joint contraction of the levator ani muscle
and the external urethral sphincter. Therefore, in the treatment of SUI, the solution is the
repair and reconstruction of the levator ani muscle and external urethral sphincter. The
surgical technique should be improved according to findings in anatomical pathogenesis
of SUI, and by anatomical basis, we should develop and use more appropriate slings to
reduce the impact of surgical operations on pelvic organs [41].
Life 2023,13, 1480 8 of 10
3. Conclusions
There are many options for treating SUI in women, the most used are autologous fascial
slings, midurethral tapes and colposuspension. Historically, colposuspension was the most
used procedure, but now, after years of research, most patients are offered midurethral tape.
The new guidelines (EAU, NICE and Cochrane) recommend offering first-choice MUS to
women with SUI and no complications as the preferred surgical intervention.
It is important for the surgeon to discuss with the patient the risks and benefits of each
intervention, to evaluate their personal needs, social status and how incontinence affects
their life. The choice of the technique and the operative moment must be adapted to the pa-
tient’s expectations. They must be realistic and as reproducible as possible postoperatively.
The role of the surgeon is to mediate the patient’s needs with the surgical possibilities.
MUS remains the most extensively studied treatment with the lowest complication
rates, but women should be informed regarding the rare but serious erosions mesh-related
complications. Perspectives in the development of new bio-synthetic mesh materials may
lead to new surgical techniques with fewer complications.
Careful contemplation of alternative surgical options and a better comprehension
of their associated risks and benefits is a must requirement before opting for different,
potentially less effective non-MUS procedures.
Increasing concerns regarding mesh-related complications renewed interest in autolo-
gous fascial slings because of the lack of complications of mesh erosions, but the potential
morbidity after harvesting of fascia makes it less used. By improving the fascia sampling
technique and standardizing the insertion procedures, we can obtain better results with
minimal complications.
The newest guidelines (EAU guidelines) suggest providing a colposuspension proce-
dure if a midurethral sling cannot be considered.
A better evaluation and acknowledgment of complications after surgery for stress
urinary incontinence is imperative. It is important to promote awareness of later compli-
cations, and it could be very useful to record them in national databases and registries to
generate uniform data for each surgeon to access.
Both at the scientific level and at the level of each patient, there is a clear need to
identify personal needs as well as to evaluate the associated risks for good control of the
risks and benefits of each intervention.
Author Contributions:
Conceptualization A.N. and C.D.S.; methodology D.D.; validation R.G.I. and
L.I.C.; resources B.C.C.; writing A.E.M.; visualization G.-A.R.; supervision B.C.C. All authors have
read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement:
This review was registered to PROSPERO with the ID NR.
CRD42023409430/10.04.2023.
Informed Consent Statement: Not applicable.
Data Availability Statement: Not applicable.
Conflicts of Interest: The authors declare no conflict of interest.
Abbreviations
SUI Stress urinary incontinence
MUS Midurethral sling
EAU European Association of Urology
NICE National Institute of Health and Care (England)
MUS Urethral sling
TOT Transobturator
TVT Tension-free vaginal tape
Life 2023,13, 1480 9 of 10
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