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Urinary Incontinence, Medical and Surgical Aspects: Follow-up
Updated: Feb 9, 2007
Outcome and Prognosis
Measuring and comparing outcomes following the surgical treatment of incontinence is arguably the most difficult and challenging aspect of incontinence-related research for many reasons. Lack of standardization of outcome criteria and study methodology is one reason for the difficulty. Outcomes can be measured subjectively or objectively. When performed simultaneously, objective measurements of success tend to be somewhat lower than subjective rates. Objective criteria are more easily quantifiable and comparable, but, in many cases, the urodynamic tests used to obtain objective data have not been standardized or sufficiently studied. Subjective patient-oriented criteria may be more clinically relevant but may be more subject to bias. Long-term observation of patients can be difficult, and missing data can be a problem.
Measuring and comparing outcomes are also difficult because of varying definitions of successful outcomes. Some studies may define success as a patient who is dry. Other studies may use varying definitions relating to a decreasing number or severity of incontinence episodes, decreased pad use, or pad weight.
Length of observation is also an issue. The efficacy of incontinence procedures is believed by most to decrease with time. Many procedures show a steep fall in cure rates at 1-5 years. After 5 years, the rates may stabilize, but far fewer data exist on the efficacy of incontinence procedures in the long term. With the increasing awareness of incontinence disorders and the increasing lifespan, efficacy at 10, 20, and even 30 years becomes relevant.
Measuring and comparing outcomes is also difficult because of the variability of patient populations across studies. Groups with prior operative failures have higher failure rates with subsequent operations. Other variables, such as age, obesity, sphincter involvement, coexistent DI, ethnicity, medical comorbidities, and postoperative lifestyle issues, may affect outcome and are difficult to control. Another problem is variations in technique across studies. Small variations in surgical technique have an unknown but potentially significant effect on outcomes. Variations in surgeon experience may affect the degree to which findings can be generalized. Other considerations include cost, quality of life issues, and complication-related morbidity, which are not measured universally and consistently in studies. Although difficult to measure, these aspects of outcome analysis are important.
In 1992, the stress, emptying, anatomy, protection, and inhibition (SEAPI) staging system was developed to address some of the inconsistencies in outcome analysis. The system has a subjective arm, based on patient symptoms and an objective arm, based on physical examination and urodynamic studies. The system can be used preoperatively to grade incontinence and postoperatively to describe outcomes. Each patient has 5 components graded subjectively and objectively. The 5 components form the acronym SEAPI, as follows:
E - Emptying ability
A - Anatomy
P - Protection (pads or incontinence undergarments)
I – Inhibition
Each component is graded on a scale of 0 (best) to 3 (worst). The interested reader is directed to the original publication (see Bibliography) for more details. Perhaps in the future, tools such as this will be used to standardize outcome analysis.
Surgical outcomes for GSI
Many studies of the results of individual operative procedures for incontinence have been published. Most are flawed because of flawed design, inadequate power, and short observation. Relatively few studies comparing procedures prospectively have been reported. When considering the body of literature as a whole, the following general statements can be made:
- Open paravaginal defect repairs have a lower long-term cure rate than open Burch procedures.
- Some data indicate that laparoscopic Burch procedures may not be as durable as the open operation, but all of the data are not collected yet.
- Burch, MMK, and suburethral sling procedures have similar short-term and long-term cure rates.
- Primary procedures appear to have higher success rates than repeat procedures.
- Higher failure rates may be observed in patients with coexisting DI, ISD, abnormal perineal EMG findings, and a Valsalva voiding mechanism.
Retropubic urethropexies
Retropubic colposuspensions (ie, Burch, MMK) generally have been shown to be more effective than anterior colporrhaphy with Kelly plication or needle urethropexy. One notable exception is a series by Riggs and Riggs (1997), in which cure rates for modified Pereyra procedures and MMK procedures were approximately the same (87.8% vs 84.8%). Observation ranged from 6 months to 27 years. How clinical cure was determined is unclear in the report.
A well-known randomized controlled study compared GSI cure rates for the Burch retropubic urethropexy, the modified Pereyra needle urethropexy and anterior repair, and the Kelly plication. Objective outcome parameters were used. The results at 1 year of observation were cure rates of 87%, 70%, and 69%, respectively. At 5 years, cure rates had fallen to 82%, 37%, and 43%. This landmark prospective study suggests that the Burch procedure is the most durable of the 3 procedures.
An institutional retrospective review of 544 incontinence procedures was conducted. Five years after the operation, patients were contacted to arrange for assessment. The authors were successful in evaluating 60% of the original group. Objective continence rates of 61%, 49%, and 79% were reported for modified Kelly plication, anterior colporrhaphy plus needle suspension, and Burch colposuspension, respectively. The choice of procedure was at the discretion of the surgeon. Of note, in a subgroup of patients with grade 1 or mild incontinence, modified Kelly plication carried an 82% 5-year cure rate. With grade 2 and 3 incontinence, cure rates fell to 55% and 0%, respectively. The authors believe that, although the Burch procedure had overall superior results, anterior colporrhaphy still may have a place, especially in a patient with mild incontinence who is frail.
In a study from Switzerland, the cases of patients treated with a retropubic urethropexy were followed for 5 years. Rigid criteria were used to define success, including patient reports of being completely dry and free of symptoms and negative findings on a cough stress test with 400 mL in the bladder. Researchers reported an 82% cure rate. One group reported long-term follow-up of 10-12 years in 109 patients. The success rate reached a plateau at approximately 69%. As a repeat procedure, success rates of 69% and 80% were reported in 2 studies. The percentage of patients with ISD in these studies is unknown. The first of these studies also found that in 63% of the patients expressing dissatisfaction with the surgery, the major complaint was sensory-urgency. Finally, in a retrospective examination of retropubic urethropexy failures, a group reported pelvic floor neuropathy to be a significant risk factor for failure.
Laparoscopic retropubic urethropexy
Research in incontinence surgery has often revolved around the evaluation of laparoscopic approaches. Studies of the laparoscopic Burch urethropexy have demonstrated cure rates ranging from 6-100% with follow-up at 3-36 months. Complication rates from 0-25% have been cited, with surgeon inexperience being the major contributing factor. Procedures using mesh/staple or suture/staple combinations have resulted in cure rates in the range of 70-100%. Observation has been from 6-25 months, and complication rates have been from 5-17%. The laparoscopic paravaginal plus procedure, which combines the Burch procedure and paravaginal repair, has yielded excellent results in the hands of experienced surgeons. A cure rate of 93% for stress incontinence and cystocele was recently reported using this approach. Trials comparing open and laparoscopic Burch procedures have yielded mixed results. Several trials demonstrate equal efficacy.
Two studies, in particular, stand out because they report higher failure rates in the laparoscopic group. One study shows a 96% cure rate in the open group and an 80% cure rate in the laparoscopic group. This study has been criticized due to the use of only 1 suture on each side of the bladder neck in the laparoscopic group. The other study reports a cure rate of 93% in the open group and 60% in the laparoscopic group after 36 months of observation. This study has been criticized mainly because of the use of a small needle in the laparoscopic group that may have resulted in inadequate tissue bites. More head-to-head comparisons are needed.
The cost of laparoscopic retropubic urethropexy compared to the open approach has been examined in a few studies. One study reported equal costs. Longer hospital stays with the open procedures were balanced by higher operating room and equipment costs in the laparoscopic group. A slightly higher cost in the laparoscopic group was the finding of another group. Increased operating time in the laparoscopic group was cited as a major contributor to the cost.
Needle urethropexies
Needle procedures have yielded vastly different outcomes in different hands. At least part of the problem in studying needle procedures, as a whole, has been the wide range of variation in technique. These procedures as a group have cure rates ranging from 20-88% across studies, with observation ranging from 6 months to 27 years. Both objective and subjective methods of observation are included. Long-term observation of the Pereyra procedure yielded a 10-year success rate of 20%. A 24% success rate was reported with the Raz procedure after 27 months of observation. The Stamey procedure has been shown to have an 18% success rate after 5 years in one study. Another study showed a 33% success rate at 10 years. In an 8-year observation of the Gittes procedure, investigators reported a cure rate of 23% with another 27% improved. Most failures occurred during the first 2 years.
Suburethral slings
Suburethral slings have yielded impressive cure rates rather consistently. Cure rates have ranged from 70-95%. The vast number of reports of sling procedure outcomes are impossible to compare due to differences in observation length; assessment methods; and, most importantly, variations in sling length, sling material, and attachment points. Generally, results have been comparable to the findings for the Burch, although the urodynamic characteristics of the populations studied may differ. Groups chosen to undergo sling procedures often have a high incidence of ISD. Complication rates with sling procedures traditionally have been thought to be higher, although this may be changing. Most worrisome are urinary retention, prolonged catheterization, sling erosions, de novo DI, and infections. The negative quality of life impact of some of these complications actually may exceed that of the original incontinence disorder. The need for revision or removal is not rare.
An overall impression that can be gained from reviewing the literature is that choice of sling material may not affect cure rates as much as it does complication rates. Removal rates of as high as 25% have been reported with some synthetic materials. Sling tension probably is another major determinant of outcome, but this variable is very hard to measure. No standard methods of adjusting sling tension exist, and no studies compare sling techniques directly.
For many years, the presence of ISD and urethral hypermobility has been considered the ideal indication for a suburethral sling. In some studies, retropubic urethropexies have had higher failure rates in this subgroup of patients. Recently, a study demonstrated similar good results using the Burch procedure in this setting. The authors tied the Burch sutures tighter than usual to create a pronounced negative resting cotton swab angle. Another group has used the Ball-Burch variation in patients with ISD and hypermobility with results equivalent to the sling. In a third study, the Burch was compared to the suburethral sling in patients with a MUCP urethral closure pressure less than 20 cm H2 0. Urethral mobility was described as hypermobile, normal, and rigid. No patients with rigid immobility were included in either group. Specific criteria for classifying mobility were not described. Equivalent subjective and objective success rates were noted.
Little has been reported in the literature concerning the use of sling procedures in cases of GSI without ISD. A report on rectus fascia slings from an experienced group in Texas includes a subgroup of patients with GSI alone. The cure rate in this subgroup was 96%, with an overall cure rate of 93% with an average observation period of 22 months. This same study reported a 75% cure rate of urge incontinence in patients with a mixed disorder. Another group reported on their experience treating each form of incontinence with slings; overall, the combined cure and improvement rate was 94% for stress incontinence and 77% for urge incontinence at 1 year. Finally, another group reported a 69% rate of resolution of urge incontinence with the sling procedure at 3 months of observation. From a video urodynamic standpoint, they attributed their success in treating urge incontinence to achieving bladder neck closure at rest.
A study of sling procedures using cadaveric fascia lata was recently conducted. The outcome was reported in terms of improvement in SEAPI incontinence scores. The researchers noted decreases in the incontinence score from approximately 7 preoperatively to 1 postoperatively in both the allograft and autograft groups. Observation was short. Another study of allografts examined histological specimens after failed sling procedures and sacral colpopexies. Among 35 suburethral sling procedures, 6 failures were reported. All failures occurred between 1 week and 9 months postoperatively. In 4 cases, graft material could not be identified grossly at reoperation. In 2 cases, softened graft fragments were identified in the retropubic tunnels. The group concluded that cadaveric freeze-dried irradiated fascia should not be used for suburethral slings or other pelvic reconstructive procedures pending further research.
The tension-free vaginal tape (TVT) procedure is a variation of the sling procedure that appears to be less invasive, resulting in a low incidence of postoperative voiding problems and a good success rate. A report of 50 women observed at 2-6, 12, 24, and 36 months postprocedure showed an 86% cure rate, with the condition improving in 11% of the women. A recent, small, randomized trial compared the TVT procedure with the laparoscopic Burch procedure in 46 surgically treated women. Subjective and objective cure rates were not significantly different (82% for both groups). Major complications were very infrequent for both procedures.
A multicenter trial of the TVT procedure with a mean follow-up time of 56 months demonstrated an objective and subjective cure rate in 85% of patients, a significant improvement in 10.6% of patients, and a failure rate of 4.7%. Nilsson et al reported no cases of mesh erosion or long-term urinary retention.
The pubic bone suburethral stabilization sling procedure is a promising operation in which a synthetic mesh is secured to the underside of the pubic bone with titanium screws. In a study of 105 patients with recurrent stress incontinence, approximately 90% were dry and 10% improved with subjective observation in the 4- to 8-year range. Importantly, no cases of osteomyelitis have been reported. This author treats any patient with a vaginal pH of greater than 4.5 with metronidazole for a week before surgery. If the pH is still greater than 4.5 just before surgery, a therapeutic course of antibiotics for 5 days is prescribed. Although infrequent, reports of osteomyelitis with major morbidity complicating bone screw procedures can be found in the literature.
Reports of sling surgery in men with ISD are sparse. In one small series, slings and bladder augmentation were performed in men with neurogenic bladder and urethral incompetency. Sixty-nine percent were completely dry and performing ISC postoperatively. Approximately 15% required collagen injections after the sling. In a group of patients with postradical prostatectomy, 56% were dry after sling placement with another 8% improved. After sling retightening procedures, the total success rate improved to 75%.
A small series from Egypt reported on a mixed group of patients with incontinence due to prostatectomy, myelodysplasia, and spinal cord trauma. At an average of 13 months of observation, 10 of 11 patients were dry. Slings also have been performed in children with neurogenic incontinence. Combined with ISC, continence rates of greater than 90% have been reported. The interest and research in sling procedures are large. Many hope that these investigations will determine which methods and materials result in the best outcomes, in terms of both high cure rates and low morbidity.
Periurethral injections
The short-term results have been good, with cure plus improvement rates ranging from 70-100%. A review of 15 studies with an average of 2 years of observation reported a cure rate of 49%, with a combined cure and improved rate of 67%. The multicenter North American Study Group reported a cure rate of 96% at 1 year. The average number of treatments was 2.5, and the average amount of collagen used to achieve a cure was 24 mL. These figures are greater than were reported in most previous studies.
A recent investigation of 181 women with approximately equal numbers of type I, type II, and type III incontinence reported a cure rate of 23% at 2 years. Improvement and failure rates were 52% and 25%, respectively. The cured group required an average of 1.6 treatments and a mean collagen volume of 5.6 mL. These numbers were 2.9 and 11.4 in the improved group. Several other studies have noted no significant differences in cure rates, number of treatments, or total injection volume when comparing ISD patients with and without urethral hypermobility.
A small study of patients with neuropathic urethras described 7 of 11 patients as cured or improved after periurethral collagen injections. They reported an increase in the Valsalva leak point pressure from a pretreatment mean of 60 cm H2 0 to a posttreatment value of 117 cm H2 0. The periurethral and transurethral techniques were compared in a recent study of 45 women. With short-term observation only, cure and improvement rates were similar. The average amount of collagen used in the periurethral group was significantly greater; yet, the average number of treatments was the same. In men, the short-term efficacy of transurethral collagen injections has been well demonstrated.
A recent study followed the cases of 68 men with ISD due to various forms of prostate surgery. With a mean observation of 36 months, the cure rate was 10%, with an additional 10% experiencing marked improvement. These relatively poor long-term results occurred despite an average of 5 treatments and an average total injection volume of 36 mL. A subgroup with incontinence after transurethral prostate resection did better than groups with more radical surgery.
Artificial urethral sphincter
The AUS has been used with improving results for years in severe cases of sphincteric incontinence. In women, success rates of 91-100% have been reported. Mechanical complications requiring repeat surgery occurred in 21%. Considerably more experience exists with this device in men. A recent French study demonstrated complete dryness in 61% and considerable improvement in an additional 28% in a group of men with postprostatectomy incontinence. The revision rate was 21%. In a high-risk population, after radical pelvic surgery and radiation therapy, socially acceptable continence was achieved in 91% of patients. The need for revision was 38%. A study of 166 patients with a mean observation period of 42 months reported 75% as dry or nearly dry and an additional 15% as improved. Forty reoperations were reported.
In pediatric patients with congenital neurogenic incontinence, the artificial sphincter is the operative therapy of choice. Success rates of 85-90% have been reported. Enterocystoplasty has been combined successfully with artificial sphincter placement. The authors emphasize that good bowel preparation, IV antibiotics, and sterile urine are important factors in reducing infectious complications. In addition, entrance into the augmented bladder during sphincter placement should be avoided.
The long-term outcome in a group of patients with artificial sphincters for 10-15 years recently was reported. Sixty-one percent of patients were continent and were using the device. Another 14% had died but were believed to be continent just before death. The sphincter had failed and was abandoned in 15% of the patients. Of note, 80% of patients required 1 or more revision. Only 13% were continent with the originally implanted device. This report and others have shown that complications and the need for revision are high and both physician and patient should anticipate the possibility of future surgery. The issue of incontinence after artificial sphincter placement was addressed in a recent study. The authors found these incontinence problems could be addressed successfully approximately 90% of the time.
In summary, artificial sphincters are useful in severe sphincter deficiency, including congenital neuropathic and postprostatectomy incontinence. Cure rates are high, but the need for revision, replacement, and further surgery likewise are high. With close observation and diligence, most postoperative complications and failures can be addressed.
Surgical treatment versus medical treatment
No studies prospectively compare surgical and nonsurgical therapy for GSI. Retrospective analysis of cure rates, if undertaken, probably would not be valid because the populations undergoing surgical and nonsurgical therapy may differ. Often, less severe cases of incontinence are considered for medical management or cases in which a contraindication to surgery exists.
Pregnancy after incontinence surgery
Little solid data exist to guide clinical decisions in this area. Eight cases of MMK procedures following pregnancy have been reported. Seven patients delivered vaginally and 1 by cesarean delivery. All remained continent in the short-term following delivery. A survey of members of the American Urogynecology Society (AUGS) membership recently was conducted to address this issue. Forty vaginal deliveries and 47 cesarean deliveries following incontinence surgery were reported. Among women with vaginal deliveries, the subsequent continence rate was 73%, compared to 95% following cesarean deliveries. This retrospective analysis is subject to recall bias, but it represents the best data to date. Most incontinence surgeons recommend cesarean delivery following incontinence surgery. Whether surgery should be performed if women consider bearing more children remains unanswered.
Fistula repair
Most studies show successful closure of urogenital fistulae in approximately 90% of cases. Importantly, most of these are simple vesicovaginal fistulae of small-to-moderate size resulting from gynecological surgery mishaps. The results of treating larger and more complex fistulae are less clear.
A recent study sought other urodynamic diagnoses in a group of 38 patients with genitourinary fistulae. The study found additional disorders in 83% of the patients. Fifteen of 38 patients had more than 1 additional diagnosis. Overall, 47% had GSI, 40% had DI, 17% had impaired bladder compliance, and 50% had voiding dysfunction. GSI and DI were found more commonly in urethrovaginal and bladder neck fistulae. After surgical treatment of the fistula, 92% were cured of incontinence problems. DI was the most common persistent abnormality. This study points out that additional urodynamic diagnoses are common in individuals with urogenital fistulae, and surgical correction eliminates the additional problems in most patients. DI is the most common additional abnormality that persists after surgery. These findings bring to light important considerations in counseling and treating patients with urogenital fistulae.
Urethral diverticulum repair
Success rates of approximately 90% can be expected with good surgical technique. Coexisting GSI and/or ISD are not uncommon. Small series suggest that incontinence procedures, such as suburethral slings, can be combined safely with urethral diverticulum repair.
Cost-effectiveness of incontinence operations
The cost-effectiveness of surgical approaches to stress incontinence has not been studied directly. An interesting recent report used objective cure rates from prospective and retrospective studies of incontinence procedures and hospital cost data from third-party payers to estimate the cost-effectiveness of 3 common incontinence procedures. The estimated cost per cure at 5 years was $7878 for the Burch colposuspension, compared to over $13,000 for both the modified Pereyra procedure and anterior colporrhaphy. These long-term findings were in contrast to the immediate costs that were lowest for the anterior repair followed by the modified Pereyra and Burch procedures, respectively. More cost analysis research concerning incontinence treatment most likely will be performed in the future.
Therapeutic index of stress incontinence surgery
The concept of a therapeutic index traditionally has been applied to pharmacologic interventions only. Calculation of the index requires knowledge of the median effective dose and the median toxic dose. A recent publication proposed the application of the concept of therapeutic index to incontinence surgery. The authors proposed using the median percent cure rate and the median percent complication rate as variables. The preliminary findings of the study show the anterior colporrhaphy as having the highest therapeutic index, mostly due to very low complication rates. Needle procedures had the worst (ie, lowest) therapeutic index, with retropubic procedures and sling procedures falling in the middle.
The study has many flaws, including incomplete data on the sling procedure and lack of consideration of complications and failures at reoperation in the overall formula. Despite the flaws, the concept of a surgical therapeutic index is exciting and may make decision making for both the patient and the physician easier, in terms of the choice of surgical procedure.
Detrusor instability
Data regarding the long-term results of the treatment of DI are sorely lacking. Recently, over 1000 patients received follow-up care after a minimum of 6 months. Most of these patients (90%) were treated with anticholinergic medications for their urge incontinence. Only 5.5% were cured at the time of observation. Another 48% reported significant improvement. Only 18% continued with their medication beyond 6 months. Of those patients treated with bladder reeducation drills, 75% reported cure or significant improvement. DI was diagnosed in the patients in this study based on urodynamic findings in addition to a history and physical examination.
Future and Controversies
Interest and research in the specialty of urogynecology has been increasing. With this increased interest, exciting innovations appear to be forthcoming.
Minimally invasive surgical approaches are being investigated, and many of these approaches appear promising. The laparoscopic approach to retropubic urethropexy is especially attractive due to the improved visualization and hemostasis afforded by this mode of access. Procedures using new materials, such as mesh, staples, and corkscrews, are tempting to use because of their simplicity of application, compared to laparoscopic suturing. Equivalent outcomes with open or even laparoscopic Burch procedures (using suture) cannot be assumed; therefore, these new methods should be compared to existing methods in scientific studies and found to be safe and efficacious before being adopted widely. Unfortunately, consumer and marketing pressures have resulted in the use of these procedures and products before they have been studied adequately.
Vaginal dissection for the treatment of pelvic support disorders and urinary incontinence has been scrutinized recently regarding the potential for pelvic floor denervation. The existing evidence demonstrates that vaginal approaches result in more denervation injury than abdominal approaches. Recovery of some of the lost neurologic function has been observed over time. Whether denervation injury results in poorer long-term outcomes in the vaginal surgery group is not yet answered. This controversy has served to increase interest in the laparoscopic approach. Laparoscopic pubovaginal sling procedures may carry the theoretical advantage of less denervation injury and, possibly, less postoperative sexual discomfort. Initial attempts at this approach to sling surgery have been disappointing, but a great deal of interest remains.
The use of suburethral sling procedures, in general, is surging because of their efficacy, durability, and flexibility as an incontinence procedure. A strong advantage of sling procedures over other incontinence procedures is the ability to treat coexisting GSI due to hypermobility and ISD effectively. Some urogynecologists and urologists believe that sling procedures should be the incontinence procedure of choice. Proponents state that using the sling procedure obviates the need to identify ISD preoperatively in patients with stress incontinence because the operation treats both hypermobility and sphincteric problems. Opponents state that sling procedures are associated with increased postoperative morbidity, including obstruction, voiding dysfunction, and erosion of sling material. Many experts believe that tying the sling with little or no tension can minimize these complications.
The choice of sling material is an area of ongoing controversy. The ideal sling material has not been found. Artificial materials have the advantages of excellent strength, durability, and availability. The major disadvantages are increased rates of infection, rejection, and erosion of sling material. Endogenous fascia enjoys the advantage of low complication rates but requires additional incision(s) and intraoperative time for harvesting, and, in many instances, endogenous connective tissue may be of suspect quality. Cadaveric donor fascia is an attractive alternative due to low rejection and erosion rates and the avoidance of additional incisions. The quality of the highly processed end product may vary considerably. Suture pull-out can be a problem. Whether autolysis of this tissue in vivo may compromise long-term efficacy is uncertain. Finally, DNA has been found in some samples of donor fascia. The theoretical risk of disease transmission is still a concern.
Tissue engineering is an exciting biologic breakthrough that may allow growing tissues and even organs in the laboratory. People with incontinence with such disorders as bladder exstrophy and epispadias may benefit greatly from this advancement. In addition, this technology may be applicable to patients with bladders damaged by disease, radiation, trauma, and cancer.
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Further Reading
Keywords
urinary incontinence, stress incontinence, SUI, enuresis, urinary leakage, urogynecology, bladder, urethra, ureters, pelvic floor, weakening of connective tissue, genitourinary atrophy due to hypoestrogenism, nocturnal diuresis, involuntary bladder contractions, detrusor hyperreflexia, vesicovaginal fistula, vesicocutaneous fistula, exstrophy of the bladder, genuine stress incontinence, GSI, urethral diverticula, epispadias, intrinsic sphincter deficiency, ISD, urethral instability, overflow incontinence, outlet obstruction, detrusor instability, DI, urge incontinence, continuous incontinence, functional incontinence, benign prostatic hyperplasia, BPH, mixed incontinence, Marshall-Bonney test, modified Marshall-Marchetti-Krantz procedure, Ball-Burch procedure, paravaginal repair, laparoscopic retropubic urethropexy, needle urethropexy, suburethral sling procedure, tension-free vaginal tape, patch sling with suture arms, paraurethral fascial slingurethropexy, microwave therapy, periurethral injectionprocedure, fistula repair, urethral diverticulum repair, cystoplasty, denervation procedure, implantable sacral neuromodulation device, artificial urethral sphincter, urinary diversion, complex reconstructive procedure, Kegel exercises
