**8. Surgical technique**

222 Urinary Incontinence

analog scale ≦2), and (3) the absence of re-treatment. There was a higher success rate for treating anterior vaginal wall prolapse with anterior colporrhaphy (Chmielewski et al., 2011). In the past, the discrepancy in success rates of anterior colporrhaphy for the treatment of anterior vaginal wall prolapse can be attributed to varying definitions of success. As we know, a higher success rate is associated with a higher complication rate for the treatment of pelvic organ prolapse. Physicians should base the definition of success on patient perceptions and satisfaction according to clinically relevant definitions of success rather

The use of mesh has also become common practice in pelvic reconstructive procedures in recent decades. An increasing number of commercial kits have been designed for sitespecific defect repair or total mesh-augmented vaginal repairs to reinforce the supportive function of the vagina. Recent literature demonstrates that graft-augmented repairs seem to have a high success rate and conventional standard repairs (no mesh augmentation) have relatively high recurrence rates. However, potentially high success rates resulting from use of mesh products are accompanied by a high complication rate. Complications or sideeffects associated with vaginal mesh include mesh erosion or extrusion, infection, pain, and dyspareunia (Baessler et al. 2006; Maher and Baessler 2006; Natale et al., 2006; Wu MP, 2008; Jelovsek et al. 2007; Gomelsky et al., 2011). Therefore, researchers from the Third International Consultation on Incontinence concluded that because of mesh's high potential morbidity, mesh placed transvaginally should only be used in well-designed clinical trials

and not in general practice until more data is available (Brubaker et al. 2005).

**6. Staged or concomitant procedures for treating pelvic organ prolapse and** 

Currently, choosing either a concomitant or stepwise approach to treat concurrent pelvic organ prolapse and stress urinary incontinence is still debatable. A proper balance between the risk of incomplete treatment and exposing a patient to an unnecessary operation requires consideration when explaining the treatment outcomes to the patient. Some surgeons recommend concomitant procedures to treat co-existing stress urinary incontinence and pelvic organ prolapse in order to avoid the possibility of secondary surgery. However, they may encounter some inherent risks and unexpected adverse effects such as postoperative voiding difficulty, bladder outlet obstruction, and/or de novo detrusor overactivity. Others prefer staged procedures to correct pelvic organ prolapse first, followed by re-evaluation for the presence of stress urinary incontinence after the wound has healed and stabilized (Gordon et al., 2001; Huang et al., 2005; Winters JC, 2008; Wu et al., 2010). As mentioned before, anterior colporrhaphy might also cure stress urinary incontinence and its success rate is as high as 60% (Jarvis 1994). Intuitively, staged procedures most likely prevent two-thirds of unnecessary procedures for incontinence when

The Cochrane Database of Systematic Reviews revealed that the use of mesh or graft inlays at the time of anterior vaginal wall repair may reduce the risk of recurrent anterior vaginal

than on physicians' perceptions of success.

**stress urinary incontinence** 

contrasted with concomitant operations.

**7. Rationale for suburethral slingplasty** 

The basis of the current procedure is to place a tension-free and customized mesh underneath the proximal urethra and bladder to act as a supporting suburethral hammock to reinforce the anterior vaginal wall while undergoing pelvic reconstructive operations. The self-fashioned mesh may augment the supporting and suspension effects against an increase in mechanical forces of daily activities and gravity. Concurrently, the mesh patch may also act as a frame for inducing fibroblasts in fibrogenesis during healing (Hung et al. 2010).
