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**14** 

*USA* 

**Refractory Stress Urinary Incontinence** 

Treatment of stress urinary incontinence (SUI) caused by urethral hypermobility or intrinsic sphincter deficiency with urethral sling procedures may yield up to a 80-90% success rate depending on the definition of success. (Nilsson et al. 2001; Liapis et al. 2002; Rodriguez & Raz 2003; Nilsson et al. 2004; Ward & Hilton 2004) In a minority of patients, however, there is persistence or worse incontinence after surgical therapy. In the general population, risk factors for midurethral sling (MUS) failure are BMI >25, mixed incontinence, intrinsic sphincter deficiency, diabetes mellitus, advanced patient age >75 years old and prior continence surgery. (Cammu et al. 2009; Stav et al. 2010) Potential surgery related reasons for failure include improper adjustment of the sling or misplacement of the suburethral tape. Female patients with urethral incompetence and severe incontinence due to multiple failed surgeries,

Patients with neurologic conditions have sacral arc lesions with paralysis of the skeletal musculature and an open urethra. All other patients who have failed multiple sling and anti-incontinence procedures may have severe symptoms of SUI and an open urethra with a low valsalva leak point pressure. These patients often have an incompetent, difficult to compress, urethra likely due to a combination of urethral denervation, and violation of the periurethral fascia, as well as their underlying risk factors for SUI. (Bump & Norton 1998) These patients have been shown to have low chances of cure after repeat anti-incontinence surgery and be more likely to suffer from complications including retention, osteomyelitis,

In the recurrent or refractory stress urinary incontinence female patient, a routine sling procedure providing only posterior support will not typically yield an appropriate response. Management options include repeat placement of a "tight" pubovaginal sling or replacement of a different type of sling, a spiral sling, periurethral bulking agents, adjustable continence therapy (ACT) device and the artificial urinary sphincter (AUS) prior to bladder neck closure with continent urinary diversion. This manuscript will review the evaluation and management options for recurrent stress urinary incontinence in this

There are a significant number of patients in the United States that undergo successful sling placement for SUI, however a minority will present with persistent or recurrent

neurologic injury, or congenital anomalies represent a unique surgical challenge.

**1. Introduction** 

and pelvic abscess. (Petrou & Frank 2001)

challenging population.

**2. Evaluation** 

Sara M. Lenherr and Arthur P. Mourtzinos *Lahey Clinic Medical Center, Department of Urology* 

