**1. Introduction**

290 Urinary Incontinence

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Stress urinary incontinence (SUI) is defined as the complaint of involuntary leakage of urine on exertion or on sneezing or coughing **(Abrams et al, 2002)**. Female SUI is a common distressing health problem, affecting large number of women worldwide, with prevalence rates ranging from 12.8% to 46.0% **(Botlero et al, 2008)**. SUI is considered the most common type of urinary incontinence among women and presents about 50 % of these populations, while mixed urinary incontinence presents 36 % and only 14 % are due to urge urinary incontinence **(Hannestad et al, 2000)**. SUI has a negative impact on women quality of life specially their social, physical, occupational, psychological, and sexual aspects of life.

SUI arises when the bladder pressure exceeds the urethral pressure, in the setting of sudden increases of intra-abdominal pressure (coughing, sneezing …etc). Most researchers now identify two main etiologic mechanisms for the development of SUI: urethral hypermobility due to loss of urethral support - the hammock-like supportive layer described by DeLancey **(DeLancey, 1994 )**, and intrinsic sphincter deficiency (ISD), with most patients having elements of both disorders (Table 1).

There are several options for treatment of female SUI. Conservative treatment (pelvic floor muscle exercise) is usually advocated as a 1st line therapy since it carries minimal risks and studies have shown up to 70% improvement in symptoms of SUI following appropriately performed pelvic floor exercise **(Price, Dawood and Jackson, 2010)**. Conservative management strategies include:


Regarding pharmacotherapy, no drug till now has been approved to be used by the Food and Drug Administration (FDA) for the treatment of female SUI. Duloxetine is a serotonin– norepinephrine reuptake inhibitor (SNRI) has been investigated, it can significantly improve the quality of life of patients with SUI, but it is unclear whether or not benefits are sustainable in addition it has a common side-effects **(Mariappan et al, 2007)**.

Futuristic Concept in Management

**2. Midurethral slings for SUI treatment 2.1 Surgical principle of midurethral slings** 

the need for cystoscopy use after tape placement (figure 1 and 2).

Fig. 1. TVT in position **(Morley and Nethercliffe, 2005)**.

Fig. 2. TOT in position **(De Leval, 2003).** 

of Female SUI: Permanent Repair Without Permanent Material 293

Petros and Ulmsten proposed the integral or midurethral theory of the female pelvic floor and urethral closure mechanism **(Petros and Ulmsten, 1993)**, which has been the basis upon which many of the newer treatments for SUI have been developed. The idea that a loss of mid-urethral support is a causative factor in female SUI led to the use of synthetic midurethral tapes which became popular because of ease of placement and excellent outcomes. After their introduction by Ulmsten and Delorme, TVT and TOT gained a great popularity and rapid widespread and become now the gold standard treatment minimally invasive treatment of female SUI. Both techniques (TVT and TOT) aimed to recreating urethral support using a polypropylene mesh placed at midurethral without tension to create an artificial collagenous neoligament, using the foreign body reaction induced by the host defense mechanism. TVT acts as a pubourethral neoligament anchored suprapubically, which tightens around the urethra in the setting of increased intra-abdominal pressure. TOT had the following advantage over TVT by avoiding the blind trocar passage in the retropubic space by passing the trocar through the obturator muscles and membrane, thus decreasing the risk of major bladder, bowel perforation and vascular injury also decreasing


Table 1. Show various etiological factors involved in the pathophysiology of SUI.

Surgical treatment for SUI should be undertaken for women with SUI who have failed conservative treatment strategies or if the patient wants definitive treatment from the start.

Over the past years, many surgical procedures have been used for the treatment of female SUI with varying degrees of success. Recently, a number of new minimally invasive surgical techniques have been developed for treatment of female SUI that aimed to decrease the morbidity, improved safety and improvement of the surgical outcomes, while maintaining the efficacy of traditional open incontinence surgery. The Tension free vaginal tape (TVT) procedure was first described and evaluated by Ulmsten et al in Sweden in 1996 **(Ulmsten et al, 1996)**, then the Transobturator tape (TOT) procedure was developed in 2001 by DeLorme to avoid the retropubic space **(DeLorme E, 2001)**. Midurethral slings (TVT and TOT) have the following advantages:


Further improvement in surgical procedures towards less invasive sling technique has led to the innovation of a mini-sling e.g. TVT Secur system, which is a surgical device requiring only a single suburethral incision to be inserted **(Neuman and Shaare-Zedek, 2007)**. Mini-slings have the following advantages over the ordinary midurethral slings (TVT and TOT):

