A myriad of surgical procedures have been described for the treatment of stress urinary incontinence(Table 1). The operating physician has the perplexing job of deciding which procedure will yield the best surgical results for a given patient. It has become important for the surgeon to be familiar with a variety of surgical options, to select the most appropriate procedure, while at the same time keep morbidity and risks to a minimum. For example, in the case of a woman with stress incontinence who requires a hysterectomy that is amenable to a vaginal approach, the physician must choose between performing a vaginal hysterectomy with a needle suspension, or an abdominal hysterectomy combined with a retropubic urethropexy. The choice of operative approach must maximize functional outcome, while minimizing morbidity from the combination of procedures. In this line of thought, as an alternative, a vaginal hysterectomy combined with a laparoscopic retropubic urethropexy may offer benefit. A more complicated scenario is presented if the patient requires a vaginal vault suspension and repair of a paravaginal defect.TABLE 1. Surgeries for Stress Urinary IncontinenceA thorough knowledge of urinary incontinence, pelvic anatomy, and the various surgical procedures used to treat stress incontinence is necessary for the care of patients with this disorder. With the emergence of the field of urogynecology and reconstructive pelvic surgery, our reservoir of knowledge has helped to improve the outcome of women with stress incontinence. This chapter will review factors that allow step-wise selection of the most appropriate surgical procedure for a given class of patients. These factors can then be applied to an algorithm(Fig. 1)that directs decision making toward the most suitable operation.FIG. 1. Algorithm for surgical management of stress urinary incontinence.
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