Ideally, the choice of surgery for stress urinary incontinence should be determined by the underlying pathophysiology. Generally, the diagnosis is refined to either urethral hypermobility (UHM) or intrinsic sphincteric dysfunction (ISD) based on history, questionnaires, physical exam, and various special tests including assessment of urethral mobility (Q-tip test or lateral cystogram), stress test, pad test, and video or nonvideo urodynamic studies. Unfortunately, there is no gold standard test or algorithm to allow diagnostic precision in every case, and the diagnosis is usually arrived at based on various combinations of the above investigations along with clinical acumen and experience. Nonetheless, the importance of arriving at the correct diagnosis lies in its role in determining the appropriate surgical intervention. Although this principle of practice has been challenged more and more in recent years (1,2), traditionally, UHM is treated with one of the bladder neck suspensions (BNSs) and ISD with one of the sling procedures, urethral bulking agents, or artificial urinary sphincter. For UHM, once the diagnosis is made, one must decide on the appropriate BNS, for which there exist two main types based on surgical approach: retropubic or transvaginal. Differences in efficacy aside, the decision to proceed with one approach or the other should be driven by any associated pathology requiring concomitant surgical repair. For example, if concomitant vaginal repair of a symptomatic rectocele is undertaken, then a transvaginal anti-incontinence procedure is appropriate. Conversely, if an abdominal hysterectomy is required, then a retropubic approach is logical.
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