Surgical repair of stress urinary incontinence.

Genuine SUI is defined as that associated with hypermobility of the urethra and bladder neck. Accurate history-taking and physical examination allows for proper diagnoses and subsequent therapy in the majority of cases. Patients in whom bladder instability or intrinsic sphincteric deficiency are suspected may benefit from urodynamic testing. Regardless of method, all surgical procedures used to treat genuine SUI aim at supporting the bladder within the pelvic cavity. This allows for adequate compression of the urethra by those intra-abdominal forces that would otherwise only act to expel urine through a compromised outlet. The operation of choice should be determined by its ability to provide this proper positioning over the long-term with the least morbid approach. Comparison of the various procedures is hampered by the lack of objective long-term data. For a vaginal approach, we prefer either the modified Pereyra as developed by Raz, or the placement of a sling beneath the bladder neck to provide firm, long-term support. For those patients who have not had prior abdominal surgery, the laparoscopic approach is an exciting method to obtain accurate dissection and fixation of the bladder neck and urethra. With careful evaluation and performance of these multiple techniques, therapy can be individualized for patients with excellent results.