Surgical treatment The main indications for surgical treatment include: 1. Patients who have poor results or cannot adhere to non-surgical treatment, cannot tolerate it, and have poor expected results. 2.Patients with moderate to severe stress urinary incontinence, which seriously affects the quality of life. 3, Patients with high quality of life requirements. 4, with pelvic organ prolapse and other pelvic floor functional lesions need to perform pelvic floor reconstruction, anti-stress incontinence surgery should be performed at the same time. Before performing surgical treatment, attention should be paid to: ① Consult the patient and family’s wishes and make a choice based on adequate communication; ② Pay attention to assessing the function of the bladder and urethra, and perform urodynamic examination if necessary; ③ Select the surgical procedure according to the patient’s specific situation. ③Select the procedure according to the patient’s specific situation. Consider the efficacy, complications and cost of surgery, and try to choose a less invasive procedure; ④Try to take into account the classification and typing of urinary incontinence; ⑤Camera should be used for special cases, such as patients with multiple surgeries or pelvic fixation due to urinary extravasation, the bladder neck and posterior urethra should be fully released before anti-incontinence surgery; for patients with type III ISI) without significant urethral movement, the first choice of procedure is transurethral For patients with type III ISI without significant urethral movement, the first choice of procedure is transurethral injection, followed by artificial urethral sphincter and mid-urethral sling [1]. The common complications of surgical treatment are shown in Appendix VI, the level of recommendation is shown in Appendix VII, and the consultation and treatment strategy chart is shown in Appendix VIII. (I) Highly recommended Tension-free midurethral sling Principle: DeLancey proposed the new hypothesis of midurethral hammock theory in 1994, suggesting that the rise in midurethral closure pressure caused by the accompanying increase in abdominal pressure is one of the main mechanisms of urinary control [2]. Accordingly, Ulmsten (1996) et al. applied tension-free transvaginal midurethral sling (tension-freevaginaltape, TVT) for the treatment of stress urinary incontinence, bringing a whole new revolution in the treatment of stress urinary incontinence [3]. Efficacy: comparison of tension-free midurethral sling with other similar sling procedures showed no significant difference in cure rate, with short-term efficacy above 90% [4-12]. The greatest advantages are stable efficacy, less injury and fewer complications. The main methods: TVT and TVT-O are more commonly used in China, and other methods such as IVS and TOT are also available. 1, TVT Efficacy: long-term follow-up results show that its cure rate is above 80% [13-16]. the cure rate of TVT for recurrent urinary incontinence is similar to that of primary urinary incontinence [17,18]. The efficiency rate for treating mixed incontinence is 85% [19]. It is 74% effective in patients with intrinsic sphincter defects [20]. Complications (incidence shown in the table): (1) Bladder perforation: it is likely to occur in beginners or in patients who have undergone previous surgery. Repeated intraoperative cystoscopy is an essential step. If intraoperative bladder perforation occurs, the bladder should be reperforated and installed and the ureter retained for 1 to 3 days; if found postoperatively, the TVT should be removed and the ureter retained for 1 week and the TVT repositioned at the second stage. (2) Bleeding: bleeding and retropubic hematoma are not uncommon, mostly due to the puncture being too close to the retropubic bone or the presence of scar tissue. When bleeding from the retropubic space occurs, the bladder can be filled for 2 hours while pressure is applied to the lower abdomen, the vagina is filled with uterine gauze and closely monitored, and it is mostly self-absorbing. (3) Difficulty in urination: Mostly due to too tight suspension. In some other patients, it may be related to impaired contraction of the bladder force/bladder outlet obstruction before surgery, and further urodynamic examination may be helpful in such patients. Intermittent catheterization can be performed for difficult urination in the early postoperative period. About 1% to 2 or 8% of patients with postoperative urinary retention need to be cut off from the sling. The TVT sling can be loosened or cut off vaginally under local anesthesia, and the difficulty in urination disappears immediately after surgery, while the adhesions produced by the sling still have therapeutic effects on stress incontinence. (4) Other complications: including foreign body reaction to sling placement or delayed healing of the incision, erosion of the sling into the human urethra or vagina, bowel perforation and infection, and the most serious one is iliac vessel injury [21-25]. 2, TVT-O Efficacy: the recent efficiency is 84%-90%, which is basically equivalent to TVT, but the long-term efficacy still needs further observation [20,26-28]. Complications: The surgical principles of TVT-O and TOT are the same as those of TVT, but the puncture route is through the closed hole instead of behind the pubic bone, which basically excludes the possibility of injury to the bladder or iliac vessels [1,27-29], but may increase the risk of vaginal injury [30]. Some experts believe that the TVT-O procedure is safer than TOT due to the different direction of puncture access [31]. The main rare serious complications are sling vaginal erosion and closed-hole hematoma and abscess formation [1,32,33]. The mid-urethral sling procedure has stable efficacy and fewer complications and is highly recommended as an initial and reoperative procedure for urinary incontinence, with TVT-O or TOT being more advantageous due to less trauma, shorter hospital stay and fewer complications [34]. (B) Recommendations 1. Burch vaginal wall suspension Principle: The vaginal wall on both sides of the bladder floor, bladder neck and proximal urethra are suspended by sutures via the posterior pubic bone from Cooper’s ligament, lifting the bladder neck and proximal urethra, thus reducing the mobility of the bladder neck trap’. It has also been suggested that this procedure also has an effect on the position of the pelvic floor support tissue (MRI examination revealed that the degree of shortening of the distance between the anal levator muscle and the bladder neck was significantly correlated with the success rate of the procedure) [36]. METHODS: There were 2 types of surgery: open surgery and laparoscopic surgery. Efficacy: the cure rate was above 80% at the initial surgery [25,37,38]. the cure rate was essentially the same at the 2nd surgery as at the initial surgery [39-41]. The efficacy of the Burch procedure is not affected by concomitant hysterectomy and does not increase the incidence of comorbidities [44]. This procedure is basically similar to percutaneous puncture suspension and principle, but the efficacy is more definite [38], mainly because: firstly, the suture is anchored more firmly on Cooper’s ligament; secondly, the adipose tissue is sufficiently free to form more extensive adhesions [45]. Complications: dyspareunia (9% to 12, 5%, managed by intermittent catheterization, urethral dilatation, etc. [40], overactivity of the detrusor muscle (6, 6% to 10%), uterovaginal prolapse (22, 1%, of which about 5% require further reconstructive surgery), intestinal hernia, etc. [20]. Laparoscopic versus open Burch: (1) Efficacy: several Meta-analyses have shown controversial efficacy of both. Some studies showed no difference in subjective cure rates between the two groups at 6 to 18 months of follow-up [37,46-49], while others showed that laparoscopic Burch surgery was less effective than open surgery, with an effective rate of 64% to 89% [50]. (2) Advantages and disadvantages: poor visualization and less secure sutures in laparoscopy than in open surgery may be the reason for its poor efficacy [51]. Laparoscopy has less bleeding, less injury, better tolerance and faster recovery than open surgery. However, the operative time is long, technically demanding and expensive. Comparison between Burch surgery and TVT: (1) Efficacy: both are the most stable procedures with the most consistent efficacy, and randomized controlled studies have shown that the urinary control rate is basically similar, mostly above 90%, and the recent clinical application of TVT for stress urinary incontinence has been reported significantly more than that of Burch surgery. (2) Advantages and disadvantages: TVT has a shorter operative time and hospital stay than Burch, with less trauma and faster recovery [20,52-54]. TVT surgery time patients’ pain, discomfort and other symptoms, as well as hospital stay are significantly shorter than laparoscopic Burch surgery [55-60]. Butch procedure has stable efficacy and fewer complications, but is more invasive. 2, bladder neck sling (Sling) procedure Principle: The bladder neck is suspended and anchored from below the bladder neck and proximal urethra in a suprapubic direction and fixed to the anterior rectus abdominis sheath to change the angle of the bladder urethra, fix the bladder neck and proximal urethra, and produce a slight compressive effect on the urethra. The sling material is mainly its own material, but it can also be a homograft, allograft or xenograft and synthetic material. Efficacy: more positive. The mean urinary control rate for the initial procedure is 82% to 85%, and Meta-analysis showed an objective urinary control rate of 83% to 85% and a subjective urinary control rate of 82% o-84% [61]; when used in patients undergoing reoperation, the success rate is 64% to l00%, with a mean cure rate of 86% [1,62]. The rate of urinary control at 10 years of long-term follow-up was not significantly different from that at 1 year [63]. It can be applied to patients with all types of stress urinary incontinence, especially type II and III stress urinary incontinence has better efficacy [63-70]. There are no studies comparing the differences in the efficacy of bladder neck sling procedures with different materials, and there is more literature on self-material slings. Complications: (1) dyspareunia: incidence 2,2%-16%, most patients urinate on their own within 1 week after indwelling urinary catheter and urethral dilatation, and those who still cannot be relieved should undergo sling release, about 1,5%-7% of patients with dyspareunia still persist after the above treatment, requiring long-term own intermittent catheterization [60,71,72]. (2) Overactivity of the detrusor muscle: the incidence is 3% to 23% [61,63,73], and it is not clear whether this is related to potential preoperative detrusor overactivity or to factors such as surgically induced denervation and irritation of the bladder neck. Elevated maximal urethral closure pressure is often found in these patients [74]. (3) Other complications such as bleeding (3%), urinary tract infection (5%), urethral necrosis, urethrovaginal fistula and infectious diseases (e.g. hepatitis, HIV) in allografts [62]. Caution: unlike tension-free midurethral slinging, how to adjust the tightness of the sling on the urethra to obtain urinary control while reducing the occurrence of voiding difficulties is a key aspect of the procedure. Intraoperatively, the patient is instructed to cough when the bladder is fully filled to facilitate the determination of sling tightness [60]. This procedure is more effective but has a higher complication rate [74]. (C) Optional 1. Marshall-Marchetti-Krantz (MMK) procedure sews the bladder base, bladder neck, urethra and anterior vaginal wall on both sides of the urethra to the pubic symphysis periosteum in order to restore the bladder neck and proximal urethra to their normal position, reduce the mobility of the vesicourethra and restore the vesicourethral angle. This procedure can be done openly or laparoscopically [75]. Disadvantages: (i) the efficacy is lower than that of the Burch procedure and mid-urethral sling [34,37,76]; (ii) there are many complications. The overall complication rate is 22% and the incidence of osteomyelitis of the pubic bone can exceed 5% [77,78]. 2, Needle suspension surgery A small incision is made on the pubic bone of the abdominal wall, a fine needle is punctured immediately behind the pubic bone to enter the vagina, and the anterior vaginal wall on the side of the bladder neck is lifted with a suspension wire and suspended and fixed on the rectus abdominis muscle or pubic bone in order to pull the anterior vaginal wall toward the abdominal wall, elevate and fix the bladder neck and proximal urethra, correct the vesicourethral angle, and reduce the mobility of the bladder neck and proximal urethra. There are more surgical approaches, including Pereyra, Stamey, etc. The main advantages are simple operation, less trauma, and good patient tolerance. Disadvantages: ①Long-term efficacy is poor. The efficiency of puncture suspension is 43% to 86% [3], but the long-term outcome is poor, with a subjective success rate of 74% at 1-year follow-up [79]. , the two-and-a-half-year data showed an effective rate of only 17%, and the main causes of incontinence recurrence included urethral overactivity (88%), defective intrinsic urethral sphincter function (ISD, 6%), and overactivity of the detrusor muscle (6%) [80]. The efficacy of puncture suspension is equal to or slightly better than that of anterior vaginal wall repair, but significantly less than that of Burch vaginal wall suspension [45,77]. (ii) Complications are more frequent. a Meta-analysis of randomized or semi-randomized trials performed by Glazener and Cooper showed a perioperative complication rate of 48% [79]. The procedure with suspension fixation on the pubic bone also has a risk of causing osteomyelitis of the pubic bone [81]. (iii) It is not suitable for those with a bulging bladder. This procedure is simple and less invasive, but its short-term and long-term efficacy is poor and complications are more frequent, thus limiting its application [82]. 3, Injection therapy is performed under direct endoscopic view by injecting a filler into the submucosa of the endourethral orifice to narrow and elongate the urethral lumen to increase urethral resistance, lengthen the functional urethral length, and increase the closure of the endourethral orifice for urinary control purposes [83]. Unlike the aforementioned treatments, injection therapy does not produce therapeutic effects by changing the angle and position of the bladder urethra, but mainly by increasing the urethral closure capacity. Commonly used injection materials include silicone granules (Macroplastiqup), polytetrafluoroethylene (TeflonTM) and carbon-coated zirconium beads (Durasphere), while other available injection materials include sodium cod liver oil acid, glutaraldehyde cross-linked bovine collagen (ContigerLTM), autologous fat or cartilage, hyaluronic acid/polyglycolic anhydride and myogenic stem cells. The advantages are low trauma and low incidence of serious complications. Disadvantages: ① The efficacy is limited, with a near-term efficacy of about 30% to 50% and a poor long-term efficacy. Double-blind randomized controlled clinical studies have confirmed that the difference between the efficacy of autologous fat injection and placebo is not significant [84-92]; ② there are certain complications, such as short-term voiding disorders, infection, urinary retention, hematuria, possible allergy to individual materials and migration of particles, with serious complications such as urethrovaginal fistula [83]. Due to poor efficacy, especially in the long term, it can be used selectively in patients with type I and type III stress urinary incontinence with less bladder neck mobility, especially with severe comorbidities who cannot tolerate anesthesia and open surgery. 4. The artificial urethral sphincter places a cuff of the artificial urethral sphincter in the proximal urethra, thereby producing circumferential compression of the urethra. The application in the treatment of female stress urinary incontinence has been reported relatively rarely and is mainly used in patients with type III stress urinary incontinence [93,94]. Patients with significant pelvic fibrosis, such as multiple surgeries, urinary extravasation, and pelvic radiotherapy are not suitable for this procedure. The advantages are the definitive efficacy in type III stress urinary incontinence and the long-term urinary control obtained. The main disadvantages are the high cost and the high rate of complications, which commonly include mechanical failure, infection, urethral erosion, urinary retention, recurrence of incontinence, and the need to remove the artificial urethral sphincter if necessary [95-100]. 5. Anterior vaginal wall repair is the repair of the anterior vaginal wall to enhance the supporting tissues of the bladder base and proximal urethra, to reposition the bladder and urethra, and to reduce their mobility. The main advantages are: (i) simultaneous treatment of pelvic organ prolapse and vaginal reconstruction, which can be an option for patients with stress urinary incontinence with significant vaginal bulge; (ii) lower complication rate, less than 6% overactivity of the detrusor muscle, less hospital stay and bleeding compared to vaginal wall suspension, and no significant distant voiding disorders [2]. Disadvantages: (i) poor long-term outcome, with a near-term urinary control rate of about 60% to 70% [61] and a 5-year effective rate of about 37% [43,77] and a 10-year effective rate of 38% in another central study [101]; (ii) susceptibility to nerve injury, with anatomical and histological studies showing that the autonomic nerve (pelvic nerve) innervating the bladder neck and proximal urethra is close to the subvesical vascular plexus, near the anterolateral vaginal wall 4 and 8 o’clock positions into the urethral sphincter. This procedure may result in denervation of the urethral sphincter due to extensive separation of the anterior vaginal wall [95,102]. V. Management of combined disorders (a) Combined overactive bladder The 2005 ICI guidelines recommend that patients with mixed incontinence should first be treated with appropriate measures such as behavioral bladder therapy, pelvic floor muscle training, and anticholinergic agents to control symptoms of urge incontinence. The OAB guidelines published by the Chinese Medical Association (CUA) in 2006 are basically the same, i.e., the diagnosis of urge incontinence should be managed first, and then stress incontinence should be managed after stabilization. (ii) Combined pelvic organ prolapse The diagnosis and management of pelvic organ prolapse involves urology, gynecology and obstetrics, and anorectology. Uterine prolapse or posterior vaginal wall bulge alone often has no urinary symptoms, whereas stress urinary incontinence may occur with anterior vaginal wall bulge. In severe anterior vaginal wall bulge, dyspareunia can also occur due to the angular deformity of the prolapsed vesicourethra and the urethra that is relatively fixed behind the pubic bone. The recommended management principles are as follows: l. For those who have symptoms of stress urinary incontinence but do not require surgical treatment for pelvic organ prolapse, the stress urinary incontinence part can be treated as stress urinary incontinence and it is recommended to explain to the patient the possibility of further surgical treatment. l. For those who have symptoms of stress urinary incontinence but do not require surgical treatment for pelvic organ prolapse, the stress urinary incontinence part can be treated as stress urinary incontinence. 2.For those who have symptoms of stress incontinence and whose pelvic organ prolapse requires surgical treatment, the cure rate can be 85% to 95% if anti-stress incontinence surgery is performed while repairing pelvic organ prolapse [2,3]. 3, The treatment of those who have no symptoms of urinary incontinence but only pelvic organ prolapse is still controversial. Since pelvic organ prolapse may be combined with occult stress incontinence and symptoms of incontinence after correction of prolapse [4], many authors recommend concurrent anti-incontinence surgery during pelvic reconstruction to prevent the occurrence of postoperative stress incontinence, but there is no consensus on which procedure to adopt to prevent potential stress incontinence [5-7]. (iii) Combined impaired contractility of the detrusor muscle When the urinary flow rate is low (%10 cmH2O) and impaired contractility of the detrusor muscle is considered, if the impairment is mild, the maximum detrusor systolic pressure is >15 cmH2O, there is no significant residual urine volume, and there is usually no significant abdominal pressure in the voiding state, conservative treatment and medication can be used first to deal with stress incontinence, and anti-stress incontinence surgery is considered when it is ineffective, but the family should be informed of the preoperative The possibility of intermittent catheterization. Severe damage to the detrusor muscle, maximum detrusor systolic pressure ≤ 15 cmH2O, or a large amount of residual urine or usually for obvious abdominal pressure urination, should pay attention to the possibility of other urinary incontinence, such patients are not recommended anti-stress incontinence surgery, can try anti-stress incontinence drug treatment, such as the emergence of difficulty in urination should be promptly discontinued. (iv) Combined bladder outlet obstruction BOO should be lifted first, and stress urinary incontinence should be evaluated and managed after stabilization. For patients with frozen urethra and urethral strictures, BOO release and incontinence treatment can be performed at the same time. If the urethra is released, a midurethral suspension is performed at the same time.