Obstetrics & Gynaecology Forum Volume 29 | Issue 3 | 2019

O&G Forum 2019; 29: 7 - 10 REVIEW term data on efficacy and relative safety is lacking. 17 2.3. Needle Suspension procedures: Data shows that needle suspension procedures such as the Raz and Stamey procedures are not as effective as traditional colposuspen- sion procedures, with an equivalent efficacy to anterior repairs (also no longer used to treat stress urinary incontinence). 11 2.4. Sling procedures: Traditional/Pubovaginal slings AFS (autologous fascial sling) is the most widely evaluated bio- logical sling and is an effective and durable treatment for SUI. Pubovaginal slings are slings placed at the bladder neck. Mesh has been previously used for these slings but generally fascia harvested from rectus or thigh is preferred. 18 The autologous fascial sling is the most extensively researched biologic sling and has found to be an efficacious and enduring modality for the treatment of SUI. 10 Pubovaginal slings are versatile and can be used for primary SUI in the context of ISD, a hypermobile urethra, or in patients who are not candidates for mesh. They can also be used in recurrent SUI as a salvage procedure, for example in the case of a failed mid urethral sling. They are useful as an adjunct procedure during urethral and/ or bladder reconstruction. 18 Mid-urethral slings The advent of the retropubic sling in the 1990’s revolutionised the treatment of SUI. Mid-urethral slings have since then become the gold standard for stress urinary incontinence surgery, and they form the bulk of anti-incontinence surgery world-wide. 19 The retropubic or transvaginal tape (TVT): The transvaginal or retropubic sling was designed by Ulmsten and introduced in 1996. Since then, it has shown good efficacy in the short and long term, including in patients with previous failed incontinence surgery, intrinsic sphincter deficiency, and mixed incontinence. 19 The TVT is associated with a slightly increased probability of visceral and neurovascular injury, although the overall risk of peri-operative complications is decreased with appropriate training and standard- isation of method. 19 The transobturator tape (TOT) was developed in an attempt to avoid the aforementioned complications of the TVT. Multiple studies have shown that the TOT and TVT have similar efficacy and safety on terms of SUI treatment. The increased risk of bladder injury associated with TVT must be balanced against the elevated risk of inguinal pain related to the insertion of the TOT. 19 Figure 3. An example of a transobturator mid-urethral sling. Reproduced with the permission of Coloplast South Africa. Single incision slings Developed in an attempt to decrease the morbidity associated with mid-urethral slings, and allow an in-office incontinence procedure, single incision/mini slings have been available on the market since 2006. Trials reviewing the single incision slings are confounded by the fact that they review dissimilar slings in terms of make, several of which are no longer in production. Studies conclude that mini- slings are non-inferior to standard MUS in the short to midterm, with similar adverse effects apart from less pain, particularly in the short term. 11 Figure 4. The Altis single incision sling. Reproduced with the permission of Coloplast South Africa. 2.5. Bulking Agents: The mechanism of action of bulking agents is improved coaptation of the urethral sphincter thus increasing resistance to increased abdominal pressure. They are minimally invasive, can be used in fully anti-coagulated patients, can be performed in-office under local anaesthetic, and will not hinder the performance of subse- quent procedures. These advantages should be balanced by the risk of failure, extrusion, and the need for repeat injections. 20 Figure 5. Bulking agents are injected into the submucosal tissues of the proximal urethra by three to four opposing deposits until urethral coaptation is achieved. Reproduced with permission from Contura. ere is a lack of good quality evidence to aid the clinician in selec- tion the correct patients for bulking agents but one might consider bulk- ing agents in patients with stress urinary incontinence with a normal post-void residual who prefer to avoid mesh, or are fragile, with previous failed treatments, or previous pelvic radiotherapy. 20 Currently in South Africa we have two available types of urethral bulking agents: Urolastic (available for academic trial centres) and Bulk- amid. Clinical data pertaining to bulking agents is scanty and heteroge- nous. Comparative studies between the di erent agents are not available, and a 2017 Cochrane review found that there is insu cient evidence to OBSTETRICS & GYNAECOLOGY FORUM 2019 | ISSUE 3 | 9