An update on slings

PURPOSE OF REVIEW: The aim of this article is to review the year's literature on the treatment of female incontinence with suburethral slings. RECENT FINDINGS: The use of slings to treat female stress urinary incontinence has had resurgence with new surgical techniques. The tension-free vaginal tape created in 1996 was the basis of most of the studies performed over the past year. The device was compared with more traditional surgical techniques as well as new techniques such as the trans-obturator tape. In addition the tension-free vaginal tape was examined in women with pelvic organ prolapse and older in age. The complications of the device are well known and several studies recounted these with an attempt to predict patients who will have success. Modifications to surgical technique are described to improve patient results as well as further analysis of outcomes with post-surgical urodynamic-based studies. SUMMARY: The majority of papers center on the tension-free vaginal tape and comparing other methods of incontinence surgery with the tape's success. With 7-year data, the device has secured its place in the treatment of female stress incontinence. Newer methods are being explored and are now compared with the tension-free vaginal tape's outcomes.     

Present state of female urology

This chapter critically reviews the literature on surgery for stress urinary incontinence (SUI) and pelvic organ prolapse (POP), and medical treatment for overactive bladder in women. The midurethral polypropylene sling was reported to provide a durable option with significant improvement. The tension-free vaginal tape (TVT) procedure is based on a theory of pathophysiology of stress incontinence presented by Petros and Ulmsten. In their "integral theory" impairment of the pubourethral ligament is one of the primary cause of SUI. The transobturator sling was found to be effective in SUI patients with less incidence of perioperative complications and voiding difficulties. Prolapse of the uterus/vaginal apex and posterior vaginal wall may also be found in women with stress incontinence. There are many procedures for the correction of POP. Transvaginal repair of anterior and posterior compartment prolapse with polypropylene mesh has been developed in recent years. It is necessary to assess and compare the current quality of outcomes.     

Symposium 3 "female urology in the future"

Symposium 3 entitled "Female Urology in the Future" is very timely as female urology, a urological subspecialty mainly managing stress urinary incontinence (SUI), pelvic organ prolapse (POP) and overactive bladder (OAB), is now beginning to blossom in Japan. In 1986, the first Japanese female incontinence clinic was opened at the Department of Urology, Nagoya University. In 1999, the tension-free vaginal tape (TVT) procedure using polypropylene mesh tape to support the mid-urethra was introduced into Japan, and it dramatically changed the SUI treatment with less era"). invasiveness and durability ("mesh Recently, a variation of the TVT procedure, transobuturator tape (TOT) procedure, and POP repair using polypropylene mesh such as tension-free vaginal mesh (TVM) procedure, are the focus of concern among Japanese urologists and gynecologists practicing female pelvic floor medicine. The International Continence Society derived a new symptomatic definition of overactive bladder (OAB) in 2002. The Neurogenic Bladder Society in Japan published the OAB guideline aiming at public education and shared care in 2005. Five symposists discuss the advantages and pitfalls of the new mesh procedures for SUI and POP, conservation of the uterus in POP repair, gender specificity of OAB, basic research to develop OAB drugs other than anticholinergics, collaboration between urologists and gynecologists, and pediatric female urology.     

Failures and complications in pelvic floor surgery

Objectives

To review current literature on the failures of different surgical approaches in pelvic floor surgery, in particular the use of alloplastic materials, and to analyze complications related to them.

Methods

A Medline search was performed to retrieve English language literature (from the year 1995 to 2011) on the success rates, failures, and complications profiles of pelvic floor surgery. Search terms used are “pelvic organ prolapse,” “stress urinary incontinence,” “complications,” “vaginal mesh,” “mid-urethral slings,” and “colposuspension.” The review includes surgical techniques for the correction of pelvic organ prolapse and stress urinary incontinence. Failure rates and complications in different studies are compiled and analyzed.

Results

Use of synthetic materials in pelvic organ prolapse surgery has reduced surgical failures but it is associated with an increased risk of complications compared to traditional surgical repairs. Synthetic mid-urethral slings for stress urinary incontinence seem to have good success rates over long term, but they have unique complication profile including denovo development of overactive bladder, voiding dysfunction, sling exposures, dyspareunia, and long-term pain. However, some of these complications seem to be related to wrong surgical indications and improper surgical techniques, although some complications may be directly related to the use of synthetic material itself.

Conclusion

Use of synthetic materials in pelvic floor surgery has definitely reduced surgical failures, but at the same time, it is associated with an increased risk of complications (some of which are unique to synthetic materials) compared to traditional surgical repairs.     

Tension-free vaginal tape bowel perforation

A 73-year-old para 3 white female with posthysterectomy pelvic organ prolapse and stress urinary incontinence underwent pelvic reconstructive surgery and placement of tension-free vaginal tape. On postoperative day 4, she underwent exploratory laparotomy for small bowel obstruction. She was found to have an injury to the small bowel secondary to a through-and-through perforation by tension-free vaginal tape. The entire tape was removed. Partial small bowel resection and primary anastomosis were performed. Her subsequent recovery was uneventful.     

同期手术治疗女性压力性尿失禁与盆腔脏器脱垂的临床研究

目的 探讨同期手术治疗女性压力性尿失禁(SUI)与盆腔脏器脱垂(POP)的适应证及治疗效果.方法 回顾性总结16例同期手术治疗SUI与POP患者的病例资料,其中有SUI症状并伴有中度以上阴道前壁膨出的患者12例,主诉阴道脱出物,检查发现子宫中度以上脱垂伴排尿困难4例,术前经查体、尿动力及膀胱造影检查确诊均存在Ⅱ型SUI.盆底修补手术包括Gynemesh网片、Prolift前片及全片植入,抗尿失禁手术采用TVT或TVT-O术,术中先行盆底修补术.结果 随访6～30个月,全部患者获满意效果,达到完全控尿,同时无排尿困难发生,未发现盆底膨出复发.结论 对合并有症状或中度以上POP的SUI患者,应积极同期处理相应的POP,以免加重POP的程度或排尿困难的发生;对单独发生的POP患者,应警惕隐性SUI的可能,同期行相应的控尿手术可避免术后SUI的发生.     

Incontinence and Prolapse—An Integrated View

There is a complex interaction of factors contributing to the development of urogenital prolapse and stress incontinence. These aetiological factors are exactly the same for prolapse as for urinary stress incontinence. These factors include pregnancy and childbirth, collagen status, weight, and chronic airways disease while anti-incontinence surgery itself can be a cause of prolapse. Our understanding of why some women develop stress incontinence, others develop prolapse without stress incontinence, and some develop both, is incomplete. However, the identical aetiologies of the two conditions suggest that an integrated approach to managing stress incontinence and prolapse may be beneficial. This paper looks at the advantages offered by some combined techniques including paravaginal repair and slings, combined cystocoele repair and slings, combining tension-free vaginal tape (TVT) and prolapse repair, combining vault prolapse repair with repair of stress incontinence, combined mesh sling, and a number of combined laparoscopic approaches. Although a combined approach to treatment should be beneficial, there is still insufficient evidence to assess which combined approach is best, which materials to use, and which patients to select.     

Review of synthetic mesh-related complications in pelvic floor reconstructive surgery

There is significant risk of re-operation after pelvic reconstructive surgery. In an attempt to improve outcome, synthetic materials are increasingly being used to augment pelvic organ prolapse repair despite lack of strong evidence to support their routine use. The use of synthetic mesh to correct apical, anterior and posterior vaginal wall prolapse is not without complications. This review aims to evaluate the long-term complications of synthetic mesh in pelvic reconstructive surgery.     

Synthetic slings: which material, which approach

PURPOSE OF REVIEW: The success in the use of the tension-free midurethral sling procedures (tension-free vaginal tape, suprapubic arch, transobturator tape) has dramatically altered the approach to the surgical management of stress urinary incontinence in women and marked a resurgence in the use of mesh. We will analyze the characteristics of synthetic meshes and explain the rationale for using monofilament materials with larger pore sizes. Thus, the purpose of this review is to introduce the surgeon to a variety of commercially available mesh materials and the characteristics that make mesh suitable for use as sling grafts. RECENT FINDINGS: Type I macroporous mesh materials appear most suitable for transvaginal implantation. Utilization of these materials in a minimally invasive retropubic or transobturator approach, promising early and intermediate follow-up data has been achieved. The outcome of these procedures in women with urethral hypermobility and genuine stress incontinence seems clear. No controlled data, however, exist to define the role of these procedures in difficult cases of stress incontinence. Newer generations of minimally invasive slings may offer treatment alternatives in these difficult cases. SUMMARY: Minimally invasive slings using Type I mesh materials are safe and effective. 'Hybrid' type slings may offer alternatives in difficult cases of stress urinary incontinence.     

Surgical management of pelvic organ prolapse in women: a short version Cochrane review

BACKGROUND: Pelvic organ prolapse may occur in up to 50% of parous women. A variety of urinary, bowel and sexual symptoms may be associated with prolapse. OBJECTIVES: To determine the effects of the many different surgeries in the management of pelvic organ prolapse. SEARCH STRATEGY: We searched the Cochrane Incontinence Group Specialised Trials Register (searched 3 May 2006) and reference lists of relevant articles. We also contacted researchers in the field. SELECTION CRITERIA: Randomised or quasi-randomised controlled trials that included surgical operations for pelvic organ prolapse. DATA COLLECTION AND ANALYSIS: Trials were assessed and data extracted independently by two reviewers. Six investigators were contacted for additional information with five responding. MAIN RESULTS: Twenty two randomised controlled trials were identified evaluating 2368 women.Abdominal sacral colpopexy was better than vaginal sacrospinous colpopexy in terms of a lower rate of recurrent vault prolapse (RR 0.23, 95% CI 0.07 to 0.77) and less dyspareunia (RR 0.39, 95% CI 0.18 to 0.86), but the trend towards a lower re-operation rate for prolapse following abdominal sacrocolpopexy was not statistically significant (RR 0.46, 95% CI 0.19 to 1.11). However, the vaginal sacrospinous colpopexy was quicker and cheaper to perform and women had an earlier return to activities of daily living. The data were too few to evaluate other clinical outcomes and adverse events. The three trials contributing to this comparison were clinically heterogeneous. For the anterior vaginal wall prolapse, standard anterior repair was associated with more recurrent cystoceles than when supplemented by polyglactin mesh inlay (RR 1.39, 95% CI 1.02 to 1.90) or porcine dermis mesh inlay (RR 2.72, 95% CI 1.20 to 6.14), but data on morbidity, other clinical outcomes and for other mesh or graft materials were too few for reliable comparisons. For posterior vaginal wall prolapse, the vaginal approach was associated with a lower rate of recurrent rectocele and/or enterocele than the transanal approach (RR 0.24, 95% CI 0.09 to 0.64), although there was a higher blood loss and postoperative narcotic use. However, data on the effect of surgery on bowel symptoms and the use of polyglactin mesh inlay or porcine small intestine graft inlay on the risk of recurrent rectocele were insufficient for meta-analysis.Meta-analysis on the impact of pelvic organ prolapse surgery on continence issues was limited and inconclusive, although about 10% of women developed new urinary symptoms after surgery. Although the addition of tension-free vaginal tape to endopelvic fascia plication (RR 5.5, 95% CI 1.36 to 22.32) and Burch colposuspension to abdominal sacrocolpopexy (RR 2.13, 95% CI 1.39 to 3.24) were followed by a lower risk of women developing new postoperative stress incontinence, but other outcomes, particularly economic, remain to be evaluated. AUTHORS' CONCLUSIONS: Abdominal sacrocolpopexy is associated with a lower rate of recurrent vault prolapse and dyspareunia than the vaginal sacrospinous colpopexy. These benefits must be balanced against a longer operating time, longer time to return to activities of daily living and increased cost of the abdominal approach. The use of mesh or graft inlays at the time of anterior vaginal wall repair may reduce the risk of recurrent cystocele. Posterior vaginal wall repair may be better than transanal repair in the management of rectoceles in terms of recurrence of prolapse. The addition of a continence procedure to a prolapse repair operation may reduce the incidence of postoperative urinary incontinence but this benefit needs to be balanced against possible differences in costs and adverse effects. Adequately powered randomised controlled clinical trials are urgently needed.     

Surgical intervention for complications of tension-free vaginal tape procedure

PURPOSE: The tension-free vaginal tape procedure has become a state of the art operation for female stress urinary incontinence. Cases of complications requiring surgical revision are reported to be rare. We report on 6 patients with complications necessitating surgery. MATERIALS AND METHODS: Six patients who previously underwent the tension-free vaginal tape procedure required surgical management of complications, including intravesical polypropylene mesh tape with incrustation and chronic urinary tract infection in 2, vaginal mucosal mesh erosion of the vaginal incision in 1 and permanent urinary retention in 3. RESULTS: The intravesical tapes were resected via a suprapubic approach. In the case of disturbed wound healing the periurethral part of the tape was resected transvaginally. A patient in urinary retention underwent resection of the periurethral sling, while in the other 2 the tapes were transected transvaginally. Two patients in whom incontinence recurred were successfully treated with a repeat tension-free vaginal tape procedure during followup. CONCLUSIONS: Complications of the tension-free vaginal tape procedure that require surgical intervention are rare. The surgeon must be aware that this operation may lead to an additional surgical procedure, significantly increasing morbidity.     

Controversies in the management of mesh-based complications: a urology perspective

Since the introduction of the synthetic midurethral sling, several transvaginal mesh delivery systems have been developed for treating stress incontinence and pelvic organ prolapse. Widespread use of these "kits" has introduced a new dilemma of mesh-specific complications that female pelvic surgeons must manage. Differing treatment techniques have been described and controversy exists as to which method is preferred for vaginal mesh extrusion, mesh perforations, pelvic pain, and dyspareunia. This article addresses the differing management strategies for mesh complications after reconstructive surgery and highlights the available literature on the success of each option.     

无张力阴道吊带修复女性压力性尿失禁

目的探讨无张力阴道吊带（tension—free vaginal tape，TVT）术的适应证、手术方法及并发症的预防。方法2003年9月～2004年12月共收治女性压力性尿失禁（stress urinary incontinence，SUI）患者40例，年龄30～73岁，平均56．3岁，病程1～42年，平均7．2年。其中伴膀胱或直肠膨出8例，子宫脱垂1例。均采用TVT术进行修复，对合并子宫脱垂或阴道前／后壁膨出者，一并行阴道前后壁部分剪除蝶形补片。结果40例患者术后均获满意效果，术后合并短时轻度排尿困难2例，膀胱穿孔及盆腔血肿各1例，经处理后均痊愈。患者均获随访1～15个月，无尿失禁复发及排尿困难。结论TVT术是一种治疗SUI的有效方法。     

Tension-free vaginal mesh repair for anterior vaginal wall prolapse

OBJECTIVES: We determined the efficacy of the use of a tension free prolene mesh to correct a grade III anterior vaginal wall prolapse recurrence. METHODS: Twelve women (mean age 65.6 years) with stress urinary incontinence (SUI) (4 type II and 1 type III) and bladder prolapse entered the study. After vaginal incision a pretailored polypropylene mesh was fixed to its four angles by absorbable sutures to the urethropelvic ligaments and pubocervical fascia anteriorly and to the cardinal ligaments and pubocervical fascia posteriorly. When present, a posterior descensus was corrected during the same procedure. SUI was treated with the tension-free vaginal tape procedure (TVT) through a separate vaginal incision over the mid-urethra. RESULTS: All patients were available for postoperative pelvic examination at 3-month intervals, for a mean follow-up of 20.5 months (range 15-32). Nine patients were considered cured (no cystocele recurrence) while in 3 patients a grade 1 asymptomatic cystocele was present postoperatively (asymptomatic). No significant postoperative pain was reported by the patients. CONCLUSIONS: This study confirms that in patients with moderate cystocele a tension-free mesh to support bladder base and neck effectively treats the cystocele. It is particularly recommended in the treatment of previous failure with traditional techniques and when the quality of suspending tissue is poor or defective. A long-term study on a large number of patients is still warranted to confirm and validate its clinical use.     

Tension-free vaginal tape and associated procedures: a case control study

OBJECTIVES: We compare objective and subjective cure rates after tension-free vaginal tape procedures performed alone or in conjunction with vaginal procedures. METHODS: One hundred eighty-six women underwent a tension-free vaginal tape procedure for stress or mixed urinary incontinence. One hundred women treated with tension-free vaginal tape alone (group 1) were compared with 40 women treated with tension-free vaginal tape and concomitant vaginal hysterectomy (group 2), and 46 patients treated with tension-free vaginal tape and pelvic floor reconstruction (group 3). Patient outcomes, surgical difficulties and complications are reported. Postoperative voiding diaries, standing stress-test results, and patient satisfaction were compared. RESULTS: There were no significant differences among the three groups in terms of age, menopausal status, BMI, previous incontinence surgery, or the type and degree of incontinence. Parity was significantly higher in the group treated with tension-free vaginal tape and pelvic floor reconstruction ( p=0.04 ). The overall perioperative complication rate was 15.6%. Women treated with tension-free vaginal tape and hysterectomy (group 2), and those treated with tension-free vaginal tape and pelvic floor reconstruction (group 3) had a significantly higher incidence of bladder injury (17.9% and 13%, respectively, versus 5% in group 1; p=0.05 ). Estimated blood loss and the frequencies of postoperative urgency and voiding disorders did differ significantly between women treated with tension-free vaginal tape alone and those who underwent associated procedures. The mean follow-up time was 24.5+/-2.6 months. No difference in the objective cure rate was found between the tension-free vaginal tape group and the other two groups (93% versus 97.5% and 91.1%; p=0.3 ). No difference in the subjective cure rate was found between the tension-free vaginal tape group and the groups undergoing associated procedures (72% versus 72.5% and 68.8%; p=0.4). CONCLUSION: Pelvic floor defects, benign uterine disorders and stress urinary incontinence can be safely treated with tension-free vaginal tape and vaginal procedures during the same surgical procedure.     

The contemporary role of Burch colposuspension

PURPOSE OF REVIEW: The purpose of this review was to define the current role of Burch colposuspension for treatment of female stress urinary incontinence. Publications from 2004 were reviewed. RECENT FINDINGS: The open Burch colposuspension is reviewed with highlights on its efficacy, mechanism of continence, recent reports on intraoperative ultrasound, postoperative catheterization, coital incontinence, and the effect of concomitant procedures. Long-term efficacy has remained at approximately 70%. Less invasive Burch approaches are evaluated including the laparoscopic techniques and the mini-incisional Burch colposuspension. The laparoscopic Burch approach is satisfactory if sutures rather than mesh are used. Three well designed, prospective, randomized trials comparing the Burch (one open and two laparoscopic) colposuspension with tension-free vaginal tape are discussed. SUMMARY: The open Burch procedure with its long-term success rates remains a gold standard for surgical treatment of genuine stress urinary incontinence. Less invasive Burch procedures require longer term follow-up studies with comparison to the open approach and tension-free vaginal tape before its role can be settled. At this point, tension-free vaginal tape appears to be at least equivalent to the Burch colposuspension and, with longer follow-up studies, may challenge its role as a gold standard surgical treatment for female stress incontinence.     

A prospective trial comparing tension-free vaginal tape and transobturator vaginal tape inside-out for the surgical treatment of female stress urinary incontinence: 1-year followup

PURPOSE: We prospectively compared the efficacy and safety of tension-free vaginal tape and transobturator vaginal tape inside-out for female stress urinary incontinence. MATERIALS AND METHODS: A total of 120 women with stress urinary incontinence were alternately assigned to the tension-free vaginal tape group (60) or the transobturator vaginal tape inside-out group (60). Preoperative evaluation included urodynamic study and a Korean version of the incontinence quality of life questionnaire. One year after operation the surgical result, patient satisfaction, incontinence quality of life questionnaire, long-term complications and uroflowmetry were evaluated in the 2 groups. RESULTS: Patient characteristics were comparable in the 2 groups. Mean +/- SD operative time was significantly shorter in the transobturator vaginal tape inside-out vs the tension-free vaginal tape group (11 +/- 1.4 vs 15 +/- 1.8 minutes). In the transobturator vaginal tape inside-out and the tension-free vaginal tape groups the rates of cure (86.8% and 86.8%), improvement (6.6% and 8.2%) and failure (6.6% and 5.0%, respectively) were similar. Incontinence quality of life questionnaire parameters 1 year after surgery were improved significantly in each group and there was no difference between the 2 groups (p <0.001 and >0.05, respectively). There was no long-term complication in either group. Preoperative urge incontinence resolved in 80% of the tension-free vaginal tape group and in 100% of the transobturator vaginal tape inside-out group. De novo urgency developed in 4 patients (6.6%) in the transobturator vaginal tape inside-out group. CONCLUSIONS: The tension-free vaginal tape and transobturator vaginal tape inside-out procedures were minimally invasive and similar in operation related morbidity. Transobturator vaginal tape inside-out appeared to be as effective and safe as tension-free vaginal tape for the surgical treatment of stress urinary incontinence in women at 1-year followup.     

Do we need meshes in pelvic floor reconstruction?

Objectives

Transvaginally placed mesh in pelvic reconstructive surgery for women with pelvic organ prolapse has gained popularity because of excellent anatomical outcomes, but postoperative mesh-related complications have lead to a number of cautious reviews and warnings. This review focuses on functional outcomes after synthetic transvaginal mesh placement.

Methods

MEDLINE database was searched from 2010 to August 2011 for original articles on transvaginal mesh surgery for pelvic organ prolapse not included in recent reviews. The following search terms were used: pelvic organ prolapse, genital prolapse, cystocele, rectocele and mesh, synthetic graft, and repair. Studies were assessed and appropriate data extracted and tabularized. Studies were excluded if the follow-up time was less than 12?months and if studies did not contain original data or data on subjective outcome.

Results

Eleven studies irregularly reported functional outcomes. After trocar-guided transobturator vaginal mesh surgery, symptomatic recurrence of pelvic organ prolapse was reported between 7 and 33%. If analyzed cumulatively, 76 of 370 patients (21%) complained of prolapse symptoms postoperatively. De novo stress urinary incontinence occurred in 12–17% and persisted in up to 68% after trocar-guided mesh surgery. De novo dyspareunia was present between 2 and 15%, worsened or de novo dyspareunia between 25 and 44%. Deteriorating coital incontinence was described in 6 of 16 women after anterior Prolift in one trial.

Conclusions

When counseling women for pelvic reconstructive surgery, we should provide them with evidence-based information on functional outcomes and subsequently take the patient’s concerns and preferences into account. Pelvic floor symptoms were scarcely reported in reviewed trials, but demonstrated a worse scenario than anatomical outcomes.     

Concomitant pelvic organ prolapse surgery with TVT procedure

The aim of this study is to evaluate the efficacy and feasibility of concomitant pelvic reconstructive surgery with tension-free vaginal tape (TVT) procedure to treat pelvic organ prolapse women with urodynamic stress incontinence (USI) or occult USI. Seventy-five women with pelvic organ prolapse and diagnosed as USI or occult USI were enrolled in this study. All patients with USI or occult USI underwent TVT treatment under general anesthesia, combined with transvaginal total hysterectomy (VTH), anterior–posterior colporrhaphy (APC), and/or right sacrospinous ligament suspension (SSS) reconstructive surgeries. The subjective assessment was evaluated by using a visual analog scale (VAS) score and a urinary symptomatic questionnaire. The objective assessment was carried out with a 1-h pad test, cough stress test, and urodynamic examination. Of the 75 patients, 35 patients with grade III uterine prolapse underwent VTH and APC, 30 patients with grade IV uterine prolapse underwent VTH, SSS, and APC, and the other 10 patients who had previous hysterectomy with total vaginal vault prolapse underwent SSS and APC. The mean follow-up interval was 25 months (12–42 months). The mean hospitalization was 5.9 days and the mean catheterization time was 3.8 days. The subjective success rate for the treatment of urine incontinence was 88%, and the objective complete cure rate was 84%. The rate of postoperative complications with persistent urinary urgency, de novo detrusor overactivity, dysfunctional voiding, and tape erosion were 50, 8, 12, and 1.3%, respectively. There were no bladder perforations during the TVT procedure and no perioperative complications requiring conversion to laparotomy. Pelvic organ prolapse women with USI or occult USI can be treated by reconstructive surgeries combined with a TVT procedure to treat and prevent postoperative USI.     

Pelvic Floor Dysfunction Management Practice Patterns: A Survey of Members of the International Urogynecological Association

The authors report results of a survey of the practice patterns of International Urogynecological Association (IUGA) members in the management of urinary incontinence and pelvic organ prolapse. A questionnaire regarding current urogynecological clinical practice was developed by the Research and Development Committee of IUGA and mailed to all members of IUGA. Age, specialty, and geographic location factors were used for response comparisons. One hundred and fifty-two surveys (30%) were returned, 35% from North America, 51% from Europe/Australia/New Zealand, and 14% from elsewhere. The average age of respondents was 47.2 years (SD = 9.5), 89% were gynecologists and 11% were urologists. Overall, the procedures of choice for stress incontinence (SUI) were tension-free vaginal tape (TVT; 48.8%) and Burch colposuspension (44%). There were significant geographic variations noted. For SUI with low-pressure urethra/intrinsic sphincteric deficiency, TVT was used by 44.6% and suburethral sling by 32.3%. Various materials are used for suburethral slings, including autologous fascia (46.5%), Marlex mesh (27.8%) and cadaveric fascia lata (11.6%). Bulking agent injection therapy is used for ISD by 75% of respondents. Traditional reconstructive procedures are performed by the majority of respondents, including sacrospinous fixation (78%), abdominal sacrocolpopexy (77%), paravaginal repair (65%) and vaginal enterocele repair (93%); 6.5% use defecography in evaluating rectoceles and 44% use the POP-Q. Seventy-two per cent use urodynamic evaluation routinely in prolapse cases with no manifest SUI. Most IUGA members perform commonly accepted procedures for surgical therapy of urinary incontinence and genital prolapse. IUGA members do not frequently use anorectal physiology and fluoroscopic investigations to evaluate rectoceles prior to repair.