Comparing risk of repeat surgery for stress urinary incontinence after mid-urethral slings and polyacrylamide hydrogel.

INTRODUCTION: Over the last two decades synthetic mid-urethral slings (MUS) have become established as the main surgical method for correcting stress urinary incontinence (SUI). However, transurethral injections with polyacrylamide hydrogel are gaining popularity. We used surgical codes from a national registry to explore potential differences in risk of later surgery for SUI comparing retropubic slings, obturator slings, and polyacrylamide hydrogel injections. MATERIAL AND METHODS: This cohort study used surgical codes from The Norwegian Patient Registry. All women recorded as having had surgery for SUI coded as retropubic sling, obturator sling, or polyacrylamide hydrogel injection from 2008 until end-of-study censoring in 2017, were included. Main outcome was time to any recorded new SUI procedure later in the study period. Unadjusted comparison between groups was done using Kaplan-Meier. A Cox regression analysis was then performed to adjust for hospital unit size and patient age at surgery. RESULTS: The unadjusted analyses showed significant differences between the chosen index method and the risk of later SUI surgery favoring retropubic slings (p < 0.01). The proportions of patients without any recorded new SUI procedure at 1 and 5 years were 99.3% and 97.7% for retropubic MUS, 98.7% and 96.1% for obturator MUS, and 82.7% and 72.4% for polyacrylamide hydrogel injections. The majority of women having a repeat procedure for SUI after a polyacrylamide hydrogel injection underwent repeat treatment within 1 year (63%). After adjusting for age at time of surgery and hospital size, obturator slings (hazard ratio 1.8, 95% CI 1.4-2.4) and polyacrylamide hydrogel (hazard ratio 23.1, 95% CI 17.6-30.3) remained associated with a higher risk of later incontinence surgery. CONCLUSIONS: Both retropubic and obturator slings have low long-term risks of repeat incontinence surgery compared with polyacrylamide hydrogel injections. Retropubic slings were found to have superior longevity of the surgical result.

Previous obstetrical history does not impact short-term mid-urethral sling outcomes.

INTRODUCTION AND HYPOTHESIS: Pregnancy and delivery are known risk factors for stress and mixed urinary incontinence. The most common surgical treatment is mid-urethral sling (MUS) surgery. This study evaluated the potential impact of the obstetrical history on the short-term subjective and objective failure rates after MUS surgery. METHODS: A registry-based surgical cohort study using data from the Medical Birth Registry of Norway (MBRN) and the national Norwegian Female Incontinence Registry (NFIR). Data from 14,787 women that underwent MUS surgery from 1998 to 2016 with complete registrations in the MBRN were included. Outcomes were 6-12-month postoperative subjective and objective failure rates. The potential impact of obstetrical and constitutional factors on both outcomes was tested in a multivariate logistic regression model. RESULTS: Several obstetrical variables seemed to impact both outcomes in the univariate analyses. However, in the multivariate analyses, none of the obstetrical variables significantly impacted subjective failure, and only being nulliparous before MUS surgery remained a risk factor for objective failure [aOR 1.60, (95% CI 1.07-2.40), p = 0.022]. High body mass index at time of surgery, non-retropubic slings, high preoperative urgency symptom load, and surgical complications were all strong risk factors for poor outcomes in the multivariate analyses. CONCLUSION: Although childbirth is considered a risk factor for developing stress urinary incontinence, childbirth does not appear to affect the result of MUS in parous women. Our results suggest that nulliparous women with SUI may have a different pathophysiology than SUI after childbirth.

Is antibiotic prophylaxis necessary in mid-urethral sling surgery?

INTRODUCTION AND HYPOTHESIS: Antibiotic prophylaxis is commonly used when implanting a mid-urethral sling (MUS) for female stress urinary incontinence. Use of antibiotics may lead to adverse events and the development of antibiotic resistance. This study compared a variety of outcomes after MUS surgery with and without antibiotic prophylaxis using data from the national Norwegian Female Incontinence Registry. METHODS: Preoperative and 6-12 months postoperative subjective and objective data from 28,687 patients who received MUS surgery from 1998 through 2017 were extracted from the registry. Categorical outcomes were compared between women with or without antibiotic prophylaxis using chi-square test for independence. Primary outcome was incidence of postoperative surgical site infection (SSI). Secondary outcomes were incidence of tape exposure, de novo or persistent urgency urinary incontinence, postoperative pain > 3 months, subjective and objective cure rates, and patient satisfaction. RESULTS: Antibiotic prophylaxis was used in 9131 and not used in 19,556 patients. SSIs and prolonged postoperative pain occurred significantly more often without antibiotic prophylaxis. Subjective and objective cure rates were significantly higher and tape exposures significantly lower in women not receiving prophylactic antibiotics. There were no significant differences in other outcomes. CONCLUSIONS: Antibiotic prophylaxis resulted in fewer women developing postoperative infections or prolonged postoperative pain after MUS surgery, but did not offer protection against tape exposure. The differences in cure rates were small and probably without clinical relevance. If a small increase in surgical site infections is accepted, the routine use of antibiotic prophylaxis can probably be omitted.

The completeness and accuracy of the Norwegian Female Incontinence Registry.

INTRODUCTION: Medical quality registries have gained popularity as tools for monitoring the quality of medical treatments and they serve as data sources for research. The Norwegian Female Incontinence Registry (NFIR) was established in 1998 to monitor and improve the quality of surgery for women with stress and mixed urinary incontinence in Norway and to collect data for research. This study aimed to assess the completeness and accuracy of the Norwegian Female Incontinence Registry, and potential differences in data accuracy over time and according to surgical volume of the reporting hospitals. MATERIAL AND METHODS: A random selection of 300 women from a total of 20 610 operated for urinary incontinence between 1998 and 2016 reported to the Norwegian Female Incontinence Registry from 28 public hospitals were selected for validation. The database completeness was estimated for 2008-2017 by comparing surgical procedures registered both in the Norwegian Female Incontinence Registry and the Norwegian National Patient Registry. Historical data recorded in the Registry for 10 selected key variables were extracted and compared with the patients' individual medical records at the reporting hospitals as reference. The reviewers were blinded to the previously stored information. The intraclass correlation coefficient for continuous variables and Cohen's kappa for categorical variables were calculated. RESULTS: Primary source data on 285 of the 300 women selected from Norwegian Female Incontinence Registry were successfully retrieved. The completeness of the registry has increased from 61% in 2008 to 99% in 2017. The national coverage has increased from 12 reporting departments in 1998 to all 38 public departments performing female incontinence surgery in 2017. Excellent accuracy was found for both continuous variables (intraclass correlation coefficient >0.94) and categorical variables (Cohen's kappa >0.86). No differences in data accuracy were found comparing high-volume hospitals with low-volume hospitals, or when comparing data accuracy over time. CONCLUSIONS: The Norwegian Female Incontinence Registry is a reliable tool for quality assessment of incontinence surgery and research. The registry completeness has improved over time and now contains data on nearly all women undergoing incontinence surgery in Norway.

Childbirth after mid-urethral sling surgery: effects on long-term success and complications.

INTRODUCTION AND HYPOTHESIS: To evaluate long-term outcomes in women with one or more childbirths after mid-urethral sling (MUS) surgery and potential differences in outcomes based on mode of delivery. METHODS: A population-based cohort study using data from two national registries. Women registered with childbirth after MUS (case group) or without childbirth after MUS (control group), with equal follow-up time, underwent a structured telephone interview using a validated short-form urinary disease-specific questionnaire. Primary outcomes were current stress urinary incontinence (SUI) rate and change in cure rate. Secondary outcomes were effect of delivery mode, rates of repeat operations for SUI, complications, treatment satisfaction and urgency urinary incontinence rate. Childbirth as an independent risk factor for SUI recurrence was also evaluated. RESULTS: Seventy-two women with and 156 women without childbirth after MUS were included. Median follow-up time was 10 years for both groups. Subjective SUI cure rates were 82% (cases) and 75% (controls), respectively (p = 0.31). A significantly lower SUI cure rate was seen in the women with more than one childbirth after MUS (50% vs. 88% p = 0.006). No differences in primary or secondary outcomes were found between groups at follow-up, nor did mode of delivery affect outcomes. Childbirth after MUS was not an independent risk factor for subjective SUI recurrence (OR 0.8 CI 0.3-1.7). CONCLUSIONS: No differences in outcomes were seen between groups at follow-up independently of delivery mode. However, having more than one delivery after MUS seems to impact the continence status.

Comparison of retropubic midurethral slings in the treatment of female stress urinary incontinence.

INTRODUCTION AND HYPOTHESIS: Over 50 different types of midurethral slings have been marketed. They have generally been considered comparable in performance. Many studies have compared retropubic with obturator slings, but few have compared different makes of retropubic slings with each other. We have compared the performance of retropubic slings using data from the Norwegian Female Incontinence Registry. METHODS: From June 2015 through 2017, 2843 women underwent a retropubic sling procedure, with 6-12-month follow-up data available for 2612 (92%). Results for six different types of slings used in this time period are presented: TVT Exact, TVT Classic, Advantage, Advantage Fit, TVT A.M.I. and RetroArc. The TVT Exact was the most prevalent sling, and the outcomes were compared with this sling as reference using chi-square and Dunnet's tests with significance at 0.05. RESULTS: There were only small differences among the four slings, TVT Exact, TVT Classic, Advantage and Advantage Fit, with subjective cure rates from 77.7 to 81.9% and objective cure rates from 90.8 to 96.6%. The TVT A.M.I. sling had a high cure rate but significantly fewer satisfied patients and less improvement in urgency bother. The Retro Arc's results were clearly inferior. There was little difference in terms of obstruction or de novo urgency incontinence among the six slings. Most complication rates were not statistically different. CONCLUSIONS: At 6-12-month follow-up there was no significant difference in clinical results between the TVT Exact, TVT Classic, Advantage and Advantage Fit slings, while RetroArc and to some extent TVT A.M.I. slings underperformed.

Mid-urethral slings in young, middle-aged, and older women.

AIMS: To compare subjective and objective outcomes of mid-urethral sling (MUS) surgery in women in different age decades and the utilization rates for MUS in Norwegian women. METHODS: Data from the national Norwegian Female Incontinence Registry on 21 832 women with stress or mixed urinary incontinence who underwent MUS surgery from 1998 to 2016 were used. Primary outcomes were treatment satisfaction and absence of objective stress leakage at 6-12 months follow-up and "MUS utilization rate." Secondary outcomes were increase in urgency incontinence symptoms and surgical complications. RESULTS: Women in the sixth decade and older had more objective postoperative stress urinary leakage, and women in the seventh decade and older were less satisfied. Urgency incontinence symptoms (persistent and de novo) after MUS increased with age. Intermittent catheterization occurred significantly more often in the seventh decade and bladder perforation in the seventh and eighth decades. Women younger than the fifth decade had fewer complications, except the need for tape transection in the fourth decade. The "MUS utilization rate" increased in all age groups during the study period, but declined slightly in the oldest age group after 2010. CONCLUSION: All age groups had a high percentage of "very satisfied" and no objective stress leakage at 6-12 months follow-up, but declining slightly with age after the sixth decade. Urgency incontinence symptom bother increased with age, but the overall complication rates were low. Our study strengthens the argument that management of stress urinary incontinence with MUS seems suitable regardless of age.

Outcome of TVT operations in women with low maximum urethral closure pressure.

AIMS: (i) To establish whether low maximal urethral closure pressure (MUCP) is associated with a poorer prognosis after TVT-surgery, and if so to establish an MUCP cut-off value for poor outcome. (ii) To characterize the population with a low MUCP. METHODS: Retrospective analysis of data from 6,646 women with stress/mixed urinary incontinence included in the Norwegian Female Incontinence Registry. Postoperative subjective (degree of satisfaction), objective (leakage on stress test) and composite cure according to preoperative MUCP were analyzed in unadjusted and adjusted analysis. Preoperative variables were compared between women having a low or normal MUCP. Non-parametric tests were used on continuous variables and χ2 tests on categorical variables. Logistic regression was used for the adjusted analysis. Level of significance: P < 0.05. RESULTS: An analysis of centiles of preoperative MUCP showed that a cut-off at 20 cm H2 O did best identify women at risk of not being cured. In unadjusted analysis MUCP ≤20 cm H2 O (n = 422) was associated with objective (OR: 2.48), subjective (OR: 1.60), and composite failure (OR: 1.95) compared to MUCP >20 cm H2 O. In adjusted analysis MUCP ≤20 cm H2 O was associated with neither objective, subjective, nor composite failure. Women with MUCP <20 cm H2 O were preoperatively significantly older, had larger leakage on stress and 24 h pad test, lower mean voided volume and maximum flow rate and higher stress and urge indices. CONCLUSIONS: Women with MUCP ≤20 cm H2 O have similar objective, subjective, and composite outcomes after TVT-surgery compared to women with MUCP >20 cm H2 O after adjusting for preoperative variables. Neurourol. Urodynam. 36:1320-1324, 2017. © 2016 Wiley Periodicals, Inc.

Sling mobilization in the management of urinary retention after mid-urethral sling surgery.

OBJECTIVE: To compare intermittent catheterization, sling mobilization, and sling transection for treatment of urinary retention after mid-urethral sling surgery. METHODS: Data registered in the Norwegian Female Incontinence Registry from 1998 to 2013 were analyzed in this cohort study to compare subjective and objective outcomes after intermittent catheterization, sling mobilization, and sling transection as management of postoperative urinary retention after mid urethral sling surgery. Subjective outcomes were degree of symptom bother and the percentage of women stating "very satisfied" at the postoperative follow-up. The objective outcome was leakage at a cough-jump pad stress test. RESULTS: Intervention due to urinary retention was performed in 585 of 18,772 women (3.1%). Women who had their sling mobilized or had intermittent catheterization, scored better on all postoperative outcomes than those who had their sling transected (P < 0.001). Sling transection was more often needed after intermittent catheterization than after mobilization (P = 0.023). No outcome differences were found between intermittent catheterization only and sling mobilization only. Intention to treat analysis showed that women who underwent sling mobilization as the primary procedure significantly more often had a negative stress test (P = 0.033) and were more often "very satisfied" with the treatment (P = 0.006) than those who were primarily catheterized. CONCLUSIONS: Sling mobilization is a more successful treatment than intermittent catheterization or transection for urinary retention after mid-urethral sling surgery. CLINICAL TRIAL REGISTRATION: Clinical trial registration was not applicable because this study is based on an analysis of anonymous data from The Norwegian Female Incontinence Registry. Neurourol. Urodynam. 36:1091-1096, 2017. © 2016 Wiley Periodicals, Inc.

Risk factors for long-term failure of the retropubic tension-free vaginal tape procedure.

AIMS: To investigate potential risk factors for long-term (10-year) subjective and objective failure of the retropubic tension-free vaginal tape procedure (TVT). METHODS: Secondary risk analysis was performed using data from a recently published multi-center study that were merged with additional preoperative and operative data individually stored in the Norwegian Female Incontinence Registry (NFIR). Subjective data from 483 women and objective data from 327 women were obtained 10 years after retropubic TVT surgery. A validated questionnaire was used for subjective outcome data and a stress test for objective outcome data. Uni- and multivariate logistic regression analyses were performed using preoperative and operative variables extracted from the NFIR. The outcomes were 10-year subjective failure defined as women stating not cured, and objective failure was defined as ≥1 g urinary leakage during stress testing. RESULTS: Age ≥56 years at the time of TVT surgery was associated with both long-term subjective failure (adjusted OR: 2.15, CI: 1.40-3.30) and long-term objective failure (adjusted OR: 2.81, CI: 1.30-6.09). Mixed incontinence was associated with subjective, but not objective failure if the urgency incontinence component was severe (adjusted OR: 2.33, CI: 1.27-4.28). Surgical complications occurring at or immediately following surgery were associated with both outcomes in the univariate analyses, but were only an independent risk factor for subjective failure in the multivariate analysis (adjusted OR: 3.02, CI: 1.53-5.95). CONCLUSIONS: Age ≥56 years, a severe preoperative urgency incontinence component and surgical complications seem to represent independent risk factors for long-term (10-year) failure.

Pad stress tests with increasing load for the diagnosis of stress urinary incontinence.

AIM: The aim of the study was to test the ability of pad stress tests with increasing load (supine, jumping on the floor, and jumping on a trampoline) to document stress incontinence in subjectively stress incontinent women. METHODS: In this prospective study 147 subjectively stress and mixed incontinent women performed consecutively the three pad stress tests with a bladder volume of 300 ml. Nineteen women performed a second trampoline pad stress test to test repeatability of the test. Nine continent women performed a trampoline pad stress test in order to determine if subjectively continent women would leak during the test. RESULTS: Seventy-two women (49%) leaked during the supine, 136 (93%) leaked during the jumping, and 146 (99%) leaked during the trampoline pad stress test. The differences between pad stress tests were significant with P < 0.005. Correlation between the two trampoline pad stress tests was high at 0.8. None of the nine continent women leaked during the trampoline pad stress test. CONCLUSION: The supine pad stress test has low sensitivity and is therefore often falsely negative. The jumping pad stress test is a simple test to perform and is satisfactory for everyday use. Subjectively stress incontinent women who do not leak during the jumping pad stress test may perform a trampoline pad stress test to document stress incontinence. The trampoline pad stress test is also simple to perform and detected leakage in 91% of the women who did not leak during the jumping pad stress test.

How often does detrusor overactivity cause urinary leakage during a stress test in women with mixed urinary incontinence?

INTRODUCTION AND HYPOTHESIS: The study examined how often detrusor overactivity (DO) causes leakage during a stress test in women with mixed urinary incontinence (MUI) and whether there are differences between those who do and those who do not have DO during the stress test. METHODS: A retrospective study was performed in 100 women who had an ambulatory urodynamic recording done where bladder, urethral, and vaginal pressures, and leakage were recorded. The stress test consisted of 20 jumping jacks and three forceful coughs. RESULTS: All the women leaked during the stress test: five due to simultaneous stress test and DO, 87 due to the stress test only, and eight during the stress test as well as due to DO before or after the stress test. CONCLUSIONS: During the stress test, 5 % of women with MUI leaked due to the coughs and jumps and simultaneous DO. Women in whom DO was detected had significantly higher Urgency Incontinence Index and leakage during the 24-h pad test.

Long-term follow-up of the retropubic tension-free vaginal tape procedure.

INTRODUCTION AND HYPOTHESIS: Retropubic tension-free vaginal tape (TVT) was introduced in 1996 as a new and innovative surgical approach in the treatment of stress urinary incontinence (SUI). In this study we evaluate the long-term objective and subjective outcomes in a non-selected patient population 10 years after the retropubic TVT procedure. METHODS: All women (603) operated on with retropubic TVT at four gynecological departments from September 1998 through December 2000 were identified, and those still alive (542) were invited to participate in this population-based prospective study. For subjective data a short-form urinary incontinence disease-specific questionnaire was used. For objective evaluation the women underwent a stress test. Data collected were merged with previously stored data in the Norwegian National Incontinence Registry Database. RESULTS: We included 483 women; 327 attended a clinical follow-up consultation and 156 had a telephone interview. Median duration of follow-up was 129 months. Objective cure rate was 89.9 %, subjective cure rate was 76.1 %, and 82.6 % of the patients stated they were "very satisfied" with their surgery (treatment satisfaction rate). Only 2.3 % of the women had undergone repeat SUI surgery. Subjective voiding difficulties were reported by 22.8 %, the majority describing slow stream or intermittency. De novo urgency incontinence increased significantly from 4.1 % 6-12 months after surgery to 14.9 % at the 10-year follow-up. CONCLUSIONS: Long-term objective and subjective outcome after retropubic TVT is excellent with a low number of re-operations even in a non-selected cohort of patients.

TVT compared with TVT-O and TOT: results from the Norwegian National Incontinence Registry.

INTRODUCTION AND HYPOTHESIS: The aim of this study is to compare the outcome and complication rates of the tension-free vaginal tape (TVT) operations with the transobturator vaginal tape (TVT-O and TOT) operations in the treatment of urinary stress incontinence. METHODS: This is a multicenter, prospective cohort study. Preoperative and postoperative assessments included a validated Stress and Urge Incontinence Questionnaire, a 24-h pad test, and a standardized stress test. RESULTS: The study included 5,942 women--4,281 women had a TVT operation and 731 and 373 women had TVT-O and TOT operations, respectively. Median follow-up time was 8 months. Women in the TVT group had less leakage during stress test and fewer subjective stress incontinence symptoms, and were more satisfied with the operation compared with the women in TVT-O and TOT groups, but more complications were reported after TVT operation. CONCLUSIONS: The TVT operation is more efficient than TVT-O and TOT operations in treating stress incontinent women.

Effects of anterior trocar guided transvaginal mesh surgery on lower urinary tract symptoms.

AIMS: To assess the effects of trocar guided transvaginal mesh on lower urinary tract symptoms after anterior vaginal wall prolapse repair. METHODS: One hundred twenty-one patients undergoing anterior transvaginal mesh surgery was prospectively evaluated at baseline and 1 year after surgery using the urogenital distress inventory (UDI). RESULTS: Overall UDI scores declined from 91 before surgery to 31 one year after surgery (P < 0.001). UDI subscales for obstructive and irritative symptoms improved 1 year after surgery (P < 0.001 for both) while stress symptoms did not (P = 0.11). CONCLUSION: Trocar guided transvaginal mesh surgery for anterior vaginal wall prolapse was associated with an overall resolution of most symptoms associated with overactive bladder syndrome and bladder outlet obstruction. These beneficial effects should be weighed against an increased risk for stress urinary incontinence related to the procedure.

Surgical strategies for women with pelvic organ prolapse and urinary stress incontinence.

INTRODUCTION AND HYPOTHESIS: This study aims to compare the result of an incontinence procedure performed at the time of prolapse repair or 3 months later in women with pelvic organ prolapse (POP) and stress urinary incontinence (SUI). METHODS: In a multicenter prospective randomized trial, women with POP and SUI were randomized to have a tension-free vaginal tape (TVT) at the time of prolapse repair (n = 87; group I) or 3 months later (n = 94; group II). Women in group II were evaluated for SUI 3 months after the prolapse repair. Those with confirmed SUI had a TVT performed (n = 53). The main evaluation of all women was 1 year after the last surgery. RESULTS: On-treatment analysis resulted in 95% cure of SUI in group I and 89% in group II (p = 0.12). Twenty-seven percent were cured after prolapse surgery alone. CONCLUSIONS: No differences were found between the two treatment strategies, but almost one third of women were cured of SUI by prolapse surgery alone.

Follow-up of TVT operations in 1,113 women with mixed urinary incontinence at 7 and 38 months.

A follow-up was done 7 and 38 months after tension-free vaginal tape (TVT) operation in 1,113 women with mixed urinary incontinence. Mixed incontinence and predominant bother were subjectively defined. The results were analyzed according to the women's predominant bother: stress incontinence, urge incontinence, or stress and urge incontinence equally. Across the groups, stress incontinence was cured in 87 and 83% of the women at 7 and 38 months, respectively, with no difference between the three groups. Women with predominant stress incontinence had significantly better results at both 7 and 38 months than those in the other groups, especially those predominantly bothered by urge incontinence. Women with mixed incontinence were significantly more often cured both objectively and subjectively at 7 than 38 months. Only 11% of the women experienced an increase in urge incontinence 38 months after TVT. Before a TVT operation, women with mixed urinary incontinence should be informed that their prognosis depends on their predominant bother. TVT is an appropriate treatment in mixed urinary incontinence, but women with predominant urge incontinence have poorer results than those with predominant stress incontinence.

The tension free vaginal tape operation for women with mixed incontinence: Do preoperative variables predict the outcome?

AIMS: The aims of our study were (1) to investigate subjective and objective outcomes after tension free vaginal tape (TVT) operations in mixed incontinent women, (2) to detect if preoperative subjective and objective variables predict the outcome, and (3) to evaluate whether the surgical outcome is different for women who preoperatively find stress incontinence, urge incontinence, or urge and stress incontinence equally the predominant bother. METHODS: A prospective cohort study was performed on 450 mixed incontinent women. A short-form disease-specific validated questionnaire, 24-hr pad test, standardized stress test, residual urine, and maximum urinary flow were used before and after a TVT operation. "Cure" was defined as a condition where the women were very satisfied with the TVT operation and had negative stress- and 24 hr pad tests. RESULTS: Preoperatively 69% had stress incontinence, 7% urge incontinence, and 24% urge and stress incontinence equally as the predominant bother. Cure rates were 80%, 52%, and 60%, respectively, in these groups. Postoperatively 43% of the women had no urge incontinence, while 49% were less, and only 8% were more bothered by urge incontinence. A higher preoperative urge incontinence index was correlated with significantly higher postoperative bother for all indices and leakage during 24-hr pad test. CONCLUSIONS: Mixed incontinent women with predominant stress incontinence had a better cure rate than those with predominant urge incontinence and those who were equally bothered by urge and stress incontinence. This point needs to be addressed when informing mixed incontinent women before a TVT operation.