Initially, stress urinary incontinence should be treated by conservative measures, such as weight reduction, hormonal substitution, physiotherapy, pelvic floor exercise and/or the use of pessaries. Incontinence surgeries are only recommended in case of unsuccessful conservative therapy. Today, tension-free suburethral sling insertions represent the gold standard of incontinence surgery yielding very good outcomes (cure rates of 80–90 %). Pelvic-floor sonography provides important information on decision of surgical methods and the management of complications. Furthermore, intra- or paraurethral injection of bulking agents is a promising, minimally invasive surgical alternative. This article discusses treatment concepts, pre-, intra- and post-operative examinations, decision on surgical methods, operational details for surgical success, and the prevention and management of complications.

Introduction The studyʼs objectives were to determine the success rate following radiofrequency endometrial ablation to treat abnormal menstrual bleeding and to assess risk factors for failure of the method. Materials and Methods 195 women who were treated with bipolar radiofrequency endometrial ablation between 01/2009 and 06/2016 were included in this prospective cohort study. Postoperative data from 187 women were collected at a median of 17.5 months (IQR 4.5–34.9; 1–82). Multivariate analyses of risk factors were performed. Success was defined as amenorrhoea or spotting. Results Patient characteristics were as follows: mean age 44 years (SD ± 5), median parity 2 (IQR 2–3), median hysterometer 8.7 cm (SD ± 1.1), and median BMI 23.5 kg/m2 (IQR 21–27). 30 patients (19.5%) had intramural masses that could be measured with ultrasound. Postoperative success rate was 86.1%. 10 patients (5%) had a hysterectomy postoperatively – 6 for heavy bleeding, 3 due to prolapse, and 1 due to dysmenorrhoea. Multivariate analyses showed the presence of intramural masses in women < 45 years was a significant risk factor for therapeutic failure (p = 0.033; 95% CI 1.08–12.57), with an increased risk of hysterectomy (OR 7.9, 95% CI 1.2–52.7, p = 0.033). Conclusion Bipolar radio frequency endometrial ablation was highly successful in the absence of an intramural mass (88%). Even smaller intramural fibroids (DD: adenomyomas of a median of 15 mm) reduce the success rate (76%), which is why preoperative ultrasound is recommended. In the presence of intramural masses, the risk of a hysterectomy for women < 45 years increases eightfold.

Zusammenfassung. Zusammenfassung: Eine Belastungsinkontinenz sollte immer zuerst konservativ behandelt werden. Schon eine Gewichtsreduktion, Hormonpräparate, Physiotherapie, Beckenbodentraining und/oder die Anwendung von Pessaren können zum Erfolg führen. Nach Ausschöpfen dieser Therapien werden heute Inkontinenzoperationen mit meist sehr guten Heilungschancen (ca. 80–90 %) angeboten. Der operative Goldstandard ist die suburethrale Schlingeneinlage. Die Pelvic-Floor-Sonografie liefert dazu sehr wichtige Hinweise zur Wahl der Operationstechnik und zur Behebung von Komplikationen. Ferner bildet die intra- oder paraurethrale Injektion von Bulking Agents eine vielversprechende, wenig invasive operative Alternative. In diesem Artikel werden Behandlungskonzepte, prä-, intra- und postoperative Untersuchungen, Wahl der Operationsmethode, operationstechnische Details für den Operationserfolg sowie Vorbeugung und Behandlung von Komplikationen diskutiert.

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