Transobturator tape (TOT) insertion is a newer development of the MUS and is a modification on the retropubic technique. It dates back to the early 2000s and similarly involves the placement of a manufactured synthetic tape suburethrally. However, in TOT, the tape is anchored through the obturator foramen [2, 15]. Avoiding the retropubic space makes TOT procedures both less invasive and safer [2, 15]. There are two methods of inserting a transobturator tape with the difference being the direction of penetration. With the “inside-out” technique, the needle passes from the midline suburethral position laterally, while for the “outside-in” method, the needle is passed from a lateral position to sit suburethrally. A review by Latthe et al. identified no major difference in efficacy or morbidity between the two techniques [26]. Both techniques avoid the blind passage of the needle through the retropubic space, which is required in the insertion of the TVT [2]. Two meta-analyses demonstrated that TVT and TOT have similar efficacy. However, the risk of bladder perforations and pelvic hematoma are significantly less common in patients treated with TOT [15]. The TOT operation is associated with more groin pain postoperatively. Large studies using observational data suggests that the TOT may have a slightly lower success rate than the retropubic MUS [27].

Mini-slings were first introduced in 2006. The aim of the mini-sling was to further reduce morbidity related to MUS. The mini-sling is a short tape mesh sling measuring between 8 and 14 cm with paired anchors at each end, inserted under local analgesia via a single vaginal incision. The mini-sling can be deployed either into the retropubic space or in a similar fashion to the TOT. The fixation ends of the tape are often placed in indeterminate soft tissue. Consequently, fixation into good tissue can neither be guaranteed nor tested at time of surgery. The potential benefit of mini-slings is the reduction of adverse events such as pain and visceral injury. This hypothesis has been tested by Smith et al. Their 2-year data showed excellent tolerance of local analgesia, early return to normal, and low morbidity, but very poor success rates [28]. Mini-slings could therefore be potentially used in an outpatient setting. The original mini-slings had a poor success rate [29]. Newer slings with improved design may have a better success rate [30], and this hypothesis is currently being studied in a large trial in the UK.

However, there are a few well-powered studies testing the long-term efficacy of mini-slings resulting in conflicting results. A multicenter randomized trial comparing mini-slings with TOT conducted by Mostafa et al. demonstrated that at 1-year follow-up, there were no differences in terms of subjective satisfaction or quality of life score found between the two groups, with similar success rates [30]. However, a systematic review and other studies suggest a lower cure rate for mini-slings [31]. Longer-term and multicenter outcome data is necessary to evaluate the place of mini-sling in the treatment of SUI.

These are considered as a “last hope” treatment for recurrent stress incontinence and are only offered after other surgical interventions have failed. They were introduced in the 1970s. The principle of this procedure involves increasing outlet resistance using a patient-controlled inflatable cuff around the proximal urethra. This allows intermittent deflation and bladder emptying. Good results have been reported when AUS is inserted for SUI secondary to intrinsic sphincter deficiency. Webster et al. (1992) reported over 90 % continence at 2.5 years following AUS insertion in women without previous surgery for SUI [32]. However, longer-term results are less optimistic. In addition, there is a high rate of sphincter removal due to infection or erosion [2]. This should not be unexpected as these devices are usually inserted to tissues which are scarred and damaged by previous failed surgery.

Periurethral bulking agents have been used for the treatment of SUI in women for decades. They create submucosal cushions ensuring apposition of the urethral wall, which aids continence. It can be carried out under local anesthesia and as a day case procedure. It is therefore associated with a low patient morbidity. A variety of substances have been reported to be safe and effective, but others have been withdrawn from the market after a variety of complications. A Cochrane review published in 2003 by Pickard concluded that bulking agents result in both subjective and objective short-term improvement in women with symptoms of SUI [33]. A study by Corcos in 2001 compared periurethral bulking agents with open colposuspension and TVT. Objective pad weight testing after 12 months revealed an increased curative rate but significantly higher complication rates after the latter two operations [2]. Periurethral bulking agents also have an apparent absence of postoperative de novo detrusor overactivity. However, it is recognized that two or more treatments may be necessary for the majority of patients, and the success rate is probably inferior to other surgical treatments. Despite this, some patients may prefer the low risk of complications and its minimally invasive nature as an initial treatment for SUI prior to considering more invasive surgery. Bulking agents are recommended for use in patients unfit for general anesthesia. They are most commonly used for patients after a failed MUS.