Persistent urgency or urgency urinary incontinence (UUI) can occur in patients with mixed urinary incontinence (MUI) who undergo surgery for stress urinary incontinence (SUI). Overactive bladder (OAB) symptoms after SUI surgery can have a large impact on quality of life. Hence, it is important to identify these patients for an appropriate preoperative counselling and post-surgery management.The primary aim of this study was to evaluate the prevalence and severity of persistent urgency and UUI after midurethral sling surgery. The secondary aim was to determine the predictive factors for postoperative persistent urgency and UUI in SUI

It  was a prospective study on female patients with SUI underwent “out -in” trans obturator tape (TOT) from 2002 to 2015 Exclusion criteria were as follows: women with pure SUI,comorbidities such as diabetes or neurologic disease; pelvic organ prolapse ≥ stage II. Preoperative evaluation included: urogynecologic, pharmacological history; pelvic examination using the POP-Q classification, urodynamic study and transperineal ultrasound. Urinary symptoms were evaluated using the standardised questionnaire UDI-6.TOT surgery was performed by an expert surgeon using the out-in trans-obturator technique originally described by Delorm.Follow-up visits were scheduled for 1 month, 6 months,1 year, then annually, by the same preoperative protocol. Objective cure for SUI was defined as the absence of urine leakage during the stress test.Statistical analysis was performed by using IBM SPSS statistics software, version 21.0 (IBM Corp., Armonk, NY, USA). Results were considered significant if the p-value was <0.05. We used Student's t-test and chi-square analysis. Logistic regression analysis was used to demonstrate risk factors for persistent urgency, UUI.The study was approved by local ethical committee.All patients signed informed consent

A total of 289 patients (mean age, 56.2±10.7 years) were included in the study. The mean time of symptom evaluation was 155±85 months. Overall 110 had SUI concurrent OAB dry, and 179 had MUI. Table 1 showed baseline demographic and clinic data of the patients in both groups.
Patients in the MUI group were significantly older than those in the SUI with OAB dry group (60.5±10.55 vs 58.97±10.98, p=0.003). The MUI group had a higher body mass index (BMI, 27.3±4.6 vs 25.75±3.4, p=0.002) and tended to be more overweight (BMI ≥25 kg/m2, 31.8%) than the patients in the other group (11.8%).In the SUI with urgency group, the success rate was 81%, de novo UUI developed in 23 patients (20.9%), of these 16% after 4 years. Sixtyeight patients (62.3%) had resolved urgency. In those with persistent urgency (38.1%), the subjective severity of urgency was improved in 27, the same in 10, and aggravated in 5. In the MUI group the success rate was 78%, and after the operation, 111 patients (62%) had resolved UUI, with resolved urgency in 75 (41.8%) and remnant urgency in 27 (15%). In patients with residual urgency, symptoms were improved in 24 and the same in 3. Sisixtyeight patients (37.9%) had persistent UUI . Among them, the degree of urgency was improved in 55, the same in 4, and aggravated in 13. Table 2 showed that the BMI≥25 kg/m2,age > 60 years, detrusor overactivity during preoperative urodynamic test, previous pelvic surgery and use of anticholinergics, menopause, were risk factors for de persistent urgency and UUI after SUI surgery in patients with pure SUI, and for de novo UUI in patients with SUI and OAB dry.

Our results are in agreement with the literature. In literature the reported incidence of persistent urgency in women with SUI and urgency ranged from 2% to 40%.  In women with SUI and UUI, 32% had persistent urgency incontinence ; our percentage of patients with persistence of OAB wet is slightly lower.A possible explanation for the persistent of OAB symptoms might be the result of ageing, since the prevalence of OAB increases with age, obesity and the detrusor overactivity on preoperative urodynamics.Mixed urinary incontinence was also associated with higher failure rates for SUI specific outcomes. It is possible that patients with MUI have a higher disease severity or even different pathophysiology than patients with pure SUI

Preoperative urgency and urgency urinary incontinence may persist after anti-incontinence surgery in patients with SUI, probably due to a different pathophysiology.Accordingly, patients with preoperative urgency or urgency  urinary incontinence, either reported clinically and/or demonstrated on urodynamics, should be counselled that the rate of persistent urgency and urinary urgency incontinence after synthetic mid-urethral sling placement maybe as high as 40 % .Knowing the risk factors is important for good counselling