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Urinary loss (flow) results from a relative lack of CM resistance with respect to the intravesical pressure. Surgical stabilization of the continence mechanism, at the level of the bladder neck or mid-urethra, compensates for the existing loss of urethral support and function by creating new zones for compression, absorption of transmitted pressure, and the preservation of sphincteric configuration. Our understanding of the pathophysiology of stress incontinence and the basis for surgical compensation continues to evolve. Mid-urethral complex support procedures have stimulated further investigation into the mechanics of continence.

Although exceptions exist, clinical and urodynamic findings can be predicted on the basis of the location of the neurologic lesions. Conversely, these findings can be used to predict the location of the lesion. Recognition of similar patterns allows for classification, and classification allows the physician more readily to devise a diagnostic and therapeutic plan. Furthermore, a simple and practical classification system facilitates communication between physicians.

The hypothesis that upper tract changes in the absence of vesicoureteral reflux are a function of chronically elevated intravesical pressure has had increasing impact on the management of the lower urinary tract in patients with lower tract dysfunction secondary to neurogenic bladder disease. The application of our growing ability to measure bladder and bladder outlet function objectively and in a more physiologic manner through expanding urodynamic techniques will continue to provide information that can be applied to the diagnosis and treatment of lower urinary tract dysfunction and hydroureteronephrosis after spinal cord injury. Current methods of classifying lower urinary tract behavior have not provided the ability to identify accurately those patients at greatest risk for upper tract deterioration. The application of new techniques and the use of new measures may increase our ability to identify these patients.

The factors contributing to stress incontinence of urine are reviewed and categorized with respect to their effects on coaptation and compression of the urethra. Intrinsic urethral dysfunction and poor anatomic support are discussed from both a functional and a pathophysiologic approach.

Controversy still remains concerning the timing of repair, the type of approach, and the technical guidelines most likely to prevent recurrence of both radiated and nonradiated vesicovaginal fistulae. The authors advocate the transvaginal approach because it avoids a cystotomy and involves minimal blood loss and consequently is followed by less postoperative discomfort and a shorter hospital stay. Included in this discussion are the techniques and results of the transvaginal approach for simple vesicovaginal fistulae as well as for complex cases and radiation fistulae.

Like the transabdominal bladder neck suspension, the aim of the transvaginal needle suspension of the bladder neck is to suspend the bladder neck and urethra in a fixed retropubic position. Because the transvaginal technique does not require the splitting of the abdominal wall fascia, postoperative discomfort and convalescence may be lessened. Different techniques of transvaginal needle bladder neck suspension, including suspension of the bladder neck with a fascial sling, are discussed in detail.