While obesity has been considered an established risk factor for stress urinary incotinence(SUI) , the underlying causality is not as clear. One reason for this is that many obese women with SUI have other, potentially confounding conditions, such as multiparity,
estrogen deficiency, and a history of pelvic surgery.The dominant unifying theory posits that increased intraabdominal pressure (IAP) due to obesity adversely stresses the pelvic floor and contributes to the development of SUI.While weight loss should remain a primary therapeutic intervention for SUI in obese women, this may not always be possible. First, women may be less likely to engage in exercise while actively incontinent. Second, eligibility for surgical weight loss is strict. Third, maintenance of behavioral and dietary intervention alone may be inconsistent, especially in absence of routine follow-up and encouragement. Hence, obese women may consider anti-incontinence surgery prior or, during, or after engaging in weight reduction efforts.The aims of this study were to evaluate the long-term effect of body mass index (BMI) on the outcomes and complications of  TOT.

This was a prospective study on women who underwent “out-in” TOT for SUI or MUI with predominant stress between 2013 and 2018. Exclusion criteria were as follows: women with a history of radical pelvic surgery; previous POP surgery; comorbidities such as diabetes or neurologic disease; the presence of POP stage 2 or greater.Follow-up visits were scheduled for 1 month, 6 months,1 year, then annually, with a final visit was done in September-October 2020. Women underwent physical exam, they completed the UDI6, IIQ-7 and PGI-I. They were divided in 3 groups based on BMI (normal weight (A) ,overweight (B), obese (C)). Objective cure for SUI was defined as the absence of urine leakage during the CST. Subjective cure was defined by a “noanswer” to question 3 of the UDI-6 questionnaire.The severity of complications was classified by the ICS/IUGA classification of mesh complications

We analyzed 369 patients. Mean follow up was 134 months (range 24-216), mean age was 58.9 ±10.9. Patient-reported outcome measures for stress urinary incontinence inversely correlated with body mass index,At last visit the success rates were: Group A 87 %,Group B 72.7%,Group C 66.2%. Tables 1 showed that at last visit women with BMI ≥25 had higher rate of persistence of mixed urinary incontinence and de novo urgency urinary incontinence  compared to women with BMI<25.Both in Group A and B there were 2 sling exposure (2BT3S1), treated surgically; in Group C 2 cases of which only one (2CaT3S1)treated. As BMI increased PGI-I scores declined

Numerous pathogenic consequences of obesity can lead to unconscious leakage of urine in women. For instance, obesity is widely understood to lead to a significant increase in abdominal pressure. Taking the maximum bladder capacity as the standard, every 1 kg/m2 increase in BMI or a 2 cm increase in abdominal circumference in women will lead to a 0.4 cmH2O increase in abdominal pressure . This elevated pressure directly translates to bladder pressure. However, the obesity-induced impairment of the tissues and organs involved in urinary control may be the more damaging consequence. Clinical and anatomical studies have found that long-term increases in abdominal pressure can lead to atrophy and deformation of pelvic floor muscles and weak connective tissue, leading to excessive movement of the urethra and bladder neck. Additionally, lipid droplet deposition and several other causes can also lead to muscle dysfunction and other injuries.Obesity can damage urine control structures and cause SUI in females. Current treatments of SUII are not ideal for relieving symptoms and improving quality of life, and also have no ability to reverse or repair the underlying pathological changes.

The long term success rate of TOT in patients with BMI≥25  was lower compared to its  in the normal-weight women, but the complication rate was low in all groups.