The International Urogynecological Association (IUGA) and the International Continence Society (ICS) define stress urinary incontinence (SUI) as the complaint of involuntary loss of urine in effort or physical exertion, or on sneezing or coughing [1]. 
In order to maintain urinary continence, it is very important that there is a synergy between the structures that make up the pelvic floor, the sympathetic and parasympathetic nervous systems and the motor fibers of the pudendal nerves. 
Involuntary loss of urine may occur as a result of an alteration in one or more components due to the inability of the urethra to counteract the increase in abdominal pressure. 
Predisposing factors for SUI are age, parity (especially with vaginal delivery) and obesity due to their influence on the weakening of pelvic floor structures, leading to urethral hypermobility.
Because of its safety and efficacy [2], a surgical treatment is the method of choice, when conservative therapy fails.
The purpose of this study was to investigate the success rate and complications of surgical treatment of SUI in women with TOT outside-in technique with three years of follow-up.

This was a single-center retrospective study and presents the surgical results of treatment of stress urinary incontinence in women with monofilament polypropylene tape tension-free by transobturator approach, technique outside-in, in the period from January 2011 to January 2018.
A total of 86 women, who had stress urinary incontinence or mixed urinary incontinence, with a predominantly stress component, underwent surgery.
The exemption criteria were the absence of urodynamic changes assosiated with the SUI, findings indicating infravesical obstruction and detrusor overactivity, coagulopathy, pregnancy, history of sensitivity of a foreign body (i.e. polypropylene), acute cystitis, vulvovaginitis, previous surgery to treat SUI and history of pelvic radiotherapy treatment. 
In our study, we used clinical and functional terminology that is in accordance with the standardization of the International Society for Continence.
Urinary stress incontinence was confirmed by preoperative urodynamic examination (cystometry, uroflowmetry, urethral presser profile) or clinical examination of stress test (cough provocation) with full bladder in standing and lying position.
Two surgeons, trained in urogynecological surgery, performed all operations according to the original Delorme technique (TOT outside-in) using monofilament polypropylene tape.
Before surgery, all patients signed written consent for surgery and postoperative follow-up.
All patients were invited for a follow-up examination 6, 12, 24 and 36 months after surgery.
The result of the operation is defined as cured, improved or without success. 
Cure was defined as the absence of subjective complaint of urine leakage, and the absence leakage on cough stress testing. Patients were considered improved when they had a decrease of stress incontinence. Other cases were considered as without success.

A total of 86 women, who suffered from stress urinary incontinence or mixed urinary incontinence, with a predominantly stress component, underwent surgery by placing a monofilament polypropylene tape tension-free by transobturator approach, technique outside-in.
Preoperative urodynamic examination (cystometry, uroflowmetry, urethral presser profile) was performed in a total of 53 (61.6 %) patients. In 33 (38.4 %) patients, who were not subjected to urodynamic examination, stress urinary incontinence was confirmed by a clinical trial of a stress test (cough provocation) with a full bladder in standing and lying position. 
The length of hospitalization was 1 to 4 days.
The age of the patients ranged from 33 to 72 years, with an average of 55 years.
Complications such as tape erosion occurred in 3 patients (3.5 %), incision bleeding in 2 patients (2.3 %), transient leg pain in 3 patients (3.5 %) and dyspareunia in 2 patients (2.3 %). No perforations of the bladder or urethra were observed, as well as intestines or blood vessels. Vaginal erosion occurred in 3 patients (3.5 %). 
Most complications were treated conservatively.
In our study, 71 (82.6 %) patients who underwent surgery with the TOT outside-in technique, after three years of follow-up, were cured.

Stress urinary incontinence (SUI) is a widespread, global disease that affects women around the world and is often underestimated. Most frequently it occurs among middle-aged and elderly women, as shown by the results of our study. There are several advantages, such as minimal morbidity, short operative time, rapid convalescence, and long-term efficacy that make MUSs considered the gold standard for treating SUI [3].

Our study confirms that TOT is a safe procedure in the short and medium term with very few intraoperative, early and late postoperative complications. It is also an effective and successful procedure in the treatment of stress urinary incontinence with 82.6 % of cured patients during a three-year follow-up.

Haylen BT, de Ridder D, Freeman RM, Swift SE, Berghmans B, Lee J, et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Int Urogynecol J. 2010;21(1):5–26.
Gurol-Urganci I, Geary RS, Mamza JB, Duckett J, El-Hamamsy D, Dolan L, et al. Long-term rate of mesh sling removal following midurethral mesh sling insertion among women with stress urinary incontinence. JAMA. 2018;320:1–11.
Luo Z., Jiao B., Zhao H. et al. Contasure-needleless single incision slings versus transobturator slings (TOT/TVT-O) for female patients with stress urinary incontinence: a systematic review and meta-analysis. BMC Urol. 2020 May 6;20(1):51.