This paper presents a review of various studies comparing surgical techniques using upper or lower approaches for the treatment of urinary stress incontinence with urethral insufficiency. The results are analysed and compared using the case history as well as the clinical and urodynamic examination as criteria for success. The superiority of procedures using the upper approach gives them a distinct advantage over lower approach procedures. The importance of an improved transmission factor following procedures which use the upper approach is emphasized. Finally, the factors involved in selecting the proper surgical procedure for correction of the anatomical impairments are summarized.