The female mid-urethral sling is a minimally invasive, outpatient procedure to treat stress urinary incontinence. This surgery has been performed sing the mid 1990's and has been shown to be safe and effective. The sling lies under the urethra acting as a “hammock” which maintains urethral support and keeps it closed during abdominal pressure increases (as with a cough, sneeze, or athletic activity), preventing loss of urine.
The female sling is a short (15-30 minute) outpatient surgery done under general anesthesia, spinal anesthesia or under sedation with local anesthesia. A 2-3 cm (1 inch) incision is made in the vagina as well as 2 mini incisions just above the pubic bone or in the inner thigh just beside the labia. In some cases only a single vaginal incision is made. The sling, made of surgical mesh (polypropylene), is then placed under the urethra and brought out through the mini incisions using specially designed instruments. The sling is then adjusted to the proper tension (no pressure on the urethra) and then buried under the skin incision after excess mesh is removed. The incisions are closed with dissolvable sutures. Patents usually go home within a few hours after surgery.
Information about postoperative care can be found below.
The primary aim is to improve the severity of stress urinary incontinence to a satisfactory level. Most patients (90% or more) will achieve this goal. Some of these patients (about 70-80%) are completely dry. Please note that this surgery is not designed to treat overactive bladder or urge incontinence (see Incontinence Overview for more information about this). In some cases of mixed incontinence, one may eperience an improvement in both stress and urge-related leakage events - usually these patients have a unique condition where the urge incontinence is triggered by stress incontinence episodes.
In long-term studies looking at patient-reported outcomes, the majority of properly selected patients have marked improvement in leakage. What can patients expect?
In general, the rate of any serious complication is very low (less than 2% overall) making the risk-benefit profile of this surgery highly favorable. Potential risks include:
You can download the position statement here. It is very similar to the one issued by the FDA in 2011.
Many patients have read or heard about a notification from the FDA in 2008 (updated in 2011) regarding the potentially serious complications associated with transvaginal synthetic mesh to treat pelvic organ prolapse and stress urinary incontinence. This was accompanied by recommendations on how to lessen risks and counsel pateints. The notice was predominantly directed to mesh for the use of pelvic organ prolapse and not for mid-urethral slings (such as TVT and TOT). We do NOT use any of the 'transvaginal mesh kits' for pelvic organ prolapse for which the notification was primarily intended.
The American Urogynecologic Society has issued a position statement:
complete restriction on the use of surgical mesh was not the stated intent of the FDA safety communication
the decision on surgical alternatives should be made by the patient and her surgeon
in some circumstances, pelvic organ prolapse may be the most appropriate surgical option
any restriction of mesh slings for the treatment of stress incontinence is clearly not supported by any professional organization or the FDA
any restriction of mesh placed abdominally (as opposed to transvaginally) for the treatment of prolapse is clearly not supported by any professional organization or the FDA
Mesh for stress incontinence has been extensively used for over 15 years. When used in properly selected patients usually results in excellent outcomes. As always, there are risks with surgery including TVT and TOT.
If you have questions that are not answered here, please contact us.
You will begin a voiding trial immediately following surgery. You should void every 2-3 hours. If unable to void you should perform self-catheterization if you have been taught how. Keep track of voided and/or catheterized volumes. If you have not been taught self-catheterization and cannot void you will need to go to your nearest hospital emergency room for a catheter to be placed.
If you have an indwelling catheter please see catheter care instructions.
Urinary frequency, urgency and a slower urine stream may occur in the first 1-2 weeks.
Vaginal bleeding similar to a light period is expected for 1-2 weeks.
May experience pain or discomfort around incision sites.
You may experience inner thigh discomfort.
Report any of the following to your doctor: