Is a synthetic midurethral (SMU) sling effective for treating stress urinary incontinence in patients with a high bladder neck?

Synthetic Midurethral Sling Effectiveness for High Bladder Neck

Synthetic midurethral slings are effective for treating stress urinary incontinence in patients with a high bladder neck, with cure rates of 85-87% and lower urinary retention rates (3%) compared to bladder neck slings (9-10%). 1, 2

Effectiveness of Synthetic Midurethral Slings

Synthetic midurethral slings (MUS) have become the gold standard for treating stress urinary incontinence (SUI), replacing traditional bladder neck procedures. The evidence shows:

• Synthetic slings placed at the midurethra have estimated cure/dry rates of 81-84% without prolapse treatment and 85-87% with concurrent prolapse treatment 1
• Long-term data (48+ months) show maintained effectiveness with cure rates of 76% 1
• MUS placed at the midurethral level rather than the bladder neck position results in fewer complications and better outcomes 2, 3

Comparison with Bladder Neck Procedures

When comparing midurethral versus bladder neck placement:

• Synthetic slings at the bladder neck have higher urinary retention rates (9-10%) compared to midurethral slings (3%) 2
• Autologous fascial slings placed at the bladder neck have retention rates of 5-8% 2
• Bladder neck synthetic slings have higher rates of erosion/extrusion (5% urethral/bladder, 8% vaginal) compared to midurethral slings 1

Clinical Decision Algorithm for High Bladder Neck

For patients with SUI and high bladder neck:

1. First-line option: Synthetic midurethral sling

   • Lower retention rates (3%)
   • High cure rates (85-87%)
   • Faster recovery time

2. Alternative options (if synthetic mesh is contraindicated):

   • Autologous fascial sling placed at midurethra rather than bladder neck
   • Burch colposuspension (85-88% cure rate at 24-47 months)

Complications and Considerations

The main complications to consider:

• De novo urge incontinence: 6% with midurethral slings vs. 12% with bladder neck slings 1
• Urinary retention: 3% with midurethral slings vs. 9-10% with bladder neck slings 2
• Mesh complications: vaginal extrusion (7%), urinary tract erosion (rare with midurethral placement) 1

Contraindications

Synthetic sling surgery is contraindicated in patients with:

• Urethrovaginal fistula
• Urethral erosion
• Intraoperative urethral injury
• Urethral diverticulum 1

In these cases, autologous fascial slings or alternative biological materials should be considered instead of synthetic materials.

Special Considerations for High Bladder Neck

For patients specifically with high bladder neck:

• Midurethral placement is preferred over bladder neck placement
• The procedure is equally effective for both intrinsic sphincter deficiency and urethral hypermobility 4
• Patients with previous failed anti-incontinence procedures may benefit from a bladder neck approach as a salvage procedure 5

The evidence clearly supports synthetic midurethral slings as the most effective option for SUI with high bladder neck, offering the best balance of efficacy and safety compared to bladder neck procedures.