What is the overview of midurethral sling placement for stress urinary incontinence?

From the Guidelines

Midurethral sling placement is a recommended treatment for stress urinary incontinence in women, with success rates of 80-90% and a low risk of complications, as supported by the most recent guideline update from 2023 1. The procedure involves placing a narrow strip of polypropylene mesh beneath the mid-portion of the urethra through small vaginal and abdominal incisions. There are two main approaches: retropubic (TVT) where the sling passes behind the pubic bone, and transobturator (TOT) where the sling passes through the obturator foramen.

• The procedure typically takes 30-45 minutes under local, regional, or general anesthesia, often as outpatient surgery.
• Patients can expect success rates of 80-90% with symptom improvement, as reported in the 2023 guideline update 1.
• Recovery involves 2-4 weeks of restricted activity, with potential side effects including temporary urinary retention, pain, infection, mesh erosion, and rarely, bladder or urethral injury.
• The sling works by providing support to the urethra during increases in abdominal pressure (like coughing or sneezing), preventing urine leakage.
• Patients should expect some discomfort for several days post-procedure and should avoid heavy lifting and sexual activity for 4-6 weeks, as recommended in the 2017 guideline 1.
• Most women can resume normal activities within 2 weeks, though complete healing may take longer. It is essential to counsel patients thoroughly regarding the use of synthetic mesh to treat SUI, including the benefits, potential risks, and alternatives to mesh slings, as emphasized in the 2017 guideline 1.
• The FDA safety communication regarding MUS should also be discussed, allowing patients to make an informed decision about their treatment.
• The choice of procedure should be made as a collaborative effort between the surgeon and patient, considering patient preferences, surgeon experience, and judgment, as stated in the 2010 guideline update 1.

From the Research

Overview of Midurethral Sling Placement

• Midurethral sling (MUS) procedure is the most common treatment modality for women with stress urinary incontinence (SUI) 2, 3, 4
• The procedure involves inserting a minimally invasive polypropylene mesh tape under the midurethra with trocars, which can be performed under local anesthesia with conscious sedation 3
• MUS procedures have been the surgical option of choice for most gynaecologists and urologists treating SUI in women around the world for almost 20 years 4

Efficacy and Complications

• The long-term effectiveness of MUS is good and similar to the Burch Colposuspension and the fascial pubovaginal slings 4
• Complications related to mesh midurethral slings are low and less than the complication rates with previous traditional continence surgeries 5
• Despite the high success rates, 5-20% of patients undergoing MUS experience persistent or recurrent SUI, regarded as surgical failure 2

Treatment Options for Persistent or Recurrent SUI

• Treatment options for persistent or recurrent SUI after MUS include placement of a second midurethral sling, autologous fascial sling, retropubic urethropexy, or urethral bulking 2, 6
• Sling plication has also been suggested as an alternative option, which may reduce operative time, cost, risk of trocar injury, and mesh burden 6
• Repeat MUS for prior MUS failure has shown relatively good success rates, ranging from 55 to 90%, with better outcomes obtained using the retropubic rather than the transobturator route 2