Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Surgical management of stress urinary incontinence in women: Transobturator midurethral slings

Charles W Nager, MD
Jasmine Tan-Kim, MD
Section Editor
Linda Brubaker, MD, FACS, FACOG
Deputy Editor
Kristen Eckler, MD, FACOG


Stress urinary incontinence (SUI) affects 4 to 35 percent of women [1,2]. SUI occurs when an increase in intraabdominal pressure exceeds urethral closure pressure, resulting in the involuntary leakage of urine. This may occur with exertion, sneezing, or coughing [3].

Management options for SUI include conservative and surgical treatments. Midurethral slings are a relatively new treatment option, but have become the procedure of choice for many women. The first midurethral sling, introduced in 1996, was placed by passing trocars with mesh through the retropubic space [4]. Retropubic midurethral slings are still commonly used, but transobturator slings were introduced in 2001 with the goal of avoiding some of the complications of retropubic insertion (eg, bladder perforation, vascular injury, bowel injury) [5]. Transobturator slings are placed by passing trocars with mesh through obturator canal and avoiding the retropubic space completely.

Transobturator midurethral sling procedures are reviewed here. Retropubic midurethral slings and the approach to choosing a procedure for SUI in women are discussed separately. (See "Surgical management of stress urinary incontinence in women: Retropubic midurethral slings" and "Surgical management of stress urinary incontinence in women: Choosing a primary surgical procedure" and "Surgical management of stress urinary incontinence in women: Choosing a type of midurethral sling".)


There are several types of sling procedures for treatment of SUI in women (table 1). These procedures vary by the location of the sling and by the sling material. Collectively, these slings are referred to as suburethral slings, which is a sling that is inserted through a small vaginal incision and attached to another structure in the pelvis for the purpose of supporting the urethra. Suburethral slings may be either bladder neck and midurethral slings.

Midurethral sling – A suburethral sling that is placed at the level of the midurethra in a tension-free manner. These slings are made of synthetic mesh.


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Sep 2016. | This topic last updated: May 26, 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
  1. Haylen BT, de Ridder D, Freeman RM, et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Neurourol Urodyn 2010; 29:4.
  2. Luber KM. The definition, prevalence, and risk factors for stress urinary incontinence. Rev Urol 2004; 6 Suppl 3:S3.
  3. Abrams P, Cardozo L, Fall M, et al. The standardisation of terminology in lower urinary tract function: report from the standardisation sub-committee of the International Continence Society. Urology 2003; 61:37.
  4. Ulmsten U, Henriksson L, Johnson P, Varhos G. An ambulatory surgical procedure under local anesthesia for treatment of female urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunct 1996; 7:81.
  5. Delorme E. [Transobturator urethral suspension: mini-invasive procedure in the treatment of stress urinary incontinence in women]. Prog Urol 2001; 11:1306.
  6. Walters MD, Karram MM. Sling procedures for stress urinary incontinence. In: Urogynecology and Reconstructive Pelvic Surgery, 3rd ed, Walters MD, Karram MM (Eds), Mosby Elsevier, Philadelphia 2007. p.197.
  7. Sarlos D, Kuronen M, Schaer GN. How does tension-free vaginal tape correct stress incontinence? investigation by perineal ultrasound. Int Urogynecol J Pelvic Floor Dysfunct 2003; 14:395.
  8. Dietz HP, Wilson PD. The 'iris effect': how two-dimensional and three-dimensional ultrasound can help us understand anti-incontinence procedures. Ultrasound Obstet Gynecol 2004; 23:267.
  9. Whiteside JL, Walters MD. Anatomy of the obturator region: relations to a trans-obturator sling. Int Urogynecol J Pelvic Floor Dysfunct 2004; 15:223.
  10. Majercik S, Tsikitis V, Iannitti DA. Strength of tissue attachment to mesh after ventral hernia repair with synthetic composite mesh in a porcine model. Surg Endosc 2006; 20:1671.
  11. Liapis A, Bakas P, Creatsas G. Tension-free vaginal tape in the management of recurrent urodynamic stress incontinence after previous failed midurethral tape. Eur Urol 2009; 55:1450.
  12. Latthe PM, Singh P, Foon R, Toozs-Hobson P. Two routes of transobturator tape procedures in stress urinary incontinence: a meta-analysis with direct and indirect comparison of randomized trials. BJU Int 2010; 106:68.
  13. Abdel-Fattah M, Ramsay I, Pringle S, et al. Randomised prospective single-blinded study comparing 'inside-out' versus 'outside-in' transobturator tapes in the management of urodynamic stress incontinence: 1-year outcomes from the E-TOT study. BJOG 2010; 117:870.
  14. But I, Faganelj M. Complications and short-term results of two different transobturator techniques for surgical treatment of women with urinary incontinence: a randomized study. Int Urogynecol J Pelvic Floor Dysfunct 2008; 19:857.
  15. Liapis A, Bakas P, Creatsas G. Monarc vs TVT-O for the treatment of primary stress incontinence: a randomized study. Int Urogynecol J Pelvic Floor Dysfunct 2008; 19:185.
  16. Zahn CM, Siddique S, Hernandez S, Lockrow EG. Anatomic comparison of two transobturator tape procedures. Obstet Gynecol 2007; 109:701.
  17. Duckett JR, Patil A, Papanikolaou NS. Predicting early voiding dysfunction after tension-free vaginal tape. J Obstet Gynaecol 2008; 28:89.
  18. Koops SE, Bisseling TM, van Brummen HJ, et al. What determines a successful tension-free vaginal tape? A prospective multicenter cohort study: results from The Netherlands TVT database. Am J Obstet Gynecol 2006; 194:65.
  19. de Leval J. Novel surgical technique for the treatment of female stress urinary incontinence: transobturator vaginal tape inside-out. Eur Urol 2003; 44:724.
  20. Richter HE, Albo ME, Zyczynski HM, et al. Retropubic versus transobturator midurethral slings for stress incontinence. N Engl J Med 2010; 362:2066.
  21. Giri SK, Sil D, Narasimhulu G, et al. Management of vaginal extrusion after tension-free vaginal tape procedure for urodynamic stress incontinence. Urology 2007; 69:1077.
  22. Dessie SG, Hacker MR, Apostolis C, et al. Effect of Scopolamine Patch Use on Postoperative Voiding Function After Transobturator Slings. Female Pelvic Med Reconstr Surg 2016; 22:136.
  23. Daneshgari F, Kong W, Swartz M. Complications of mid urethral slings: important outcomes for future clinical trials. J Urol 2008; 180:1890.
  24. Long CY, Hsu CS, Wu MP, et al. Comparison of tension-free vaginal tape and transobturator tape procedure for the treatment of stress urinary incontinence. Curr Opin Obstet Gynecol 2009; 21:342.
  25. Tahseen S, Reid PC, Charan P. Short-term complications of the trans-obturator foramen procedure for urinary stress incontinence. J Obstet Gynaecol 2007; 27:500.
  26. Kaelin-Gambirasio I, Jacob S, Boulvain M, et al. Complications associated with transobturator sling procedures: analysis of 233 consecutive cases with a 27 months follow-up. BMC Womens Health 2009; 9:28.
  27. Bogusiewicz M, Monist M, Stankiewicz A, et al. Most of the patients with suburethral sling failure have tapes located outside the high-pressure zone of the urethra. Ginekol Pol 2013; 84:334.
  28. Staack A, Vitale J, Ragavendra N, Rodríguez LV. Translabial ultrasonography for evaluation of synthetic mesh in the vagina. Urology 2014; 83:68.
  29. Hegde A, Nogueiras GM, Aguilar V, et al. Dynamic assessment of sling function on tranperineal ultrasound: Is it correlated with outcomes one year following surgery? (abstract). Female Pelvic Med Reconstr Surg 2013; 19:S57.
  30. Klutke C, Siegel S, Carlin B, et al. Urinary retention after tension-free vaginal tape procedure: incidence and treatment. Urology 2001; 58:697.
  31. Morey AF, Medendorp AR, Noller MW, et al. Transobturator versus transabdominal mid urethral slings: a multi-institutional comparison of obstructive voiding complications. J Urol 2006; 175:1014.
  32. Ogah J, Cody JD, Rogerson L. Minimally invasive synthetic suburethral sling operations for stress urinary incontinence in women. Cochrane Database Syst Rev 2009; :CD006375.
  33. Barber MD, Gustilo-Ashby AM, Chen CC, et al. Perioperative complications and adverse events of the MONARC transobturator tape, compared with the tension-free vaginal tape. Am J Obstet Gynecol 2006; 195:1820.
  34. Groutz A, Levin I, Gold R, et al. "Inside-out" transobturator tension-free vaginal tape for management of occult stress urinary incontinence in women undergoing pelvic organ prolapse repair. Urology 2010; 76:1358.
  35. Laurikainen E, Valpas A, Kivelä A, et al. Retropubic compared with transobturator tape placement in treatment of urinary incontinence: a randomized controlled trial. Obstet Gynecol 2007; 109:4.
  36. Abdel-Fattah M, Ramsay I, Pringle S. Lower urinary tract injuries after transobturator tape insertion by different routes: a large retrospective study. BJOG 2006; 113:1377.
  37. Tamussino K, Hanzal E, Kölle D, et al. Transobturator tapes for stress urinary incontinence: Results of the Austrian registry. Am J Obstet Gynecol 2007; 197:634.e1.
  38. Jasaitis Y, Sergent F, Tanneau Y, Marpeau L. [Vesicovaginal fistula after transobturator tape]. Prog Urol 2007; 17:253.
  39. Starkman JS, Meints L, Scarpero HM, Dmochowski RR. Vesicovaginal fistula following a transobturator midurethral sling procedure. Int Urogynecol J Pelvic Floor Dysfunct 2007; 18:113.
  40. Cadish LA, Hacker MR, Dodge LE, et al. Association of body mass index with hip and thigh pain following transobturator midurethral sling placement. Am J Obstet Gynecol 2010; 203:508.e1.
  41. Roth TM. Management of persistent groin pain after transobturator slings. Int Urogynecol J Pelvic Floor Dysfunct 2007; 18:1371.
  42. Neuman M. TVT-obturator: short-term data on an operative procedure for the cure of female stress urinary incontinence performed on 300 patients. Eur Urol 2007; 51:1083.
  43. Kobashi KC, Govier FE. Management of vaginal erosion of polypropylene mesh slings. J Urol 2003; 169:2242.
  44. Mesens T, Aich A, Bhal PS. Late erosions of mid-urethral tapes for stress urinary incontinence--need for long-term follow-up? Int Urogynecol J Pelvic Floor Dysfunct 2007; 18:1113.
  45. Wijffels SA, Elzevier HW, Lycklama a Nijeholt AA. Transurethral mesh resection after urethral erosion of tension-free vaginal tape: report of three cases and review of literature. Int Urogynecol J Pelvic Floor Dysfunct 2009; 20:261.
  46. Abouassaly R, Steinberg JR, Lemieux M, et al. Complications of tension-free vaginal tape surgery: a multi-institutional review. BJU Int 2004; 94:110.
  47. Collinet P, Ciofu C, Costa P, et al. The safety of the inside-out transobturator approach for transvaginal tape (TVT-O) treatment in stress urinary incontinence: French registry data on 984 women. Int Urogynecol J Pelvic Floor Dysfunct 2008; 19:711.
  48. Atassi Z, Reich A, Rudge A, et al. Haemorrhage and nerve damage as complications of TVT-O procedure: case report and literature review. Arch Gynecol Obstet 2008; 277:161.
  49. Rajan S, Kohli N. Retropubic hematoma after transobturator sling procedure. Obstet Gynecol 2005; 106:1199.
  50. Huffaker RK, Copas P. Blood loss in the space of Retzius and pelvis with tension-free vaginal tape and trans-obturator tape procedures. Tenn Med 2006; 99:43.
  51. Sun MJ, Chen GD, Lin KC. Obturator hematoma after the transobturator suburethral tape procedure. Obstet Gynecol 2006; 108:716.
  52. Mellier G, Mistrangelo E, Gery L, et al. Tension-free obturator tape (Monarc Subfascial Hammock) in patients with or without associated procedures. Int Urogynecol J Pelvic Floor Dysfunct 2007; 18:165.
  53. Rardin CR, Moore R, Ward RM, Myers DL. Recurrent thigh abscess with necrotizing fasciitis from a retained transobturator sling segment. J Minim Invasive Gynecol 2009; 16:84.
  54. Zumbé J, Porres D, Degiorgis PL, Wyler S. Obturator and thigh abscess after transobturator tape implantation for stress urinary incontinence. Urol Int 2008; 81:483.
  55. Leanza V, Garozzo V, Accardi M, et al. A late complication of transobturator tape: abscess and myositis. Minerva Ginecol 2008; 60:91.
  56. DeSouza R, Shapiro A, Westney OL. Adductor brevis myositis following transobturator tape procedure: a case report and review of the literature. Int Urogynecol J Pelvic Floor Dysfunct 2007; 18:817.
  57. Lee SY, Kim JY, Park SJ, et al. Bilateral recurrent thigh abscesses for five years after a transobturator tape implantation for stress urinary incontinence. Korean J Urol 2010; 51:657.