Surgical management of stress urinary incontinence in women: Choosing a type of midurethral sling
- J Eric Jelovsek, MD, MMEd, FACOG, FACS
J Eric Jelovsek, MD, MMEd, FACOG, FACS
- Director of Simulation and Advanced Skills Center and Residency Director
- Associate Professor of Surgery
- Obstetrics, Gynecology, and Women's Health Institute
- Glickman Urologic and Kidney Institute
- Cleveland Clinic
- Jhansi Reddy, MD
Jhansi Reddy, MD
- Clinical Assistant Professor
- Obstetrics and Gynecology
- New York University Langone Medical Center
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 .
Treatment of SUI includes both conservative (eg, vaginal pessaries, pelvic floor muscle exercises) and surgical options. Minimally invasive midurethral synthetic slings have become the procedure of choice for many women . The first of these was the tension-free vaginal tape, introduced in 1996 . The second major procedure, the transobturator midurethral sling, was introduced in 2001 . The transobturator procedures are designed to avoid some of the complications of retropubic insertion (eg, bladder perforation, vascular injury, bowel injury). Since that time, many other devices have been developed, with a variety of introducer mechanisms or mesh types .
The process of choosing a type of midurethral sling for women with SUI who have not had a prior anti-incontinence surgery will be reviewed here. Choosing between midurethral slings and other procedures, nonsurgical management of SUI, treatment of recurrent SUI, and diagnosis and treatment of other types of urinary incontinence are discussed separately. (See "Surgical management of stress urinary incontinence in women: Choosing a primary surgical procedure" and "Treatment of urinary incontinence in women" and "Stress urinary incontinence in women: Persistent/recurrent symptoms after surgical treatment" and "Evaluation of women with urinary incontinence".)
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 or 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.
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- FULL LENGTH SLINGS
- Transobturator versus retropubic midurethral slings
- - Efficacy
- - Complication comparison
- - Intrinsic sphincter deficiency
- - Mixed urinary incontinence
- Choosing a type of retropubic sling
- Choosing a type of transobturator sling
- SINGLE INCISION SLINGS
- Single incision versus full-length slings
- Adjustable slings
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS