Midurethral slings

Mid-urethral sling procedures are operations that are designed to help women with stress incontinence. Stress incontinence is the leakage of urine with every day-day activities such as coughing, sneezing or exercise. It is a very common and embarrassing problem affecting up to 1 in 3 women. Stress incontinence may be cured or improved with pelvic floor exercises and lifestyle

modifications, but if these methods fail then surgery may be recommended for you.

The operation includes placing a sling of polypropylene mesh about 1cm wide (suture material that is woven together) between the middle portion urethra and the skin of the vagina. The urethra is the pipe through which the bladder empties. Normally the muscle and ligaments, which support the urethra, close firmly when straining or exercising to avoid leakage. Damage or weakening of these structures by childbirth and/or the aging process can be the result of this mechanism failing, leading to urine leakage. Placing a sling underneath the urethra improves the support and reduces or stops leaking.

How are the operations done?

There are three main routes for placing the sling:

  • the retropubic route,
  • the trans-obturator route and
  • the “single incision” or “mini-sling”.

There is no clear advantage of one over the another, except for some women with severe stress incontinence where the retropubic route that is appeared to be more successful.

Minislings are still in the initial phases of investigation. Although they are less invasive than the other methods they may not be quite as effective in controlling stress incontinence in the longer term, or in women with severe incontinence.

During the retro-pubic operation the sling is placed through a small incision made in the vagina over the mid point of the urethra. Through this the two ends of the sling are passed from the vagina, passing either side of the urethra to exit through two small cuts made just above the pubic bone in the hairline, about 4-6 cm apart. The surgeon will then use a camera (cystoscope) to check that the sling is correctly placed and not sitting within the bladder. The sling is then adjusted so that it sits loosely underneath the urethra and the vaginal cut stitched to cover the sling over. The ends of the sling are cut off and they too are covered over.

The trans-obturator approach to the operation also needs a small incision to be made in the vagina at the same place as for the retro-pubic operation. The ends of the sling are through two small incisions created, this time, in the groin. Each end of the sling passes through the obturator foramen, which is a gap between the bones of the pelvis. The ends are cut off once the sling is confirmed to be in the correct position and the skin closed over them.

The mini-sling procedure is similar to the initial part of retropubic approach, except that the ends of the sling do not come out onto the skin and are anchored in position by one of a number of different fixation techniques.