Sling Procedures

A sling procedure is usually the first-line surgical approach for stress incontinence in women who have either intrinsic sphincter deficiency or urethral hypermobility. It may also be useful for managing female urge incontinence in women who have Mixed Urinary Incontinence. The purpose of a sling procedure is to create a sling or hammock underneath the mid-portion of the urethra, allowing the urethra to close tightly during episodes of increased abdominal pressure (a sneeze, cough or laugh). There are different types of sling procedures. They include:

• Suburethral/Bladder Neck Slings
• Midurethral, which includes the Tension-Free Vaginal Tape/TVT (a retropublic sling) and the Transobturator Tape/TOT (a sling that passes through the obturator foramen)

The suburethral, also called pubovaginal sling or bladder neck sling was the traditional sling procedure for many years, but has all but been replaced by the mid-urethral slings in the majority of cases. It uses a sling typically made from the patient’s own tissue (fascia) or a synthetic material.

• The surgeon makes an incision above the pubic bone and removes a layer of abdominal fascia (tissue that covers muscle fibers). This muscle strip is set aside and later serves as the sling.
• The surgeon makes an incision in the vaginal wall. The piece of muscle fiber or material is attached under the urethra at the bladder neck, somewhat like a hammock, and secured to the abdominal wall or pelvic bone.
• This sling then compresses the urethra back to its original position. The sling must be supportive without being too tense, which can cause urinary obstruction.

The Midurethral Sling procedure is considered to be the Gold Standard for the surgical treatment of Stress Urinary Incontinence. Midurethral sling procedures use slings made from synthetic mesh materials that are placed midway along the urethra. This newer type of sling procedure has become more commonly used than the conventional suburethral procedure because it can be performed on an outpatient basis using minimally invasive surgical techniques and no abdominal incisions.

There are two types of midurethral slings:

• In the retropublic procedure, the surgeon makes a small vaginal incision under the urethra and then two small incisions above the pubic bone.
• The transobturator procedure uses vaginal incision and typically two more incisions in the groin between the vagina and the thighs.