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Mid-Urethral Sling: Technique Step-by-Step and Complications

Indications for Mid-Urethral Slings

Stress urinary incontinence in women, especially with insufficiency of the anterior compartment of the pelvic floor with a hypermobile urethra.

Contraindications

• Existing or planned pregnancy
• Incomplete bladder emptying
• Untreated urge incontinence
• Stress incontinence due to other causes than anterior compartment insufficiency
• Coagulation disorders
• Urinary tract infection
• Further contraindications depend on the surgical risk due to the comorbidity of the patient.

Surgical Technique (Step-by-Step) of the Mid-Urethral Sling Procedure

Sling material:

Monofilament and widely porous polypropylene mesh with 1 cm width and 40 cm length, both ends fixed to a trocar [fig. mid-urethral sling].

Preoperative patient preparation:

Vaginal estrogen treatment for several weeks before surgery. Exclusion or treatment of a urinary tract infection. Perioperative antibiotic prophylaxis. General or spinal anesthesia, but the procedure can also be performed under local anesthesia. Lithotomy position. Vaginal examination and cystoscopy. Insert a transurethral catheter with a rigid catheter guide to allow movement of the urinary bladder and urethra.

Vaginal dissection:

Inject at least 50 ml of normal saline or dilute lidocaine at the planned vaginal incision, around the urethra, and along the intended path for the trocars. Hydrodissection facilitates the preparation and reduces the risk of urinary bladder perforation. Grasp the vaginal wall just below the urethral meatus with upward traction to improve visualization of the surgical field. Perform a sagittal incision (1.5 cm length) of the anterior vaginal wall along the urethra, at least 1.5 cm distal to the bladder neck. Gentle pulling of the transurethral catheter helps to visualize the bladder neck. Use sharp (scissors) and blunt (finger) dissection to reach the inferior ramus of the pubis.

Retropubic sling implantation:

The trocar of the sling is advanced finger-guided paraurethrally through the vaginal incision to the inferior ramus of the pubis. The bladder is deflected away from the trocar path using the rigid catheter guide. The trocar is advanced through the endopelvic fascia into the retropubic space, staying close to the pubic bone to avoid injury of the bladder. The trocar exits via a small paramedian suprapubic skin incision. Secure the sling with a clamp. The same procedure is performed on the opposite side. Exclude bladder injury with a cystoscopy.

Other systems (e.g., Sparc from AMS) use an outside-in technique: the trocar needle is passed through a suprapubic incision to the vaginal incision, and the sling is anchored to the trocar and then pulled through [fig. outside-in technique].

Retropubic sling implantation (Sparc system from AMS):
Top row illustrations: two trocars are passed around the symphysis from two small suprapubic incisions to the vaginal incision.
Bottom row images: the sling is anchored to the trocars and pulled into the vaginal incision. Tension is checked before removing the plastic sheath of the sling. With kind permission, American Medical Systems, www.americanmedicalsystems.com, Minnetonka, USA.

Adjustment of the sling tension:

The sling should be without tension with an empty bladder, and a pair of scissors should fit easily between the urethra and the sling. The effect of the sling may checked with bladder filling and applying pressure (coughing of the patient, suprapubic manual pressure). If the band is correctly positioned, remove the plastic sheath, and cut the abdominal ends below the skin level. Close the abdominal (4-0) and vaginal (2-0) incisions with interrupted synthetic absorbable sutures.

Transobturator mid-urethral sling:

Transobturator mid-urethral slings were developed as a technical alternative to reduce the associated complications of retropubic slings (bladder or bowel injury, urinary retention). Different systems are on the market; basic technical differences exist regarding the direction of trocar passage (inside-out or outside-in) [fig. transobturator sling].

Transobturator mid-urethral sling implantation (Monoarc system from AMS):
Top row illustrations: small incision of the anterior vaginal wall and preparation of the paraurethral tissue in the direction of the inferior ramus of the pubis. Below the tendon of the adductor longus muscle, a skin incision is made lateral of the inferior ramus of the os pubis. The trocar needle is guided around the inferior ramus to the vaginal incision, the finger guides the trocar and protects the urethra.
Bottom row illustrations: the sling is connected to the trocar needle and pulled to the skin incision by rotating the trocar. The same procedure is done on the opposite side. Before removing the plastic wrapping of the tape, the tension is checked, the tape should be loose. With kind permission, American Medical Systems, www.americanmedicalsystems.com, Minnetonka, USA.

Minimally invasive alternatives:

Single-incision slings are implanted via the vaginal incision, the slings are anchored in the paraurethral tissue and pelvic floor muscles [fig. short mid-urethral devices].

Postoperative Care after Mid-Urethral Sling Procedures

Bladder catheter:

Remove the catheter after 2–24 hours, unless significant hematuria suggests bladder perforation. Check postvoid residual volume after voiding trial. Sling loosening (in general anesthesia) is necessary for patients with urinary retention.

Complications

• De novo urge symptoms or dyspareunia (up to 10%).
• Numbness and pain of the groin or thigh in 10% (with transobturator slings)
• Subvesical obstruction with urinary retention (more common with retropubic slings).
• Persistent incontinence in < 10% (more common with transobturator slings)
• Urethral injury
• Uncommon: injury to the bladder, iliac vessels, or bowel (with retropubic implantation).
• Vaginal, vesical, or urethral erosion of the sling, in the long term up to 12%.

References

V. Alexandridis, A. Lundmark Drca, M. Ek, and W. S. derberg, “Retropubic slings are more efficient than transobturator at 10-year follow-up: a Swedish register-based study.,” Int Urogynecol J., vol. 34, no. 6, pp. 1307–1315, 2023.

A. Mostafa, C. P. Lim, L. Hopper, P. Madhuvrata, and M. Abdel-Fattah, “Single-incision mini-slings versus standard mid-urethral slings in surgical management of female stress urinary incontinence: an updated systematic review and meta-analysis of effectiveness and complications.,” Eur Urol, vol. 65, no. 2, pp. 402–427, 2014.

Latthe, P. M.; 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.
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Liedl u.a. 2005 LIEDL, B. ; SCHORSCH, I. ; STIEF, C.: [The development of concepts of female (in)continence. Pathophysiology, diagnostics and surgical therapy].
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Ward, K. L.; Hilton, P.; K., U. & Group, I. T. T. Tension-free vaginal tape versus colposuspension for primary urodynamic stress incontinence: 5-year follow up.
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