Despite its long-standing history, surgical treatment of female stress urinary incontinence is still a developing medical field. Better understanding of its physiopathology has allowed the creation of novel approaches. Slings have become the mainstay of treatment. The authors provide a brief overview of the development and progress of sling techniques throughout the years.
KEYWORDS: Urinary stress incontinence; Sling; Transobturator tape; Synthetic slings; Mini slings
CORRESPONDENCE: Ricardo Miyaoka, M.D., State University of Campinas, Department of Urology, Rua Durval Cardoso, 172, Campinas, Sao Paulo, 13100-213, Brazil. Email:
The understanding of physiopathological concepts of urinary stress incontinence has changed over the last few years, leading to the development of new therapies and surgical techniques.
Minimally invasive synthetic slings, such as tension-free vaginal tape (TVT), have replaced the Bursch colposuspension for the treatment of urinary stress incontinence. They have become the preferred technique in the last decade. Various factors have contributed to the popularization of slings, including the fact that techniques like the Pereira's needle suspension and all of its variants did not stand the test of time. However, the blind passage of long needles and the pull through of the sling have remained the key steps in all techniques.
There have been a number of conceptual changes and developments of biomaterials . Synthetic slings present several advantages over autologous slings. No graft harvesting is required; this was a time-consuming procedure associated with significant morbidity. The new techniques allow the procedures to be performed under local anesthesia, sometimes on an outpatient basis. Reduced postoperative pain and shorter sick leave add to the additional advantage of reduced cost .
Synthetic slings have complications related to the tape and to the surgical techniques, some of which are potentially lethal [3,4]. Most of the major complications are related to the blind nature of the needles . The reduction of needle diameter helped, but was not enough to solve these problems which occur even in experienced surgeon's hands.
In 2001, Delorme developed transobturator tape (TOT) as an alternative to the TVT procedure. This procedure eliminated the risks related to penetration in the retropubic space . Several short-term studies reported comparable cure rates and lower complication rates than those observed with previous sling procedures [7,8,9]. However, adverse events still occur, and surgeons should be fully aware of the complications that accompany all sling surgery and know how to manage them.
The most common complication is bladder perforation during passage of the needles. Interestingly, this occurs more often on the side opposite to the surgeon's dominant hand and with greater frequency in patients undergoing repeat procedures. Many studies have reported a bladder perforation rate ranging between 1â€“15%, with an average rate of 5% . The management of bladder perforation starts with recognition of the injury, followed by withdrawal and repositioning of the needle and placement of a urethral catheter for 24 to 48 hours. The transobturator technique is associated with a reduced incidence of bladder and urethral injury, which is reported to occur in less than 1% of patients and, as usual, occurs more often during the learning curve of the procedure .
Bleeding is another very important complication that can occur during needle passage. Bleeding upon entry of the retropubic space can be difficult to manage, because exposure of the perivesical venous plexus is difficult.
Care must be taken during lateral passage of the needles to avoid injury of major vessels, namely the external iliac vein or artery. Damage to these vessels is always caused by excessively lateral passage of the needles. Symptomatic retropubic hematoma, shown in Figure 1, occurs in 0-24% of patients . Management is primarily conservative with careful observation, rest, analgesia, and prophylactic antibiotics.
In an attempt to further reduce the risk of major complications, anatomical reconstruction of the urethral support was developed. The surgeon places low-tension suburethral tape anchored to the obturator internus muscles bilaterally, at the level of the tendineous arc. The procedure is shown in Figure 2. By doing so, bowel lesions and major vessel injuries are completely avoided.
This principle was applied a decade ago, but less than optimal material led to an unacceptable extrusion rate [11,12]. Long-term results with arc to arc slings using pig intestine submucosa produced good results in 60% of patients after 7 years of follow-up . The absence of an appropriate anchoring system and delivery instruments were a major drawback to its widespread use.
The first commercially available kit was the tissue fixation system (TFS), which uses 2 polypropylene anchors and a multifilament mesh. A preliminary report disclosed similar cure rates and fewer complications when compared to TOT .
Many other devices are available. Some of them depend on mesh integration for the fixation and therefore present up to 30% failure in the first postoperative month. Some devices use fishbone-like anchoring columns that allow for immediate primary fixation. An example is shown in Figure 3. Preliminary studies reported no pain, mesh exposure, vascular or visceral complications . Unquestionably, these results indicate a remarkable achievement. However, even minimally invasive procedures require a learning period and failure is an important complication.
At this point in time, it appears that mini slings could be an attractive and promising minimally invasive alternative for conventional synthetic slings, should the good results presented so far prove to be long lasting.
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To Cite this Article: Palma P, Petros P, Miyaoka R. Commentary on new developments in sling procedures for treatment of female stress urinary incontinence. UIJ June 2009;(2)3. doi:10.3834/uij.1944-5784.2009.06.04