Surgical management of stress urinary incontinence in females: Retropubic midurethral slings

INTRODUCTION — 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 [1]. Stress urinary incontinence (SUI) affects 4 to 35 percent of women [2,3]. Management options for SUI include conservative and surgical treatments.  

Retropubic midurethral sling (MUS) procedures are reviewed here. Transobturator midurethral slings and the approach to choosing a procedure for SUI in women are discussed separately. (See "Surgical management of stress urinary incontinence in females: Transobturator midurethral slings" and "Female stress urinary incontinence: Choosing a primary surgical procedure" and "Surgical management of stress urinary incontinence in females: Choosing a type of midurethral sling".)

In this topic, when discussing study results, we will use the terms "woman/en" or "patient(s)" as they are used in the studies presented. We encourage the reader to consider the specific counseling and treatment needs of transgender and gender diverse individuals.

TERMINOLOGY

●Procedure history – Midurethral sling (MUS) placement has replaced other procedures (eg, retropubic colposuspension, pubovaginal slings) as the procedure of choice for many women [4,5]. The tension-free vaginal tape (TVT), introduced by Ulmsten in 1996, was the first synthetic retropubic midurethral sling [6]. Since that time, variations of retropubic midurethral slings as well as midurethral transobturator slings have been introduced.

●Standardized terminology – The terminology for surgical procedures to treat stress urinary incontinence in women has been standardized in a joint publication by the American Urogynecologic Society and the International Urogynecological Association, and those terms will be used in this document [7]. There are two main l types of sling procedures for treatment of SUI in women: midurethral slings and pubovaginal slings (table 1)

•Midurethral sling – A midurethral sling is a vaginal surgery involving tension-free placement of a type 1 polypropylene mesh strip, or tape, between the vagina and the urethra near its midpoint. Words delineating the path (retropubic or transobturator) and direction of the trocars or the number of incisions can be used to more specifically describe the procedure [7].

•Retropubic midurethral slings are most commonly performed by passing a trocar retropubically from the vagina on each side of the urethra through the retropubic space and exit through the abdominal wall and skin in the suprapubic area bottom-to-top (figure 1) or they are inserted starting at the abdominal wall and exit under the midurethra (top-to-bottom).

•Transobturator midurethral slings are inserted in-to-out through the vaginal incision, through the obturator foramen and exit through the skin of the groin area (figure 2) or they are inserted out-to-in through the groin incision, through the obturator foramen and exiting the vaginal suburethral incision.

-Single incision or adjustable midurethral slings differ from full-length retropubic and transobturator slings in two ways: they are shorter (approximately 8 cm rather than 40 cm) and they require only a vaginal incision, and not an abdominal or groin incision. Different types of these slings may be placed in a retropubic (anchored to the urogenital diaphragm) or transobturator fashion (anchored to the obturator internus muscle).

•Pubovaginal is an abdominovaginal surgery that uses a length of fascia, tissue, or graft to support the urethra with an abdominal wall fixation site (figure 3). The sling material is most commonly autologous and thus, the procedure has been referred to as a "fascial" sling; specifically, fascia from the rectus sheath or fascia lata has been used, but other materials (including allogenic, xenogenic, or synthetic grafts) have been described with varying success rates and complications [7]. (See "Surgical management of stress urinary incontinence in females: Pubovaginal sling procedures".)

MECHANISM OF ACTION — Midurethral sling placement involves the introduction of a polypropylene tape (approximately 1 cm in width) covered in a plastic sheath beneath the midportion of the urethra. This sling functions as a backboard that offers resistance beneath the urethra during increases in intraabdominal pressure, but is tension-free at rest. Ultrasound data suggest that continence is achieved by compression of the urethra between the sling and the pubic symphysis [8-10].

For retropubic midurethral slings, the tails of the mesh pass through the retropubic space, rectus sheath, subcutaneous tissue and skin (figure 1). Once the plastic sheaths are removed, the tape is held in place by its interface with the patient's tissue; it is not held in place by sutures. The friction that initially secures the mesh is eventually reinforced with tissue fibrosis develops around and through the mesh. Porcine models demonstrate that 74 percent of the final strength has already been achieved by two weeks postoperatively and maximum strength of tissue in-growth into polypropylene mesh occurs at three months [11].

SURGICAL CANDIDATES

Indications — Indications for midurethral sling placement are:

●Symptomatic SUI or stress-dominant mixed incontinence

●Women who are planning repair of prolapse of the vaginal apex and who have known or suspected occult SUI

Symptomatic SUI may be treated with conservative measures (pelvic floor muscle training, incontinence pessaries), urethral bulking agents, or a surgical approach. Candidates for surgical treatment are women with SUI who decline or have had unsuccessful conservative treatment. (See "Female stress urinary incontinence: Choosing a primary surgical procedure", section on 'Candidates for surgical treatment'.)

Advanced pelvic organ prolapse and SUI commonly co-exist; however, in many women, the SUI becomes apparent only when the prolapse has been corrected. This phenomenon is known as occult SUI. Preoperative prolapse reduction stress testing with or without urodynamics can suggest, but unfortunately cannot completely predict, occult stress incontinence. Concomitant anti-incontinence surgery can be offered to women who are undergoing repair for advanced pelvic organ prolapse. This topic is discussed separately. (See "Pelvic organ prolapse and stress urinary incontinence in females: Surgical treatment", section on 'Symptomatic POP without symptomatic SUI'.)

Additional characteristics for consideration — Evaluating whether an individual with SUI is an appropriate candidate for surgical treatment, and a midurethral sling in particular, may depend upon additional factors, including:

●Urinary function issues (eg, intrinsic sphincter deficiency, lack of urethral hypermobility, mixed incontinence, voiding dysfunction) –

●Intrinsic sphincteric deficiency (ISD) – Data are fairly consistent that women with ISD (defined as maximal urethral closure pressure <20 cm H₂O or Valsalva leak point pressure <60 cm H₂O) have worse surgical outcomes than overall SUI patients. Overall cure rates in women with ISD tend to be lower with objective and subjective cure rates of 52.1 and 47.9 percent compared with all SUI 88.2 to 85.9 percent [12].

While historically the pubovaginal autologous fascial sling was the preferred treatment for intrinsic sphincter deficiency, the overall safety and efficacy of the midurethral sling has changed this paradigm. In a large randomized trial of 597 women with SUI undergoing either retropubic midurethral sling or a transobturator midurethral sling, lower quartile Valsalva leak point pressures, and lower quartile maximum urethral closure pressures conferred an almost twofold increased odds of objective failure regardless of sling route [13]. Other studies suggest that women with ISD may be better served with a retropubic midurethral sling rather than a transobturator sling. In a 2016 systematic review and meta-analysis comparing the efficacy of the retropubic midurethral sling with the transobturator midurethral sling, the retropubic approach resulted in a 10 percent higher subjective cure rate in patients defined to have ISD [14].

●Obesity – (See "Female stress urinary incontinence: Choosing a primary surgical procedure", section on 'Obese women'.)

●Increasing age and/or frailty – (See "Female stress urinary incontinence: Choosing a primary surgical procedure", section on 'Older, frail, or medically complex individuals'.)

●Concomitant procedures – Many women undergo anti-incontinence surgery concomitantly with other procedures (eg, pelvic organ prolapse repair, hysterectomy). Most data suggest that concomitant surgery does not decrease midurethral sling success rates. (See "Female stress urinary incontinence: Choosing a primary surgical procedure", section on 'Coexistent anatomic or functional abnormality'.)

●Previous anti-incontinence surgery – Many cases of unsuccessful previous stress incontinence surgery can be effectively treated with retropubic midurethral sling. Documented cure rates of 70 to 90 percent for the TVT as a secondary procedure have been shown with one to five years of follow-up [15-18]. (See "Stress urinary incontinence in females: Persistent/recurrent symptoms after surgical treatment", section on 'Midurethral sling'.)

Contraindications — Contraindications to midurethral retropubic sling placement include:

●Current urinary tract infection

●Current pregnancy

●Anticoagulation

●Structures in the retropubic space that are in the path of sling placement (eg, vascular graft, bowel, transplanted pelvic kidney)

Current pregnancy is an absolute contraindication to midurethral sling placement. Plans for future pregnancy are a relative contraindication. Since pelvic support may be disrupted during pregnancy, and particularly following a vaginal birth, most physicians recommend delaying surgical management of SUI until childbearing has been completed. (See 'Subsequent pregnancy' below.)

The procedure is relatively contraindicated in patients who are anticoagulated. Midurethral sling placement involves passing trocars through several tissue layers and may result in hematoma formation or hemorrhage. The risk of hematoma formation is probably more with retropubic approaches than with transobturator approaches, so women with bleeding diatheses (eg, Von Willebrand's) may be better served with administration of preoperative control measures (eg, desmopressin) and a transobturator approach.

Certain conditions or previous retropubic surgery may predispose to complications during sling placement. Previous retropubic surgery may have resulted in the presence of bowel in the retropubic space or an inguinal or abdominal hernia sac may be located along the pathway of trocar placement [19]. Likewise, a transplanted kidney [20,21] or femoral crossover graft may be in the insertion path of the sling.

For women in whom there are concerns that the retropubic space could contain bowel or other structures (eg, a vascular graft, transplanted kidney, inguinal hernia) based upon previous operative procedures or findings, or imaging studies, we suggest a transobturator approach. The retropubic and transobturator approaches have been shown to have comparable efficacy in randomized trials. (See "Surgical management of stress urinary incontinence in females: Choosing a type of midurethral sling", section on 'SUI background and treatment options'.)

Some physicians will choose a transobturator route to avoid a scarred retropubic space in women who have had a previous Burch colposuspension, pubovaginal sling procedure, or midurethral sling, but a prior history of any of these procedures is not a contraindication to placement of a midurethral sling [15]. Treatment of recurrent SUI is discussed separately. (See "Stress urinary incontinence in females: Persistent/recurrent symptoms after surgical treatment", section on 'Midurethral sling'.)

COMPARISON OF INSERTION ROUTES — There are two main variations of full-length retropubic midurethral slings, based upon the initial incision site and direction of insertion:

●Bottom-to-top – Two needle trocars are inserted through a vaginal incision and passed through the retropubic space, exiting at the abdominal wall.

●Top-to-bottom – Two needle trocars are inserted through abdominal incisions and passed through the retropubic space, exiting through a vaginal incision.

The bottom-to-top approach appears to be superior. A meta-analysis of five randomized trials, including a total of 636 women, compared bottom-to-top (TVT) and top-to-bottom (SPARC) procedures [22]. The TVT was slightly more effective; at up to one-year follow-up, the TVT group had higher subjective cure rates (85 versus 77 percent, RR 1.10, 95% CI 1.01-1.20) and objective cure rates (92 versus 87 percent, RR 1.06, 95% CI 1.01-1.11). In addition, complications occurred less frequently in the TVT group, including bladder perforation (4.7 versus 8.5 percent, RR 0.55, 95% CI 0.31-0.98); vaginal mesh erosion (0.7 versus 3.5 percent, RR 0.27, 95% CI 0.08-0.95); and voiding dysfunction (2.2 versus 6.0 percent, RR 0.40, 95% CI 0.18-0.90). Some surgeons feel more comfortable with top-to-bottom insertion because they are familiar with this approach because of historical needle suspension procedures. However, given these data, we suggest use of the bottom-to-top approach.

Choosing between retropubic, transobturator, and single incision midurethral slings is discussed separately. (See "Surgical management of stress urinary incontinence in females: Choosing a type of midurethral sling".)

PREOPERATIVE EVALUATION AND PREPARATION

Informed consent — Treatment options for symptomatic SUI should be reviewed with the patient. Surgeons should discuss the efficacy of the procedure, the placement of permanent mesh, and the risk of complications (eg, voiding dysfunction). Patients should be counseled that midurethral sling placement is not intended to treat urinary urgency, frequency, or nocturia, and that resolution of these symptoms should not be expected [23-25], although some overactive bladder symptoms may improve after midurethral sling placement [26]. In a large, well-characterized, randomized trial, mixed incontinence patients receiving a midurethral sling experienced a 75 percent reduction in urogenital distress inventory irritative scores and only 2 percent of participants experienced worsening urgency [27]. (See 'Complications' below.)

For women with known or suspected occult SUI, the option of a staged or concomitant procedure and the potential for unnecessary surgery should be discussed.

This discussion should be documented on the surgical consent form and in the medical record.

Evaluation — Women who are planning midurethral retropubic sling placement should undergo preoperative evaluation to confirm the diagnosis of SUI, exclude other etiologies of urinary incontinence, confirm normal bladder emptying, and assess surgical risk.

Components of this evaluation include:

●Medical and voiding history

●Pelvic examination

●Office urinary function testing to demonstrate stress leakage and normal bladder emptying (eg, urinary stress test, postvoid residual volume)

Current evidence does not require urodynamic testing in all women prior to surgery. We suggest that preoperative urodynamics be performed only in women with complicated SUI (eg, previous anti-incontinence surgery, neurogenic lower urinary tract dysfunction, or suspicion of a nonstress etiology of urinary incontinence) or when stress leakage cannot be demonstrated or when symptoms are not consistent with physical examination findings.

Preoperative evaluation of women with SUI is discussed in detail separately. (See "Surgical management of stress urinary incontinence in females: Preoperative evaluation for a primary procedure".)

Antibiotic prophylaxis — We recommend antibiotic prophylaxis for surgical site infection for procedures for treatment of pelvic organ prolapse or SUI that utilize surgical mesh, such as midurethral sling placement. Infectious complications of such procedures include infections associated with the surgical mesh (eg, abscess, cellulitis) and urinary tract infections, particularly for procedures that involve periurethral dissection [28-33].

Our recommendation is in concert with professional society guidelines. American College of Obstetricians and Gynecologists guidelines advise antibiotic prophylaxis for surgical site infection for urogynecologic procedures, including those with vaginal mesh [34]. American Urological Association guidelines also advise use of antibiotic prophylaxis for all patients undergoing open or laparoscopic procedures involving an implanted prosthesis [35].

Use of surgical mesh does not affect the need for antibiotic prophylaxis of bacterial endocarditis.

Thromboprophylaxis — Midurethral sling placement is minor surgery (defined as <30 minutes) and is typically performed in mobile patients. Thus, those patients who have no additional thrombotic risk factors are classified as low risk for venous thromboembolism and do not require specific thromboprophylaxis. (See "Prevention of venous thromboembolic disease in adult nonorthopedic surgical patients" and "Overview of preoperative evaluation and preparation for gynecologic surgery", section on 'Thromboprophylaxis'.)

PROCEDURE — In this section, we will describe our technique for inserting the TVT device, based upon the original technique described in 1996 [6,36]. The mean operative time for this procedure is 30 minutes [37]. A video of the procedure is included (movie 1).

Operative setting — Midurethral sling placement is typically performed in an operating room as an outpatient procedure.

Anesthesia — Midurethral sling placement may be performed under local, regional, or general anesthesia. Many surgeons combine local anesthesia with conscious sedation.

The TVT procedure was initially described using local anesthesia with conscious sedation [6]. The rationale for this approach is that a patient who is awake and has no abdominal muscle blockade can perform a urinary stress (cough) test, allowing sling tension to be adjusted if leakage of urine is noted [38]. The urinary stress test is described separately. (See "Female urinary incontinence: Evaluation", section on 'Clinical tests'.)

The use of regional anesthesia alters the results of the urinary stress test, but does not appear to affect sling success rates. When the urinary stress test is performed under regional anesthesia, less intraabdominal pressure is generated by the cough, but urethral resistance is lower (increasing the tendency to leak urine) [39,40]. These conditions differ from normal function, and thus, it is uncertain whether it is valid to adjust the sling tension based upon these results. In contrast, periurethral infiltration of local anesthetic does not appear to alter urethral function [41].

In our practice, we do not routinely perform a urinary stress test, regardless of type of anesthesia, since there is no evidence that the results of the test impact outcome.

The efficacy of sling placement under regional anesthesia was demonstrated in a randomized trial comparing spinal and local anesthesia in 103 women undergoing a TVT procedure [39]. At 13-month follow-up, the spinal and local anesthesia groups showed no significant differences in subjective SUI cure rates (97 versus 94 percent) and postoperative urinary retention (14 versus 12 percent). Patient comfort level during the procedure was not assessed in this study.

Use of general anesthesia may be associated with detrimental effects on midurethral sling outcomes. The best available data comparing midurethral sling placement under local or regional anesthesia with general anesthesia are from two large prospective cohort studies [42,43]. In one study (n = 809), at two-year follow-up, a lower subjective SUI cure rate was associated with general anesthesia compared with local anesthesia (68 versus 81 percent) [43]. In another study (n = 500), the rate of postoperative voiding dysfunction was significantly higher in women who received general anesthesia (17 versus 6 percent) [42].

Based upon these data, we suggest use of local anesthesia with conscious sedation or regional anesthesia rather than general anesthesia for midurethral sling placement, when it is being performed as an isolated procedure. General anesthesia may be used if it is preferred by the patient or if it is required for a concomitant procedure.

Instrumentation — The TVT system consists of a metal handle to which two metal needles and sling can be attached. The sling is 40 cm long and 1 cm wide covered by a plastic sheath, and the outer diameter of the trocar is 5 to 6 mm. Variations of this system have ≤3 mm trocars with plastic sheaths that cover the trocars as well as the connected sheathed 1 cm wide polypropylene sling.

Additional surgical equipment includes:

●Bladder (Foley) catheter (size 16 to 18 French)

●Rigid catheter guide

●Cystoscope

Use of size 18 French will allow the rigid catheter guide to be more easily introduced but is not necessary. This catheter guide is used to deviate the bladder away from the side of trocar placement.

Sling placement — Placement of a bottom-to-top full-length retropubic midurethral sling is performed as follows:

Patient preparation

●Patient set-up – Position the patient in dorsal lithotomy with careful attention to avoid nerve compression. (See "Nerve injury associated with pelvic surgery" and "Nerve injury associated with pelvic surgery", section on 'Prevention of nerve injury'.)

Sterilely prepare and drape the patient. Insert the bladder catheter. The bladder should be completely drained prior to dissection and again prior to placement of the catheter guide.

●Marking abdominal incisions – Mark the two planned abdominal exit points for the tape at the superior margin of the pubic bone, 2 cm lateral to the midline. Some surgeons make small stab incisions at these locations to facilitate trocar passage through the skin.

●Hydrodissection – Some surgeons hydrodissect the vaginal incision site and/or the path of the trocars. Either local anesthetic (with or without epinephrine) or sterile saline may be used. In the original description of the procedure, 40 mL of fluid was injected into the vaginal wall inferior and lateral to the urethra [6]. An additional 60 to 70 mL of fluid was injected at the planned abdominal incision sites and downward along the back of the pubic bone to the retropubic space. Alternatively, fluid may be injected into the retropubic space through the vaginal sulci.

●Midurethral vaginal incision – Make a vertical (longitudinal) vaginal incision, starting 1 cm proximal to the urethral meatus and 1 to 1.5 cm in length to accommodate the width of the sling in the appropriate location. Place Allis clamps on the lateral edges of the incision to provide exposure by retracting the vaginal mucosa laterally. The best ways to prevent a midurethral sling from being too proximal are to start the vaginal incision for the midurethral sling 1 cm from the urethral meatus, as recommended by Ulmsten in the original TVT publication, and to never use an anterior repair incision to place the midurethral sling [6].

Minimal dissection lateral to the midurethra, between the vaginal mucosa and the pubocervical fascia, is performed bilaterally with the Metzenbaum scissors. The scissors are angled towards the retropubic space just behind the pubic symphysis.

●Lateral deviation of the bladder – Drain the bladder completely, and introduce the rigid catheter guide into the bladder catheter. Deviate the bladder to the side opposite of trocar insertion.

Initial trocar insertion — Insertion of the trocar along the correct path is the critical part of the procedure to ensure that the procedure is effective and to avoid complications.

●General insertion procedure – Insert the first trocar into the tract lateral to the urethra that was dissected out with Metzenbaum scissors. Pass the trocar behind the pubic symphysis (through the retropubic space) and exit through the abdominal incision sites. The trocar or plastic trocar sheath is left in place with the tip just past the level of the abdominal skin.

●Techniques to prevent complications – The trocars must be passed along the correct path without deviation to avoid complications. Small deviations of the trocar handle create a magnified deviation of the tip of the trocar, resulting in potential injury to adjacent structures.

Deviation of the trocar in a cephalad direction may result in injury to bowel, bladder, or blood vessels [44].

Deviation of the trocar lateral to the posterior surface of the pubic symphysis may cause serious vascular injury. Major vessels (eg, external iliac vessel, obturator vessels, epigastric vessels) may be located as close as 0.9 cm from the correct path of the trocars and the mean distance from the trocar to the major vessels is 3.2 to 4.9 cm (range 0.9 to 6.6 cm) (figure 4) [44].

Techniques for successful placement include:

•The operator must maintain a firm grasp of the trocar and handle while manipulating the needle through the tissues. Resistance of the tissues may sometimes result in deviation of the needle. Use a hand in the vagina to control and direct the trocar while the opposite hand on the handle is used to apply gentle force to advance the trocar.

●Care should be taken to aim the trocar handle in the direction of the outer aspect of the patient's ipsilateral shoulder [44].

•The tip of the trocar should be positioned just behind the pubic symphysis. It is often helpful to actually place the tip of the trocar on the underside of the pubic symphysis and to gently slide it behind the bone, staying as close to the bone as possible. To do this, the surgeon must lower the hand that is holding the trocar handle so that the curve of the insertion needle follows the posterior surface of the pubic bone through the retropubic space. The trocar should pass easily in the retropubic space in direct opposition to the posterior side of the symphysis. Later, more force is needed when the trocar passes through the rectus sheath and then out through the skin at the suprapubic level.

•The trocar handle must be kept parallel to the floor during retropubic passage to prevent the lateral rotation of the trocar tip.

•After insertion, the anterior vaginal sulci are inspected and palpated to ensure that they have not been perforated by the trocar. If there is a perforation, then the trocar or the plastic sheaths with the mesh can be seen traversing the vaginal sulcus. The first sign of a vaginal perforation is often the onset of vaginal bleeding that does not appear to be coming from the midurethral vaginal incision.

Cystourethroscopy — After the trocars are placed, cystourethroscopy is performed to inspect for bladder perforation. A 70 degree cystoscope should be used and the bladder filled adequately to allow complete examination of the urethra and bladder surface [6]. Examination of the bladder requires an experienced clinician; a study of surgical trainees reported that 37 percent of bladder injuries were missed on cystourethroscopy [45]. (See "Diagnostic cystourethroscopy (cystoscopy) for gynecologic conditions".)

Although ureteral injury is extremely uncommon, intravenous administration of 10 percent sodium fluorescein (0.25 mL) may be used to check for ureteric flow if ureteral injury is suspected [46]. This has been used with success in our practice due to the unavailability of indigotindisulfonate sodium (indigo carmine). (See "Urinary tract injury in gynecologic surgery: Identification and management".)

Completing the trocar insertion — The next step in the procedure depends upon the findings of cystourethroscopy:

●If there is no bladder injury after both trocars are placed, then urethroscopy is performed and the procedure is continued.

●If a bladder perforation has occurred, the perforating trocar or sheath should be withdrawn and the bladder emptied completely. The trocar can then be replaced while hugging the posterior surface of the pubic bone. Cystourethroscopy is repeated. This can usually be accomplished even in the presence of a bladder perforation since the defects at the perforation sites result in only a minimal amount of fluid loss. If there is no further bladder injury, then the procedure is continued.

When both trocars have been inserted and cystourethroscopy is complete, the remaining portions of both trocars (or plastic trocar sheaths) and the mesh are then passed through the skin. The plastic sheaths are left in place, and the mesh is left slack at the midurethra to allow the tension to be adjusted.

Adjusting sling tension — To ensure that the sling is tension-free and does not compress the urethra while the patient is at rest, many surgeons insert an instrument (eg, Kelly clamp, Heaney clamp, mayo scissors, needle holder, or number 8 Hegar dilator) between the sling and the urethra while adjusting the sling tension. Others have used a Babcock clamp to pinch a segment of the mesh under the urethra during insertion that then ensures some laxity in the sling when this clamp is released after adjustment [47]. The important concept is that the sling functions by preventing descent of the midurethra during intraabdominal pressure events, and it should not compress or be adjacent to the urethra at rest.

An intraoperative urinary (cough) stress test may be performed at this time if the patient is under local anesthesia. If leakage occurs, the sling is tightened slightly. In our practice, we do not routinely perform a urinary stress test, regardless of type of anesthesia, since there is no evidence that the results of the test impact outcome. (See 'Anesthesia' above.)

With the spacer in place, remove the plastic sheaths; this prevents excess tightening of the mesh during plastic sheath removal. The surgeon should assess the entire plastic sheath to confirm that it has been completely removed.

Trim the mesh at the abdominal incisions. Mesh protrusion and irritation at the skin surface can be prevented by depressing the skin slightly to trim the mesh just below the skin surface. The authors keep the spacer in place during mesh trimming to prevent further tightening during mesh elevation for trimming. Based on the authors' experiences, a small gap should remain visible between the sling and the urethra at rest when adjustment is final. The mesh does not require suturing since it is held in by friction and then fibrosis [6].

Closure of incisions

●Vaginal incision – We believe everting the edges of the vaginal incision is important to increase the distance between the mesh and the incision line to reduce the risk of vaginal mesh exposure. At our institution, we close the vaginal mucosa with a horizontal mattress suture and use an absorbable suture [48].

●Suprapubic skin incisions – This can be performed in a variety of ways (suture, adhesive strips, surgical glue, no closure), based upon surgeon preference.

Postoperative voiding trial — A voiding trial is performed prior to patient discharge. In a retrospective review of nearly 170 women who underwent a retropubic midurethral sling insertion, 80 percent had a successful voiding trial in the same day, and 97 percent had a successful voiding trial within one day [49]. In multivariate analysis, risk factors for delayed voiding included age ≥65 years and use of Valsalva voiding. In a different retrospective case-control study of 464 women, approximately 80 percent of women also had a successful initial voiding trial; medical comorbidities were predictive of an unsuccessful voiding trial in this study [50].

A voiding trial can be performed in two different ways: retrograde or spontaneous filling of the bladder.

●Retrograde bladder filling – The bladder catheter is left in place at the end of the procedure. Once the patient has completely recovered from anesthesia, the bladder is completely drained through the catheter. The bladder catheter can then be attached to a catheter-tipped syringe with the piston removed or an irrigation syringe. Using only gravity to fill, 300 mL of sterile normal saline or water at room temperature is instilled into the bladder. The catheter is then removed, and the patient is asked to void in a toilet hat or measured container. The postvoid residual volume is calculated (by subtracting the voided volume from the volume instilled). Although there is no consensus on a residual that implies a low rate of subsequent urinary retention, we consider a successful voiding trial to be a postvoid residual that is <150 mL or less than half the filled amount.

●Spontaneous bladder filling – The bladder catheter is removed at the end of the procedure. Once the patient has completely recovered from anesthesia and feels that her bladder is full, she is asked to void. The voided volume is collected and measured and the postvoid residual volume is measured either using a bladder ultrasound or a bladder catheter. A successful voiding trial can be defined as a postvoid residual of <150 mL.

It is uncertain which approach to bladder filling is superior. This question has been evaluated in two randomized trials of women who underwent transvaginal surgery [51,52]. In one trial, the proportion of women that had an unsuccessful voiding trial and were discharged home with a bladder catheter was significantly lower in the retrograde group (32 versus 62 percent) [52], while in the other trial, the rate of unsuccessful trials was the same for both groups (65 percent) [51]. The different findings may reflect the different methodology of the two trials; in one, the voiding trial was performed within hours of the end of the procedure [52] and, in the other, two voiding trials were performed on the first postoperative day [51]. In addition, the applicability of these results to midurethral sling placement is somewhat limited, since many participants in both trials (55 to 60 percent) underwent procedures other than sling placement.

If a patient fails her voiding trial, she can either go home with an indwelling bladder catheter or she can be taught intermittent self-catheterization. Women who fail the voiding trial can be reassured that their surgical success rate is not compromised and some evidence suggests it may be higher [53]. Management of women with postoperative voiding dysfunction is described below. (See 'Postoperative catheter management' below.)

COMPLICATIONS — Retropubic midurethral sling placement is a minimally invasive procedure and complications are uncommon [54]. The most frequent complications of this procedure are bladder perforation, voiding dysfunction, and development of urinary urgency symptoms.

Urinary tract complications

Bladder injury — Intraoperative bladder perforation is the most common complication of retropubic midurethral sling placement. In studies of 200 or more procedures, the reported rate ranges between 2 to 6.6 percent [54-59]. In large registries including up to 4281 women, the bladder perforation rate was low (2.7 to 3.9 percent) [22]. Bladder perforation does not appear to be associated with reduced SUI cure rates or with long-term sequelae [55].

The likelihood of bladder perforation depends upon the surgeon's experience. A report of 600 procedures performed by an experienced surgeon had a 1 percent rate of bladder perforation [60], while inexperienced operators have reported rates ranging from 15 to 34 percent [45,61].

Bladder perforation is usually diagnosed with intraoperative cystoscopy. Leaving the trocar in place prior to cystourethroscopy facilitates identification of this type of injury. Bladder management after perforation depends upon the site and extent of perforation. Bladder perforations in the posterior bladder closer to the vaginal incision are theoretically at a higher risk of fistula formation than the more common anterior perforations near the dome of the bladder. Management varies, but surgeons typically continuously drain the bladder with a urethral catheter in place for one to several days [45]. However, in a retrospective study, 25 women with a bladder perforation passed a voiding trial on the day of the procedure and were discharged without a catheter and had no adverse events, suggesting that patients with perforation who do not have gross hematuria and pass a voiding trial at discharge may be safely discharged without a catheter [62]. In our practice, after the more common anterior/lateral perforation, we leave the bladder catheter in place for less than a day and typically remove the catheter without an imaging study. A posterior perforation near the trigone and near the vaginal incision is uncommon but more concerning; we drain the bladder for at least seven days and perform a cystogram to exclude extravasation before discontinuing the bladder drainage. (See 'Initial trocar insertion' above.)

It is important to recognize bladder and urethral perforations at the time of the initial procedure because delayed recognition is associated with significantly more morbidity. Occult bladder injury should be suspected if fluid leaks persistently from the vagina or the abdominal incision sites [63]. Unrecognized injuries appear to occur more frequently in women with prior retropubic surgery. In women in whom bladder perforation is recognized after the mesh has been passed, we remove all of the sling material from the bladder. This may be performed using laparotomy, cystoscopy, or cystoscopy assisted by suprapubic laparoscopic instruments.

Another mechanism of bladder injury is erosion of the mesh through the bladder wall; this complication is uncommon and the incidence is unknown [64,65]. Some reported cases of mesh erosion may have been bladder perforations that were not recognized at the time of surgery. Others may represent a true erosion of mesh that slowly extrudes through the tissue over time.

Vesical erosion typically presents several weeks to months postoperatively as urinary urgency, hematuria, or bladder stones [65-67]. This condition is diagnosed with cystoscopy. There are a variety of management options, including: cystoscopic resection using laser or scissors, cystoscopic-guided suprapubic laparoscopic resection, and suprapubic telescopy (cystoscopy through a suprapubic incision) with suprapubic or transurethral instrumentation. Depending upon the severity of the erosion and whether a fistula is present, sometimes a complete transvaginal or transabdominal reconstructive procedure is warranted.

Urethral injury — Intraoperative urethral perforation or laceration occurs in approximately 0.9 percent of midurethral retropubic sling placements [68]. This type of complication may be diagnosed during cystourethroscopy. When recognized immediately, in our practice, we do not complete the procedure, since we consider this a high risk situation for urethral mesh erosion. We then leave a urethral catheter in place for seven days. The midurethral sling may be performed at a later time after urethral healing.

Rarely, urethral injury is not recognized immediately or injury occurs postoperatively due to mesh erosion [68-71]. These injuries often present several weeks or months postoperatively with periurethral discomfort, hematuria, voiding difficulty, or irritative voiding symptoms. Urodynamic evaluation may reveal evidence of outflow obstruction. Management includes excision of the eroded portion of the mesh and urethroplasty with the use of local flaps where necessary [72,73].

Urinary tract infection — Urinary tract infection is a common complication after midurethral sling placement [74]. In one large study of 13,404 midurethral sling surgeries, 23 percent of patients developed a urinary tract infection within the first 12 months, most of which were diagnosed within the first month. Increased age, diabetes, and having urinary retention requiring catheterization were predictors of urinary tract infection [75]. Urinary tract infection should be treated, as appropriate.

Voiding dysfunction — Urinary retention or incomplete bladder emptying are commonly reported after retropubic midurethral sling placement [76]. The reported rate of voiding dysfunction varies from 19.7 to 47 percent of cases, depending upon the definition and diagnostic criteria used [52,57]. In our practice, we define incomplete bladder emptying as a postvoid residual volume of >150 mL.

In the Trial of Midurethral Sling (TOMUS) study, no preoperative urodynamic variable was identified that could predict postoperative voiding dysfunction [77]. However, other studies have reported that women with a preoperative maximum urinary flow rate <15 mL/sec compared with those with a rate >30 mL/sec had higher rates of postoperative voiding dysfunction (27 to 67 versus 4 percent) [78,79]. Preoperative counseling for patients who undergo urodynamics and have a maximum flow rate of <15 mL/sec may include a discussion of an increased risk of requiring short-term catheterization.

Postoperative catheter management — Various management strategies have been used for post-sling voiding dysfunction, including:

●Intermittent self-catheterization – The patient self-catheterizes after each void and records the postvoid residual in a voiding diary. Catheterization is discontinued when the postvoid residuals are consistently <150 mL.

●Indwelling bladder catheter – The bladder catheter is left in place and a voiding trial performed every three to four days until the postvoid residual is <150 mL.

In our practice, we usually start with an indwelling bladder catheter, followed by intermittent self-catheterization. If that approach is not successful, then we perform sling loosening or a sling release. Urethral dilation may be considered in the early postoperative period prior to tissue ingrowth into the sling. However, too much traction on the sling theoretically increases the risk of mesh erosion into the urethra, and, in general, this procedure is discouraged.

For urinary retention that lasts longer than a few days, clean intermittent self-catheterization is preferable to a long-term indwelling catheter to reduce the risk of urinary tract infection. (See "Placement and management of urinary bladder catheters in adults", section on 'Choice of catheter'.)

Antibiotic prophylaxis is not required for short- or long-term bladder catheter use. Antimicrobial therapy should be reserved for patients with a urinary tract infection. (See "Placement and management of urinary bladder catheters in adults", section on 'Prophylactic antibiotics'.)

Sling adjustment

Loosening — While most cases of postoperative urinary retention resolve with expectant management, persistent voiding dysfunction requires surgical intervention in the form of a sling loosening or release [80-82]. The timing of sling loosening or release is controversial. Most voiding dysfunction resolves spontaneously, so if there is improvement, the patient can be observed for up to six weeks [77]. However, if there is complete retention or small voids with large residuals, a sling loosening at one to two weeks after the initial procedure is reasonable. After two weeks, tissue ingrowth rarely allows sling loosening. Sling loosening can be performed in the office or in the operating room by removing the vaginal incision sutures, isolating the sling, placing an instrument behind the sling and applying gradual downward traction on the sling until it loosens, and then reclosing the incision. If this does not resolve the obstruction, then a sling release will be needed.

Release — In a study of billing codes of over 180,000 women who underwent a midurethral sling procedure between 2001 and 2010, the cumulative rate of sling release performed for the indication of urinary retention was 1.3 percent at nine years postoperatively [83]. The rate increased from 0.8 percent at six months postoperatively to 1.1 percent at two years and then generally plateaued. Similarly low rates of sling release due to urinary retention were reported in a large retrospective cohort that included 10,750 retropubic sling procedures [84].

Sling release relieves urinary retention in most women and SUI recurs in some, but not all, women. Studies of 1000 or more procedures have reported persistent voiding dysfunction following 0.6 to 2.0 percent of midurethral sling procedures [85,86]. There are few data regarding the results of sling release. In a retrospective study of 23 women who underwent sling release following TVT: all patients had complete resolution of urinary retention; 14 (61 percent) had complete cure of SUI; 6 (26 percent) had partial improvement in SUI symptoms; and 3 (13 percent) had failure of SUI treatment [85]. Another study of 50 women who had sling release reported that urinary retention did not completely resolve in 4 patients (12 percent) [86].

At our institution, we perform sling release in the operating room with local, regional, or general anesthesia, as appropriate. We use the following procedure for sling release:

●Inject local anesthesia or dilute vasopressin for hydrodissection at the midurethral portion of the vagina.

●Incise the vaginal mucosa in the midline overlying the sling.

●Identify the sling. The sling can often be identified with palpation or by transilluminating the urethra with a urethroscope to determine its location.

●Isolate the entire width of the sling from the urethra; this should be accomplished before any attempt at transection, to ensure that the sling is completely transected. This step is sometimes challenging and requires that an instrument (eg, thin tipped right-angle clamp) is inserted behind the sling. Care is taken during the dissection to isolate only the sling without compromising the urethra. Placement of a bladder catheter before this step is often helpful.

●Transect the sling completely. After transection, both ends typically retract slightly.

●Perform urethroscopy to ensure that urethral damage has not occurred and then close the vagina in layers, if possible.

Urinary urgency — Urinary urge symptoms (eg, urgency, urgency incontinence, frequency) develop in some women following retropubic midurethral sling placement. The reported incidence ranges widely from 5.9 percent to 25 percent [80,87,88].

In the immediate postoperative period, transient urge symptoms were believed to be a result of pelvic hematomas. However, one study reported a 17 percent retropubic hematoma formation after surgery but did not find a significant association between de novo LUTS and retropubic hematomas [89]. The etiology of new irritative urinary symptoms is thought to be a combination of mild urinary obstruction and urethral irritation associated with the sling. In one study, 15 of 29 women with post-sling de novo urge symptoms were successfully treated with anticholinergic medications, which are early line therapies for other etiologies of urinary urge symptoms [88].

Evaluation and management of urinary urgency symptoms are discussed separately. (See "Female urinary incontinence: Evaluation".)

Other urinary tract complications — Ureteral injury is rare. As an example, in a survey study that included 12,280 midurethral sling procedures, only two ureteral injuries were reported [90].

Urinary tract fistula is a rare, but serious, complication of midurethral sling placement [68,91,92]. Isolated cases of vesicovaginal and urethrovaginal fistulas have been reported.

Evaluation and management of urinary tract fistulas are discussed separately. (See "Urogenital tract fistulas in females".)

Vascular injury — Occasional vascular injury occurs during retropubic midurethral sling placement, due to the blind passage of the trocars through the highly vascular retropubic space. Injury may involve the paravesical veins, obturator, external iliac, femoral, inferior epigastric or circumflex vessels. Hemorrhage (defined as >500 mL of blood loss) and/or blood transfusion has been reported in approximately 2.5 percent of cases [57,93]. Excessive bleeding can be managed intraoperatively with direct pressure on the paraurethral or retropubic areas [94,95].

Venous injury typically results in a self-limited slowly expanding retropubic hematoma. Hematoma formation may result in symptoms of bladder compression (suprapubic pain, urinary urgency, urinary frequency) and/or signs of significant blood loss (tachycardia, hypotension, anemia, oliguria). Abdominal and bimanual pelvic examination may reveal a palpable mass in the suprapubic or retropubic spaces (this may be either large or small) and/or ecchymoses in the suprapubic area (bruising may track to the labia). If no signs of hematoma are evident on physical examination, a diagnosis can be made with sonography or computed tomography [96]. One study of 14 women who underwent sonographic evaluation of retropubic hematomas reported that the volume of blood in the hematoma predicted the severity of symptoms: <100 mL (rarely symptomatic); 100 to 200 mL (moderate pain); and >300 mL (severe pain requiring surgical evacuation) [96].

Retropubic venous bleeding can often be managed with close observation and conservative management. A study that followed five patients with serial ultrasound noted that it took one to five months for retropubic hematomas to resolve [96].

Acute hemodynamic decompensation suggests arterial bleeding and requires invasive measures and supportive care (eg, fluid management, transfusion) [93]. Radiographic embolization of arterial vessels associated with the retropubic hemorrhage is the preferred option in a stable patient [95]. Large hematomas may be the result of large vessel damage and may also lead to life-threatening blood loss [64]. In an unstable patient, or if radiographic embolization is unavailable, emergency laparotomy is indicated. One study reported the incidence of massive hematomas (defined as greater than 8 cm in size and/or a drop in hemoglobin >4 g/dL) was 0.33 percent (7 of 2091 retropubic midurethral slings). The majority of these hematomas presented acutely with abdominal pain and hypotension and required blood transfusions and evacuation of their clot via laparotomy [97].

Bowel injury — Bowel perforation is a rare, but serious, complication of retropubic midurethral sling procedures [98]. There are few data regarding the incidence of this type of injury. A survey of surgeons who had performed a total of over 12,000 TVT procedures reported three bowel perforations [90]. Delayed erosion of the mesh into bowel has also been described [99]. There are also rare cases of sigmoid bowel perforation with TVT trocar that led to a colocutaneous fistula [100] as well as a cecal perforation with TVT [101]. From the time of the introduction of the TVT device in the late 1990s through 2004, the US Food and Drug Administration Manufacturer and User Facility Device Experience database had recorded a total of seven deaths associated with the device, six of which were related to bowel injury [102].

Women with prior abdominal or pelvic surgery or women who have an abdominal or inguinal hernia appear to have an increased risk of bowel injury during sling placement [19,103-106]. A transobturator midurethral sling may be preferable for these patients. (See 'Contraindications' above and "Surgical management of stress urinary incontinence in females: Choosing a type of midurethral sling", section on 'Choosing among midurethral slings'.)

A measure that has been proposed to prevent bowel injury is to place the patient in steep Trendelenburg position to allow the bowel to shift out of the retropubic area [107]. In our practice, we may use slight, but not steep, Trendelenburg.

Bowel perforation is a surgical emergency. Women with severe or persistent abdominal pain following retropubic midurethral sling placement should be evaluated for bowel injury. Pain may be accompanied by fever and/or feculent or purulent drainage from the abdominal incision sites. Women with suspected bowel injury should undergo imaging with a plain radiograph or computed tomography, and surgical exploration should be expedited, if necessary. (See "Overview of gastrointestinal tract perforation" and "Evaluation of the adult with nontraumatic abdominal or flank pain in the emergency department".)

Synthetic mesh complications — Mesh exposure, previously known as erosion, is a common complication when synthetic mesh is used [108-110]. In a study of billing codes of over 180,000 United States women who underwent a midurethral sling procedure between 2001 and 2010, the cumulative rate of sling release performed for the indication of mesh exposure was 2.5 percent at nine years postoperatively [83]. The rate increased from 0.9 percent at six months postoperatively to 2.2 percent at five years and then generally plateaued. Similar results were reported in a subsequent retrospective, population-based study of British women from the National Health Service hospitals [111]. In that group of over 95,000 women undergoing first midurethral sling insertion between 2006 and 2015, the rates of sling removal were 1.4, 2.7, and 3.3 percent at one, five, and nine years, respectively. The risk of removal at nine years was lower for transobturator slings compared with retropubic slings (2.7 versus 3.6 percent, subdistribution hazard ratio 0.72, 95% CI 0.62-0.84). The overall rates of any sling-related surgery, including mesh removal, were 2.6, 5.5, and 6.9 percent at one, five, and nine years, respectively.

Common clinical presentations of vaginal mesh exposure include visible or palpable tape in the vagina, vaginal discharge, vaginal bleeding, postcoital spotting, dyspareunia, male sexual partner discomfort (hispareunia), or urinary tract infection. The diagnosis of mesh exposure is made with visual inspection of the vagina.

Management for vaginal erosions varies with the extent of the erosion and the severity of symptoms. Initial management is with conservative measures, including vaginal estrogen therapy and avoidance of vaginal insertions (tampons, intercourse) [108]. If symptoms persist and/or the patient or her partner can feel the sling and find this bothersome, surgical treatments may be offered. These include:

●Reapproximating the vaginal epithelium (this is only possible if there is sufficient tissue)

●Excision of the palpable portion of mesh [108]

●Partial/complete removal of the mesh [72,112]

Patients should be counseled that removal of all or part of the mesh may result in recurrent SUI. (See 'Loosening' above.)

Erosion of mesh into the bladder, urethra, or bowel is discussed separately. (See 'Bladder injury' above and 'Urethral injury' above and 'Bowel injury' above.)

Pelvic pain — Some women develop chronic pelvic pain following retropubic midurethral sling placement (7.5 percent in one series of 241 women) [57]. Depending upon the severity and duration, pelvic pain may be treated with expectant management, medical therapy, or pelvic physical therapy. Resolution of symptoms with removal of the mesh via laparoscopy or vaginal and thigh incisions was reported in a prospective study of 32 women who developed pelvic and perineal pain following placement of a midurethral sling [113]. At 10-month follow-up, visual analog pain scores improved by at least 50 percent in 68 percent of women; 22 percent had recurrent SUI.

The evaluation and management of pelvic pain are discussed separately. (See "Chronic pelvic pain in adult females: Evaluation".)

Postoperative dyspareunia following retropubic midurethral sling placement has not been routinely reported. However, this complication has been reported following transobturator sling procedures. (See "Surgical management of stress urinary incontinence in females: Transobturator midurethral slings", section on 'Sexual function'.)

Other complications — There have been case reports of necrotizing fasciitis [114], ilioinguinal nerve entrapment [115,116], and obturator neuropathy [117] following retropubic midurethral sling placement.

FOLLOW-UP

Postoperative care and instructions — Women may experience vaginal, periurethral, or lower abdominal discomfort and pain at incision sites for up to two weeks following the procedure. These symptoms are typically well controlled with oral narcotics or nonsteroidal anti-inflammatory drugs. Many women also have vaginal spotting for up to two weeks.

We counsel patients to call their surgeon if they experience symptoms that may be associated with a serious complication, including:

●Fever

●Heavy vaginal bleeding

●Light-headedness

●Severe or persistent abdominal pain

●Vomiting or persistent nausea

●Discharge of clear fluid or blood from the incision sites that is copious or persistent or any amount of purulent or feculent discharge

Patients who present with these symptoms should be promptly evaluated.

Urinary retention may occur even after a successful postoperative voiding trial. Patients who feel a persistent sense of urinary retention or incomplete bladder emptying should have a postvoid residual volume measured and may require catheterization. (See 'Postoperative catheter management' above.)

The sling is initially held in place solely by frictional tissue forces, and patients must allow adequate time for tissue in-growth to occur before significant intraabdominal pressure is applied to the mesh. Patients are advised to avoid heavy lifting, actions that increase intraabdominal pressure, or exercise for at least two weeks. Ambulation, however, is encouraged. Sexual activity should be avoided until the vaginal epithelium is healed, which takes approximately six weeks.

The patient may return to work when she feels sufficiently comfortable.

We see patients for a routine follow-up visit at four to six weeks. We perform abdominal and vaginal examinations to ensure that the incisions have adequately healed and to check for vaginal mesh erosion. The vaginal sulci are visualized and palpated to confirm that there are no occult extrusions of mesh. We check a postvoid residual volume to assess whether the patient has been adequately emptying her bladder. This can be measured with a bladder ultrasound or catheterization.

Patient information regarding care after pelvic surgery can be found separately. (See "Patient education: Care after gynecologic surgery (Beyond the Basics)".)

Persistent or recurrent SUI — For patients who present at the postoperative visit after a retropubic midurethral sling procedure and report persistent SUI, the position of the sling should be evaluated. The midurethra is largely considered the continence zone of the urethra and careful positioning of the sling beneath this portion of the urethra has been shown to achieve the highest rates of continence. Clinicians may assess positioning of the sling with palpation along the urethra. They may also check for the presence or absence of urethral hypermobility.

Three-dimensional transperineal, translabial, and endovaginal ultrasound can be used to evaluate sling position and correlate position with surgical outcomes [118]. Ultrasound can also differentiate between transobturator and retropubic slings, provide information on mesh type, and locate mesh and mesh position which can often be difficult to find on physical examination [119]. As an example, a case control study evaluated 100 patients following transobturator sling surgery [120]. Based upon three-dimensional transperineal ultrasound, a transobturator sling that moved concordantly with the urethra during dynamic testing, was located in the midurethra, and deformed appropriately with stress maneuvers was associated with the best success rates. Unsuccessful slings were often positioned too proximally.

In our experience, the most common cause of midurethral sling failure is incorrect placement (typically at the bladder neck instead of the mid urethra). When a midurethral sling is too proximal, continence can be achieved by placing a repeat midurethral sling properly under the midurethra without removing the nonfunctioning sling. The majority of patients do very well after repeat retropubic midurethral sling [121].

In a retrospective cohort of 17,030 patients who underwent a midurethral sling between 2005 and 2016, the cumulative reoperation rate for recurrent SUI was 1.6, 3.9, and 5.2 percent at one, five, and nine years, respectively [84]. The most common operation was the synthetic midurethral sling. Patients who initially had a single incision sling had a much greater risk of needing a reoperation when compared with the retropubic midurethral sling (adjusted hazard ratio 1.5, 95% CI 1.03-2.11).

The evaluation and management of persistent or recurrent SUI after continence surgery is discussed in detail separately [122]. (See "Stress urinary incontinence in females: Persistent/recurrent symptoms after surgical treatment".)

Subsequent pregnancy — Most physicians recommend delaying midurethral sling placement until childbearing has been completed. The rationale includes that pelvic support may be disrupted during pregnancy and birth, particularly following a vaginal birth, and that long-term outcomes data are limited. However, available data suggest that patients with subsequent pregnancy and childbirth are not at increased risk for recurrent SUI symptoms or repeat surgery [123-126].

●Risk of recurrent SUI or repeat surgery – Childbirth after MUS does not appear to be associated with an increased risk of subsequent SUI or need for repeat surgery [125,126]. A meta-analysis comparing 381 patients with childbirth after MUS placement with 860 patients with MUS only reported similar SUI recurrence and reoperation rates for both groups at a mean duration of follow-up of 9.8 years (range 2 to 18 years) [125]. Absolute SUI recurrence rates ranged from 17 to 24 percent versus 15 to 22 percent (RR 1.02, 95% CI 0.78-1.33), respectively, while reoperation rates were 3 to 12 percent versus 3 to 7 percent (RR 1.37, 95% CI 0.87-2.17). The seven included studies were observational and SUI recurrence was defined subjectively.    

●Mode of delivery – For patients who become pregnant following anti-incontinence surgery, the route of delivery should be determined by patient preference and obstetric indications. Based on the limited data available, the risks of recurrent SUI and reoperation are similar for vaginal and cesarean birth [125,127-130]. We counsel patients that vaginal birth does not appear to increase risk, nor does cesarean birth reduce risk, and discuss the caveats that the available evidence is based on small sample sizes and low numbers of events, in addition to a lack of multi-decade follow-up.

Representative studies include:

•In a 2023 meta-analysis comparing 381 patients with childbirth after MUS placement with 860 patients with MUS only, risk of SUI recurrence and reoperation were similar for vaginal and cesarean birth [125]. However, definitive conclusions regarding equivalence were limited by the low number of events and small sample sizes. For SUI recurrence, absolute rates were 4 in 25 (16 percent) versus 2 in 27 (7.4 percent, RR 1.81, 95% CI 0.48-6.80), respectively, and reoperation rates were 13 in 113 (11.5 percent) versus 12 in 139 (8.6 percent, RR 1.42, 95% CI 0.70-2.92).

•A 2018 population-based cohort study including 537 Swedish women who became pregnant following midurethral sling surgery reported no differences in SUI rates between pregnant and control women or between the vaginal and cesarean delivery groups [123].  

•A 2018 population-based cohort study of 228 individuals with mid-urethral slings who were followed for 10 years reported that one childbirth did not impact subjective success rates but more than one birth did (subjective success rates of 88 versus 50 percent, respectively) [124]. (See "Female stress urinary incontinence: Choosing a primary surgical procedure", section on 'Women finished with childbearing'.)

OUTCOME — Minimally invasive midurethral slings are widely considered to be the standard of care for women undergoing surgical treatment for SUI [37]. In a meta-analysis of 55 trials including women receiving retropubic slings, short-term subjective cure rates (within 12 months postoperatively) of 71 to 97 percent were reported [22]. In the Trial of Midurethral Slings (TOMUS; n = 597; the largest randomized trial comparing retropubic and transobturator slings to-date), for retropubic slings, the 12-month subjective success rate was 62 percent and the objective cure rate was 78 percent [37]. Patient satisfaction has been reported as over 80 percent at one year postoperatively [131].

Long-term data include a prospective cohort study that followed women for up to 17 years after TVT procedures that reported objective cure rates of 90 percent and subjective cure rates of 87 percent [132]. (See "Female stress urinary incontinence: Choosing a primary surgical procedure", section on 'Comparison of efficacy'.)

Risk factors for failure of either a retropubic or transobturator sling within one year of placement based upon data from the TOMUS trial included: previous anti-incontinence surgery (twofold increased risk); urgency symptoms (as measured by a questionnaire score; twofold); and maximum Q-tip excursion <30° on preoperative urethral hypermobility testing (1.9-fold) [133]. Objective, but not subjective, failure was associated with age (1.5-fold per 10 years). Having concomitant surgery was associated with a lower risk of subjective, but not objective, failure (0.44-fold).

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Incontinence surgery in women" and "Society guideline links: Urinary incontinence in adults" and "Society guideline links: Gynecologic surgery".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, and answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon. (See "Patient education: Urinary incontinence in females (The Basics)" and "Patient education: Urinary incontinence treatments for women (Beyond the Basics)".)

SUMMARY AND RECOMMENDATIONS

●Stress urinary incontinence (SUI) is the involuntary leakage of urine with increased intraabdominal pressure. Midurethral sling placement is the procedure of choice for treatment of SUI in many women. Midurethral slings may be placed either through the retropubic or transobturator spaces. (See 'Introduction' above.)

●Relative contraindications for retropubic midurethral sling placement include future plans for pregnancy and an increased risk of injury to retropubic structures (ie, due to prior surgery or a current hernia that may result in the presence of viscera or major vessels in the retropubic space). (See 'Contraindications' above.)

●Women who are planning primary midurethral retropubic sling placement should undergo preoperative evaluation to confirm the diagnosis of SUI, exclude other etiologies of urinary incontinence, confirm normal bladder emptying, and assess surgical risk. (See 'Evaluation' above and "Surgical management of stress urinary incontinence in females: Preoperative evaluation for a primary procedure".)

●We recommend antibiotic prophylaxis for surgical site infection for surgical procedures for treatment of pelvic organ prolapse or SUI that utilize surgical mesh (Grade 1A). (See 'Antibiotic prophylaxis' above.)

●For women undergoing retropubic midurethral sling placement, we suggest a bottom-to-top rather than top-to-bottom approach for trocar insertion (Grade 2B). (See 'Comparison of insertion routes' above.)

●We suggest use of local anesthesia with conscious sedation or regional anesthesia rather than general anesthesia for midurethral sling placement (Grade 2C). General anesthesia may be used if it is preferred by the patient or if it is required for a concomitant procedure. (See 'Anesthesia' above.)

●During sling placement, the trocars must be passed along the correct path without deviation to avoid complications. Small deviations of the trocar handle create a magnified deviation of the tip of the trocar, resulting in potential injury to adjacent structures. (See 'Initial trocar insertion' above.)

●Common complications of midurethral retropubic sling placement include bladder perforation, voiding dysfunction, and development of urinary urgency symptoms. Surgeons should be aware of the potential for serious complications, including bowel injury, vascular injury, and urinary tract fistula. (See 'Complications' above.)

●Voiding dysfunction following sling placement may be treated initially with bladder catheterization. Persistent symptoms may require sling loosening or sling release (which may result in recurrent SUI). (See 'Postoperative catheter management' above and 'Sling adjustment' above.)

●Long-term data show a SUI cure rate of approximately 80 percent following retropubic midurethral sling placement. (See 'Outcome' above.)