Surgical management of stress urinary incontinence in females: Choosing a type of midurethral sling

INTRODUCTION — Stress urinary incontinence (SUI) is an involuntary loss of urine that occurs with effort or exertion, such as sneezing or coughing. Treatment typically begins with nonsurgical treatments and progresses to surgical options. Individuals who desire surgical therapy must first select the type of surgery (eg, midurethral sling, suburethral sling, colposuspension), and for those who elect a midurethral sling, then decide among multiple options available.

This topic will discuss the process of choosing among the different midurethral sling types for females with SUI who have elected midurethral sling surgery to treat SUI and have not had prior anti-incontinence surgery. Discussions addressing the evaluation of female urinary incontinence, nonsurgical management of SUI, range of primary surgical procedures to treat SUI, treatment of recurrent SUI, combined treatment of pelvic organ prolapse and urinary incontinence prevention, and issues related to synthetic mesh in vaginal surgery are presented separately.

●(See "Female urinary incontinence: Evaluation".)

●(See "Female urinary incontinence: Treatment".)

●(See "Female stress urinary incontinence: Choosing a primary surgical procedure".)

●(See "Stress urinary incontinence in females: Persistent/recurrent symptoms after surgical treatment".)

●(See "Pelvic organ prolapse and stress urinary incontinence in females: Surgical treatment".)

●(See "Transvaginal synthetic mesh: Complications and risk factors".)

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.

SUI BACKGROUND AND TREATMENT OPTIONS

●Mechanism of SUI – SUI occurs when an increase in intra-abdominal pressure exceeds urethral closure pressure, resulting in the involuntary leakage of urine. This may occur with physical exertion, sneezing, or coughing [1,2]. There are two main mechanisms of SUI: urethral hypermobility and intrinsic sphincter deficiency. (See "Female urinary incontinence: Evaluation".)

●Prevalence – One population study of adult patients in the United States reported a 46 percent prevalence of SUI [3]. Prevalence rates of female urinary incontinence vary with the population being studied (ex, age, parity, activity level), measurement used, and time of observation. (See "Female urinary incontinence: Evaluation", section on 'Epidemiology'.)

●Treatment options

•Nonsurgical – Initial nonsurgical management of SUI typically includes evaluation for contributing factors (eg, diuretic use), lifestyle alterations such as weight loss, vaginal devices, and pelvic floor muscle exercises [4]. (See "Female urinary incontinence: Treatment", section on 'Initial treatment'.)

•Surgical options – Minimally invasive midurethral synthetic slings have become the preferred surgical procedure for most females because of their high efficacy, low risk of complications, and rapid recovery [5]. Alternative surgical options include urethral bulking injections, transvaginal pubourethral slings, and colposuspension (ie, retropubic urethropexy). These approaches are discussed and compared in detail in related content. (See "Female stress urinary incontinence: Choosing a primary surgical procedure", section on 'Types of procedures'.)

●Development of midurethral slings – The midurethral tension-free vaginal tape (TVT) was introduced in 1995 followed by the transobturator midurethral sling in 2001 [6]. The transobturator approach was designed to avoid some of the complications of a retropubic insertion (eg, bladder perforation, vascular injury, bowel injury). Since that time, other devices have been developed, with a variety of introducer mechanisms and mesh types. (See 'Retropubic or transobturator full-length slings' below.)

SLING TYPES AND ROUTES — The two main types of sling procedures for treatment of SUI in females are midurethral and pubovaginal slings (table 1). These procedures vary by the location of the sling placement along the course of the urethra (midurethra versus bladder neck) and by the sling material (synthetic versus biologic). Collectively, slings consist of material that is placed posterior to the urethra to provide support and closure for the urethra during increased pressure, thereby preventing incontinence.

Midurethral slings — Midurethral slings, one type of suburethral sling, are placed at the level of the midurethra in a tension-free manner. These slings are made of synthetic mesh and include retropubic, transobturator, and single-incision slings.

Retropubic — Retropubic midurethral slings (eg, tension-free vaginal tape [TVT]) are inserted through the retropubic space and exit through the abdominal wall in the suprapubic area (figure 1). Retropubic midurethral slings have become the preferred surgery for female SUI. The bottom-to-top approach appears to offer superior efficacy. A detailed discussion of the advantages and disadvantages of the retropubic sling types and surgical approaches is presented in related content. (See "Surgical management of stress urinary incontinence in females: Retropubic midurethral slings", section on 'Comparison of insertion routes'.)

The two main variations of full-length retropubic midurethral sling defined by 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 (eg, the original TVT device).

●Top-to-bottom – Two needle trocars are inserted through abdominal incisions and passed through the retropubic space, exiting through a vaginal incision (eg, suprapubic arch [SPARC]).

Transobturator — Transobturator midurethral slings (eg, TVT Obturator) are inserted through the two obturator foramens and exit through the skin of the groin area (figure 2). A detailed discussion of the advantages and disadvantages of the transobturator approaches is presented in related content. (See "Surgical management of stress urinary incontinence in females: Transobturator midurethral slings", section on 'Choosing a type of transobturator sling'.)

The two variations of transobturator midurethral sling procedures, which vary by direction of trocar insertion, include:

●Inside-out – The trocars are passed from a midurethral vaginal incision to exit through bilateral groin incisions (TVT Obturator).

●Outside-in – The trocars are passed from bilateral groin incisions to exit through a midurethral vaginal incision (Aris, Obtryx).

Single-inicison — Single-incision midurethral slings (also referred to as mini 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 (ie, no concomitant abdominal incisions). Purported advantages of single-incision slings are less tissue disruption, less risk of visceral injury, and fewer patients requiring catheter use postoperatively compared with retropubic or transobturator approaches [7].

There are two variations of single-incision slings, based upon their anatomic path and the site to which they are attached:

●Retropubic – U-shaped (U) position into the connective tissue of the urogenital diaphragm

●Transobturator – Hammock (H) position into the obturator internus muscle

Pubovaginal slings — Pubovaginal slings are placed at the level of the proximal urethra and bladder neck (figure 3). This procedure uses autologous fascia, tissue, or biologic graft to support the urethra to an abdominal wall fixation site through both vaginal and abdominal incisions. The arms of the sling material are affixed to Cooper's ligament or pubic bone rather than the anterior rectus fascia [8]. (See "Surgical management of stress urinary incontinence in females: Pubovaginal sling procedures".)

CHOOSING AMONG MIDURETHRAL SLINGS — Minimally invasive midurethral synthetic slings have become the preferred surgical procedure for most individuals with SUI because of their high efficacy, low risk of complications, and ease of recovery [5,9]. Surgeons who perform midurethral slings as primary surgical treatment of SUI must then consider the relative benefits and risks of full-length or single-incision slings.

A detailed discussion comparing abdominal and vaginal SUI procedures, including midurethral slings, is presented in related content. (See "Female stress urinary incontinence: Choosing a primary surgical procedure", section on 'Choosing a procedure'.)

Full-length versus single-incision — Given the available evidence, we suggest a full-length rather than single-incision sling for individuals planning primary midurethral sling surgery [10,11]. Our rationale is based on a 2023 meta-analysis evaluating 12-month subjective cure or improvement of incontinence for single-incision slings (excluding trials using the TVT-Secur sling which was removed from market in 2013) compared with either retropubic or transobturator slings [10]. This study demonstrated evidence of similar subjective cure and improvement of incontinence at 12 months when comparing single-incision slings with either retropubic or transobturator slings, but also uncertainty in differences of adverse events and long-term outcomes. The study also demonstrated that there is a larger body of evidence with longer duration of follow-up (ie, beyond 36 months) for full-length slings, evidence that those with single-incision slings may have lower quality of life at 12 months compared with transobturator slings, and evidence that single-incision slings may lead to slightly more patients requiring repeat continence surgery or mesh revision compared with transobturator slings. However, if reducing short-term postoperative pain is a prioritized concern, studies suggest a single-incision sling is an acceptable alternative [7,10]. For both single-incision and full-length slings, patients should be counseled about use of synthetic materials, risk of mesh exposure, and potential adverse events, including potential need for additional surgery [10,11].

Retropubic or transobturator full-length slings

Summary — Those who elect a full-length sling must choose between two types, retropubic and transobturator, each of which has two approaches to insertion. We believe the available data do not demonstrate clear superiority of one full-length sling type over another; we place more clinical value on data from the smaller but randomized trials, and resultant meta-analyses, rather than large retrospective cohort studies [12-23]. Therefore, selection is based on patient preferences and values around efficacy, risk of surgical injury, surgeon skill set, and risk of persistent pain, among other factors.

●Favoring retropubic midurethral sling – Patients who desire a slightly higher probability of efficacy and are willing to accept a small increased risk of adverse events usually choose retropubic midurethral sling. Retropubic slings have slightly higher efficacy at the cost of greater rates of bladder perforation, bowel injury, short-term postoperative suprapubic pain, and postoperative voiding dysfunction (which could require sling release) [9,11,22]. (See "Surgical management of stress urinary incontinence in females: Retropubic midurethral slings".)

●Favoring transobturator midurethral sling – Patients who desire lower risk of adverse events and are willing to accept a slightly lower efficacy typically choose transobturator midurethral slings. Additionally, transobturator slings are associated with more short-term postoperative groin pain but less voiding dysfunction compared with retropubic slings [9,22]. (See "Surgical management of stress urinary incontinence in females: Transobturator midurethral slings".)

●Our approach – In our practice, surgeons offer both types of midurethral slings. Those who favor retropubic slings prioritize the reported higher efficacy rate over the higher bladder injury rate compared with transobturator slings. Those who favor transobturator slings prioritize the noninferior efficacy studies combined with the lower rates of bladder injury when compared with retropubic slings.

Efficacy — Retropubic slings appear to have slightly higher short-term and longer-term efficacy [9,21,24,25]. Supporting data include:

●Network meta-analysis – A 2019 network meta-analysis of over 21,000 patients from 175 trials, obtained from earlier meta-analyses and subsequent trials, reported SUI cure rates of 89.1 percent for retropubic midurethral sling and 64.1 percent for transobturator midurethral sling [9]. Compared with retropubic midurethral sling, the odds ratio of improvement for transobturator midurethral sling was 0.76 (95% CI 0.59-0.98). However, most of the included studies were limited to approximately 12 months of follow-up.

●Meta-analysis – A 2017 meta-analysis including data from 55 trials of midurethral sling operations for SUI in patients reported no difference in subjective cure rates at one year [21]. Specifically, subjective cure rates of 62 to 98 percent were reported in the transobturator sling group and 71 to 97 percent in the retropubic sling group at one year. Fewer studies reported longer term data (greater than five years), but subjective cure rate remained similar between the two groups, although the transobturator approach had a higher rate of repeat surgery after five years.

●Trial data

•Five-year follow-up – One of the trials included in the above network meta-analysis, the Trial of Midurethral Slings (TOMUS), also reported five-year follow-up data for 597 patients randomly assigned to either sling procedure [15,17]. Additional important findings from the five-year follow-up included [17]:

-More patients reported incontinence over time regardless of sling type. The incontinence rates for transobturator versus retropubic sling procedures (56 versus 49 percent) were not significantly different. It is not known if this incontinence increase was a result of the surgical procedure, the underlying incontinence process, or natural aging.

-Patient-reported outcomes for quality of life, sexual function, and global assessment of improvement decreased with time in both treatment groups but remained greater than presurgery measurements. Compared with retropubic slings, those with transobturator slings reported more sustained improvement in urinary symptoms, quality of life, and sexual function despite the slightly lower treatment success rate.

-New mesh exposures continued to occur throughout the five-year follow-up, but the overall rate of mesh exposure remained low at 1.7 percent.

•Longer-term follow-up – Limited longer-term follow-up data suggest improved continence rates with retropubic slings. A questionnaire study of 110 patients from an earlier trial reported found cured SUI was more common following retropubic (eg, tension-free vaginal tape [TVT]) compared with transobturator (Monarc) procedures at 12 years of follow-up (42 versus 22 percent) [25]. Overall symptom improvement rates were similar for the two procedure types (80 percent for retropubic versus 77 percent for transobturator).

Risk of repeat incontinence surgery — The body of evidence suggests that reoperation for recurrent SUI is less likely following retropubic slings compared with transobturator slings [22,26,27].

●Five-year data – A five-year cohort study of over 8600 Danish patients reported that those with the transobturator slings were twice as likely to undergo reoperation as those with retropubic slings [26]. However, a subsequent study of data from the same Danish registry reported absolute five-year reoperation rates were overall low and estimated to be 6 percent for retropubic slings and 9 percent for transobturator slings.

●Eight-year data – A covariate-matched cohort study comparing patients with retropubic and transobturator slings reported that eight-year cumulative incidence rates of reoperation for SUI were 5.2 (95% CI 3.0-7.4) and 11.2 (95% CI 6.4-15.8) percent, respectively, a nonsignificant difference [22]. Longer term studies are emerging.

●Seventeen-year data – A study that followed 46 out of 52 patients from Switzerland and Italy with retropubic slings for 17 years reported overall satisfaction and negative stress test rates of 89 and 91 percent, which are similar to the one-year cure rates above [27]. However, 15 (29 percent) of these study participants reported de novo overactive bladder and were taking antimuscarinic or beta agonist therapies, and 4 percent reported persistent voiding dysfunction that was observed.

Complication comparison — In general, midurethral slings of both types have low complication rates. Overall, the majority of adverse events appears higher using the retropubic approach than the transobturator approach but the types of complications differ [22,24,28].

●Overall complication rates (all midurethral procedures) – In a database study of 9910 isolated sling procedures (combined retropubic and transobturator), the readmission and reoperation rates were 0.6 and 0.8 percent [29].

●Network meta-analysis comparison – A network meta-analysis of over 21,000 females from 175 trials reported the following outcomes by type of sling [9]:

•Retropubic midurethral slings were associated with a higher rate of suprapubic pain, as well as a higher rate of major vascular complications, bladder or urethral perforation, and voiding difficulties than transobturator midurethral sling.

•Transobturator midurethral slings had a higher rate of repeat procedures and a higher occurrence of groin pain than retropubic midurethral sling.

•The two procedure types had similar rates of tape or mesh erosion or extrusion.

●Other outcomes

•Retropubic slings – Compared with transobturator slings, increased operating time, hospital stay, and blood loss have been reported with retropubic slings [14,15,18,24,28,30]. Additionally, retropubic sling placement may increase risk of postoperative urinary retention and bowel injury, particularly in individuals with prior abdominal or pelvic surgery (including abdominal and inguinal hernia repair) [22,31-35]. A covariate-matched cohort study reported that patients in the retropubic group had an increased risk of subsequent surgery for urinary retention (hazard ratio 8.11, 95% CI 1.08-61.17) [22]. (See "Surgical management of stress urinary incontinence in females: Retropubic midurethral slings", section on 'Bowel injury'.)

•Transobturator slings – Higher rates of de novo dyspareunia have been reported with transobturator slings compared with retropubic slings [36].

Whether the transobturator and retropubic approaches have different effects on sexual function is unclear [36-39]. In secondary analysis including data from two trials comparing autologous fascial sling, Burch colposuspension, or retropubic or transobturator slings, all treatment groups had improved Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ)-12 scores (adjusted analysis) over 24 months of follow-up with no significant differences among the groups [40,41]. (See "Sexual function in females with pelvic floor and lower urinary tract disorders", section on 'Impact of treatment'.)

Adjustable slings — Adjustable midurethral slings are a subsequent development that allow postoperative adjustment of sling tension. In the setting of ongoing postoperative stress incontinence, an adjustable sling allows a provider the option of pulling a permanent suture accessible in the vagina and tightening the sling until tension is considered adequate. Comparative data regarding this sling are limited and include small studies. The Remeex adjustable sling was evaluated in a population of 38 patients with valsalva leak point pressures <60 cm H₂O or maximal urethral closure pressures less than 20 cm H₂O [42]. A total of six patients had these slings adjusted according to their symptoms: three in the immediate postoperative period and three in the late postoperative period. At the end of the study, all patients were reported to be asymptomatic for SUI. A later study of 157 patient with primary SUI who underwent insertion of an adjustable obturator tape and had 12-month follow-up reported objective and subjective cure rates of 96 and 98 percent, respectively [43].

UNIQUE POPULATIONS

Mixed urinary incontinence — Individuals with mixed urinary incontinence appear to benefit from midurethral slings, particularly for patients with a significant SUI component [44-48].

●In the 2019 US Effects of Surgical Treatment Enhanced with Exercise for Mixed Urinary Incontinence (ESTEEM) trial comparing midurethral sling with combined behavioral and pelvic floor muscle therapy versus midurethral alone for the treatment of mixed urinary incontinence, 85 percent of patients were "better" or "very much better" 12 months after midurethral sling with or without behavioral and physical therapy [48]. Both groups reported low rates of additional urinary treatments.

●A 2011 systematic review and meta-analysis of five randomized controlled trials that included data on transvaginal and transobturator slings in individuals with mixed urinary incontinence reported similar subjective cure rates at 6 to 33 months follow-up for the two procedures (odds ratio [OR] 0.9, 95% CI 0.63-1.27) [47]. In this review, the cure rates of urge incontinence (30 to 85 percent) were more variable than for stress incontinence (85 to 97 percent) and declined over time.

Intrinsic sphincteric deficiency (ISD) — Intrinsic sphincteric deficiency (ISD) has been defined as urodynamic testing showing either a maximum urethral closure pressure (measured both with the bladder empty and at capacity) of 20 cm H₂O or less and/or a pressure rise from baseline required to cause incontinence (change in Valsalva or cough leak point pressure) of 60 cm H₂O or less. Some data suggest that the retropubic sling is more effective than the transobturator sling for patients with ISD [12,13,49-51]. Single-incision slings appear to effectively treat SUI in this population as well [7,52]. Of note, ISD is no longer considered a driving factor in selecting a surgical approach for SUI. (See "Urodynamic evaluation of women with incontinence", section on 'Urethral pressure profile'.)

Obesity and sling selection — While obesity is a known risk factor for urinary incontinence and weight loss can improve some symptoms, it is unclear if BMI should impact sling type selection [53].

●Midurethral sling efficacy

•Comparison of patients with and without obesity – Studies comparing midurethral efficacy for patients with and without obesity have reported mixed results. Observational studies have indicated no significant differences in outcomes for the two groups with efficacy rates of 72 to 83 percent in patients with obesity (combined midurethral sling types) [54-57]. However, a trial including 176 patients followed for five years reported improved outcomes for patients without obesity (objective cure 87 versus 66 percent and subjective cure 77 versus 54 percent) [58]. Definitive conclusions are hindered because most studies dichotomize BMI into obese and nonobese groups, which limits statistical power. In addition, there are variable durations of follow-up and differing assessments of cure. (See 'Efficacy' above.)

•Comparison of sling types for patients with obesity – Retropubic and transobturator slings appear similarly effective [59], although duration of follow-up is limited. A comparison of 180 patients with obesity receiving either retropubic or transobturator slings reported subjective and objective cure rates (87 versus 80 percent and 91 versus 88 percent, respectively) that were not significantly different [60].

●Bariatric surgery – Weight reduction following bariatric surgery does not appear to reduce midurethral sling efficacy, although limited data are available. In a large prospective cohort study, 1565 women with severe obesity who underwent bariatric surgery were assessed preoperatively and at one and three years postoperatively for urinary incontinence. Compared with preoperative baseline values, the prevalence of urinary incontinence decreased significantly at one and three years (from 49 to 18 and 25 percent, respectively) [61].

●Risk of mesh complication – While obesity may increase some surgical risks, the risk of subsequent mesh exposure appears to be lower following midurethral sling surgery for obese compared with nonobese patients [62].

●Technical challenges – While multiple factors ultimately impact choice of midurethral sling, obesity can make placement of both retropubic and transobturator trocars challenging, although for different reasons.

•For retropubic slings, significant prepubic tissue thickness can make it challenging to fully pass the trocar from the vaginal incision to the suprapubic skin surface.

•For transobturator slings, transobturator trocar insertion can sometimes be difficult in patients with obesity who also have a large width of the pubic ramus because it becomes difficult to efficiently rotate the trocar. Several manufacturers have designed regular and large-sized trocars for this situation. Trocar insertion itself is not the problem as the adipose tissue thickness at the pubic ramus just beneath the adductor longus tendon insertion is relatively small.

●Risk of postoperative urgency symptoms – It is unclear if patients with obesity are more likely to develop postoperative urgency symptoms, with or without urine loss, compared with normal weight counterparts. One observational study reported a higher incidence of postoperative urgency urinary incontinence for individuals with obesity compared normal body weight (17.9 versus 6.4 percent, respectively), although the urgency incontinence did not impact overall objective and subjective cure rates [57]. By contrast, a trial including 176 patients reported similar rates of urinary urgency incontinence symptoms between those with and without obesity [58].

Subsequent pregnancy — The impact of subsequent pregnancy and delivery on repeat SUI risk and the impact of delivery mode are presented in related content. (See "Surgical management of stress urinary incontinence in females: Retropubic midurethral slings", section on 'Subsequent pregnancy'.)

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".)

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Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topics (see "Patient education: Urinary incontinence in females (The Basics)" and "Patient education: Surgery to treat stress urinary incontinence in females (The Basics)")

●Beyond the Basics topic (see "Patient education: Urinary incontinence treatments for women (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Definition and background – Stress urinary incontinence (SUI) is the involuntary leakage of urine on effort or exertion, or on sneezing or coughing. Treatment options include nonsurgical and surgical therapy. For those electing surgery, midurethral slings have become the procedure of choice. (See 'SUI background and treatment options' above.)

●Sling types – The two main types of sling procedures for treatment of SUI in females are midurethral and pubovaginal slings (table 1). Both are suburethral slings. Midurethral sling procedures include retropubic, transobturator, and single-incision options. The retropubic and transobturator procedures each have two different surgical routes. (See 'Sling types and routes' above.)

●Choosing among midurethral sling procedures – Midurethral synthetic slings are the preferred surgical procedure for most individuals with SUI because of their high efficacy, low risk of complications, and ease of recovery. Those who desire a midurethral sling as primary surgical treatment of SUI must then consider the relative benefits and risks of full-length (retropubic or transobturator) or single-incision slings. (See 'Choosing among midurethral slings' above.)

•Advantages of full-length versus single-incision slings – For individuals planning midurethral sling surgery for SUI, we suggest a full-length rather than single-incision sling (Grade 2B). However, a single-incision sling may be a reasonable alternative. Patients should be counseled about limited long-term data for single-incision slings and risks of adverse events for both sling types. (See 'Full-length versus single-incision' above.)

•Comparison of retropubic and transobturator full-length slings – For individuals planning full-length midurethral sling surgery for SUI, we counsel about the efficacy and potential adverse effects associated with both sling types (retropubic and transobturator) and the choice of sling is based on patient preferences and risk tolerance. We believe the amount of data from randomly assigned trials that compare the long-term (>5 years) efficacy and complications of the two approaches is insufficient to make confident conclusions about the superiority of either approach over the other.

-Retropubic midurethral slings have slightly higher efficacy but also somewhat greater rates of bladder perforation, bowel injury, short-term postoperative suprapubic pain, and postoperative voiding dysfunction (which could require sling release). (See 'Retropubic or transobturator full-length slings' above.)

-Transobturator midurethral slings have a slightly lower efficacy and more short-term postoperative groin pain, but less voiding dysfunction and lower risk of bladder perforation. (See 'Retropubic or transobturator full-length slings' above.)

●Single-incision slings – Compared with full-length slings, single-incision slings are shorter (approximately 8 cm rather than 40 cm) and they require only a vaginal incision (ie, no abdominal incisions). Single-incision slings may be placed in a retropubic (anchored to the urogenital diaphragm) or transobturator fashion (anchored to the obturator internus muscle). While supporting data are limited to 36 months of follow-up, single-incision slings appear noninferior to retropubic and transobturator slings. (See 'Single-inicison' above and 'Full-length versus single-incision' above.)

●Adjustable sling – Adjustable midurethral slings are midurethral slings that allow postoperative adjustment of sling tension. As supporting data are limited to small studies, these slings require further evaluation before routine use can be advised. (See 'Adjustable slings' above.)