Urethral Sling

What is it?

A minimally invasive, outpatient procedure to treat stress urinary incontinence.

How is it done?

The procedure is done in the operating room usually under general anesthesia. Three small incisions are made: A 1-inch incision in the vagina and 2 mini incisions between the labia and inner thigh. A ribbon of mesh, about the size of a shoestring, is then placed under the urethra and brought out through the inner thigh incisions using specially designed instruments. The sling is then adjusted to the proper tension, and the excess mesh trimmed at the skin. The incision in the vagina is closed with dissolvable sutures and the incisions in the inner thigh are closed with skin glue. The procedure usually takes around 15 minutes and you can usually go home within a few hours.

How does it work?

The sling lies under the urethra acting as a “hammock”. When abdominal pressure increases, as with a cough, sneeze, or athletic activity, the sling provides support to keep the urethra closed, preventing loss of urine.

What are the risks?

  • Failure to correct incontinence—This procedure is successful in treating stress incontinence in approximately 90% of patients. A small percentage of patients may continue to have leakage which is greatly improved, but are not completely dry. Complete failure is fortunately rare. If the procedure fails to make you dry, you may need to be re-evaluated to determine the cause. Medications, pelvic floor muscle exercises, or another procedure may need to be done in the future.
  • Bleeding—The risk is low. You will be asked to stop aspirin, Coumadin, Plavix, and other medications that interfere with blood clotting a week before the procedure. After the procedure, you may experience bleeding similar to a light period for a day or two and may want to use a pad to protect your clothing. You should not have heavy vaginal bleeding or blood in the urine. The chance of require a blood transfusion is extremely low.
  • Infection—This risk is low.
  • Urinary retention—If the sling is too tight, the tissues around the urethra swell, or if the effects of the anesthesia do not wear off right away then you may have difficulty emptying your bladder. The risk is small and the majority of patients are sent home without a catheter. If you can’t void easily you may go home with a catheter for one or two days. In rare cases (less than 2%) a second procedure to loosen or cut the sling may be necessary.
  • Sling exposure in the vagina—Rarely, the vaginal skin may not heal well over the sling and your partner may feel the sling during sexual relations. This may require a second procedure to remove the exposed sling. If a large segment needs to be removed, it may cause the procedure to fail.
  • Injury to the bladder or urethra—This risk is also small. A cystoscopy may be performed at the time of the procedure to visualize the bladder or urethra.
  • Hip and leg pain—The sling is placed through the inner thigh muscles. You may experience some soreness lasting a few days.
  • Urinary urgency/urge incontinence—This procedure treats stress incontinence (leaking with coughing, sneezing, activity). It will not treat urge incontinence (also known as overactive bladder). If a major part of your problem is urge incontinence , you should discuss this with your doctor before surgery. A minority of women may have new onset urgency following the sling procedure. This resolves in most cases, but in some medication or other therapies may be required.

What are the restrictions following the procedure?

The sling is not sewn into place; instead there are small openings in the sling to allow the body’s tissues to grow into it over time. For this to happen you will be asked to limit your activity for 4-6 weeks following the procedure so that the sling can become secure. This means no exercise, no lifting anything over 15 pounds, and nothing in the vagina (no intercourse or tampons) for 4-6 weeks. You may shower, but no baths, pools or hot tubs for 2 weeks. You may notice some of the absorbable suture pass out of the vagina as it dissolves—this is normal.

Most women have minimal discomfort following the procedure. About one third do not require anything more than Tylenol. Of course, everyone is different and in some cases patients may have more significant pain afterward. This is usually of short duration (days). You will be given a prescription for pain pills, and you should not drive or make important decisions while you are taking these medications. Most women are able to return to work (with lifting restrictions) in 3-7 days.

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