Pelvic Slings

A sling procedure — the most common surgery to treat stress incontinence — uses strips of your body's tissue or synthetic material such as mesh to create a pelvic sling or hammock around your bladder neck and the tube (urethra) that carries urine from the bladder. The sling provides support to keep the urethra closed — especially when you cough or sneeze. Slings typically have high rates of effectiveness and low risks of complications.

Categories of slings include:

• Tension-free slings. No stitches are used to attach the tension-free sling, which is made from a synthetic strip of mesh. Instead, tissue itself holds the sling in place initially. Eventually scar tissue forms in and around the mesh to keep it from moving. Though rare, serious complications from the surgical mesh can occur, including erosion, infection and pain.

Within the category of tension-free slings there are two approaches: retropubic, also known as suprapubic, and transobturator.

For the retropubic procedure, a small incision is made inside the vagina just under the urethra, and then two small openings are made above the pubic bone. These openings are just large enough for a needle to pass through. The surgeon uses a needle that is holding the sling to place the sling inside the body. Stitches are not needed to keep the sling in place, although the vaginal incision is closed with a few absorbable stitches and the needle sites may be sealed with skin glue or sutures.

The newer, transobturator approach involves a slight modification to the retropubic approach. Here, the surgeon uses a similar vaginal incision, but sling arms are not passed between the pubic bone and bladder. This approach lowers the risk of urethral and bladder injury. The needle enters next to the labia and is threaded under the urethra. Like the retropubic approach, stitches are not needed to hold the sling in place, and the needle site may be sealed with skin glue.

• Adjustable slings. Doctors are studying a sling that can be adjusted during and after surgery. After the sling is placed and while the person is awake, the doctor tests and adjusts the sling's tension according to the person's needs. Adjustments can continue to be made months or years later and require only a local anesthetic to access the adjustable portion. More study is needed to determine how effective adjustable slings are over time.

• Conventional slings. The surgeon inserts a sling through a vaginal incision and brings it around the bladder neck. The sling may be made of a synthetic material, or occasionally your own tissue, animal tissue or tissue from a deceased donor may be used. The surgeon brings the ends of the sling through a small abdominal incision and attaches them to pelvic tissue (fascia) or to the abdominal wall with stitches to achieve the right amount of tension. Conventional slings sometimes require a larger incision and an overnight stay in a hospital. A temporary catheter may be necessary after surgery as the bladder heals. Conventional slings aren't proven to be better than newer tension-free slings.

Most sling procedures use synthetic materials. Using natural sling materials taken from animals or deceased donors may be less effective than natural materials from your body or synthetics, because there's a tendency for the body to absorb animal and deceased donor material.

Sling procedures take less time than retropubic bladder neck suspension procedures, and because they're less invasive, sometimes they can be done under local anesthesia and on an outpatient basis. But in some cases, more invasive procedures may be the right ones based on your medical history and test results. Discuss with your doctor which procedure is right for you.

Recovery time for tension-free sling surgery varies. Doctors may recommend two to six weeks of healing before returning to normal activities.

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