Urethral sling procedure

Overview of Treatment

Sling surgery is a surgical procedure used to treat urinary incontinence, primarily targeting involuntary urine leakage caused by weakened support structures of the urethra. This procedure involves implanting synthetic materials or autologous tissue to secure the urethra in the correct position, restoring its normal closure function.

It is commonly performed in women with stress urinary incontinence, especially those experiencing symptoms during coughing, physical activity, or increased abdominal pressure. The surgical methods vary based on the materials and implantation techniques used, allowing for selection of the most suitable approach according to the patient's age, anatomical structure, and severity of symptoms.

Types and Mechanisms of Treatment

There are three main types:

• Open sling procedure: uses autologous fascia or synthetic materials, inserted through abdominal or vaginal incisions
• Tension-free Vaginal Tape (TVT): employs a special needle to place a polypropylene tape around the mid-urethra
• Single-incision sling (TOT): places the sling through a single vaginal incision

These materials form a supportive structure that automatically compresses the urethra when intra-abdominal pressure increases, preventing involuntary leakage.

The mechanism involves reconstructing the anatomical position of the urethra to improve the balance between urethral and bladder pressures. Artificial materials create permanent or absorbable support, with some designs enhancing urinary control through muscle contractions.

Indications

Mainly suitable for:

• Moderate to severe stress urinary incontinence unresponsive to conservative treatments
• Mixed incontinence (co-occurrence of stress and urgency incontinence)
• Urethral dysfunction caused by pelvic organ prolapse

Physicians evaluate suitability through urodynamic testing, uroflowmetry, and other assessments. Patients with severe urethral strictures or chronic infections should first address underlying conditions before surgery.

Usage and Dosage

The surgery is typically performed under general anesthesia, lasting about 1-2 hours. The steps include:

• Locating the anatomical structures around the urethra
• Puncturing or incising to insert the sling
• Adjusting tension and suturing the incision

Hospitalization usually lasts 1-3 days, with recovery taking approximately 2-4 weeks.

The concept of dosage depends on the length and tension of the sling, which must be customized based on urethral length and tissue laxity. For example, the length of the TVT sling is usually 10-12 cm and must be precisely positioned around the mid-urethra.

Benefits and Advantages

Main advantages include:

• High success rates of 70-90%, significantly improving daytime and nighttime incontinence
• Minimally invasive techniques reduce tissue damage, postoperative pain, and recurrence rates
• Shorter surgical time and recovery period—over 50% faster than traditional surgeries

Long-term follow-up shows that the five-year success rate of tension-free sling procedures can reach 85%, with a notable improvement in patients’ quality of life (QOL). Some designs also address complex symptoms involving urgency and leakage.

Risks and Side Effects

Potential risks include:

• Short-term: bleeding, infection, pain, or temporary urinary obstruction
• Long-term: sling displacement, chronic pain, or foreign body reactions
• Specific risks: mesh rejection or chronic bladder outlet obstruction
Approximately 3-5% of patients may require secondary surgery for correction.

Serious complications include urethral perforation or nerve injury, which should be performed by experienced urologists. Some patients may experience difficulty urinating, which can be improved through urethral dilation or sling adjustment.

Precautions and Contraindications

Preoperative assessments include:

• Urinary tract infection treatment
• Adjusting anticoagulant medications for bleeding disorders
• Enhanced infection prevention for diabetic or immunocompromised patients
Patients should avoid heavy lifting within 2-4 weeks after surgery.

Contraindications include:

• Uncontrolled acute urinary tract infection
• Severe systemic bleeding tendencies
• Allergy to the materials used
Pregnant women should delay surgery until postpartum evaluation.

Interactions with Other Treatments

If patients are concurrently undergoing pelvic floor muscle training or medication treatments (such as anticholinergics), medication timing should be adjusted to avoid interactions. For example, alpha-blockers may affect urine flow rate, requiring re-evaluation of dosage postoperatively.

Patients with a history of radiation therapy or pelvic surgery may have increased tissue adhesions, complicating surgery; they should inform their doctor of their medical history. Artificial materials and metal implants generally have no direct interactions but should be avoided during MRI scans to prevent metal interference.

Effectiveness and Evidence

Multicenter studies show that the three-year success rate of tension-free sling procedures reaches 85%, outperforming traditional sling surgeries at 60%. Follow-up after five years indicates that 70% of patients still experience symptom improvement, especially for stress incontinence triggered by coughing or laughing.

Randomized controlled trials confirm that TVT surgery significantly improves incontinence indices (IIEF) and international prostate symptom scores (IPSS). However, individual differences may influence long-term outcomes.

Alternatives

Non-surgical options include:

• Pelvic floor muscle training (Kegel exercises)
• Medications (such as duloxetine or selective estrogen receptor modulators)
• Urethral injections of botulinum toxin
This approach is suitable for mild symptoms or patients at high surgical risk.

Other surgical options include Burch colposuspension or artificial sphincter implantation, selected based on the degree of anatomical abnormality. For example, patients with severe sphincter deficiency may require combined procedures.

 

Frequently Asked Questions

What preoperative examinations or preparations are necessary?

Preoperative assessments include urodynamic testing, bladder function evaluation, and overall health assessment to confirm indications and exclude other conditions. Patients should stop anticoagulants (like aspirin) at least one week prior and empty the bladder as instructed. Those with diabetes or cardiopulmonary diseases should control their conditions to stability before surgery.

What common side effects may occur after surgery? How can they be alleviated?

Short-term effects may include difficulty urinating, hematuria, or perineal swelling, which usually resolve within 1-2 weeks. Severe pain can be managed with prescribed analgesics; persistent hematuria or fever warrants immediate medical attention. Long-term effects may involve urethral function impairment, requiring regular bladder function monitoring.

How long after surgery can daily activities be resumed? What actions should be avoided?

Generally, rest for 3-5 days, then gradually resume light activities such as walking, but avoid heavy lifting, prolonged sitting, or vigorous exercise for at least 4 weeks. Heavy lifting may pull on the sling and cause displacement; full activity can typically resume after 6 weeks following medical evaluation.

What factors influence the success rate of the surgery? How can treatment outcomes be improved?

The success rate ranges from 70-90%, depending on age, type of incontinence, and duration. Patients with severe stress incontinence or prior pelvic surgeries tend to have lower success rates. Postoperative pelvic floor exercises, weight control, and avoiding activities that increase abdominal pressure can prolong the benefits.

If the surgery is ineffective, can it be repeated?

If sling displacement or tissue atrophy causes recurrence, secondary procedures to adjust the sling or alternative treatments like artificial sphincter implantation may be considered. However, repeat surgeries carry higher risks and should be based on overall health and severity of incontinence.