Overview
Definition:
Stress urinary incontinence (SUI) is involuntary leakage of urine on effort or exertion, or on sneezing or coughing
Sling surgery is a surgical procedure that uses a strip of material (autologous tissue, synthetic mesh, or donor tissue) to support the urethra and/or bladder neck, thereby restoring continence
It is considered a gold standard treatment for moderate to severe SUI.
Epidemiology:
SUI affects a significant proportion of women, with prevalence increasing with age and parity
It is estimated to affect up to 30-40% of adult women, impacting quality of life
Surgical intervention is sought by approximately 10-20% of symptomatic women.
Clinical Significance:
SUI significantly impairs a woman's quality of life, leading to social isolation, reduced physical activity, and psychological distress
Effective surgical management can restore continence, improve self-esteem, and allow patients to return to normal daily activities, representing a crucial aspect of gynecological and urological practice.
Indications
Surgical Indications:
Moderate to severe stress urinary incontinence refractory to conservative management
Patient preference for surgical intervention
Presence of co-existing pelvic organ prolapse that can be addressed concomitantly
Absence of significant detrusor overactivity or significant pelvic organ prolapse that would contraindicate a sling procedure.
Patient Selection:
Careful patient selection is paramount
Patients should have predominantly SUI, with minimal urge incontinence
A thorough preoperative evaluation, including urodynamic studies, is essential to confirm the diagnosis and rule out other contributing factors like detrusor overactivity
Patients must be counselled regarding risks, benefits, and alternatives.
Contraindications:
Absolute contraindications include active urinary tract infection, severe pelvic organ prolapse requiring significant repair, significant detrusor overactivity, untreated pelvic malignancy, and inability to tolerate surgery
Relative contraindications include severe obesity, multiple pelvic surgeries, and patient factors precluding adequate follow-up.
Preoperative Preparation
History And Physical Exam:
Detailed history of incontinence, voiding symptoms, previous surgeries, and medical conditions
Physical examination including pelvic assessment for prolapse and pelvic floor muscle strength
Assessment for co-existing conditions.
Diagnostic Workup:
Urinalysis and urine culture to rule out infection
Urodynamic studies (cystometry, urethral pressure profilometry) are crucial to confirm SUI, assess bladder capacity, and identify detrusor overactivity
Post-void residual urine measurement.
Patient Counseling:
Comprehensive discussion of the procedure, including risks (e.g., pain, infection, bleeding, urinary retention, vaginal erosion, de novo urgency, recurrence), benefits, alternatives, and expected outcomes
Informed consent is mandatory
Instructions regarding bowel preparation, anesthetic considerations, and perioperative medications.
Surgical Management
Sling Types:
Midurethral slings (MUS) are the most common
These include tension-free vaginal tape (TVT) and transobturator tape (TOT) using synthetic mesh
Autologous fascial slings (using rectus fascia) and allograft slings are other options.
Procedure Steps Tvt:
A synthetic mesh tape is passed through the retropubic space and secured under the mid-urethra
Incisions are made in the suprapubic area and vaginal mucosa over the mid-urethra
Trocar needles are used to guide the tape through the pelvic fascia and obturator internus muscle
The tape is then adjusted to provide adequate urethral support.
Procedure Steps Tot:
The tape is passed through the obturator foramen, from the vaginal incision to the adductor muscles
Incisions are made in the vaginal mucosa over the mid-urethra and externally in the groin/thigh area
Tapes are tensioned to provide support to the mid-urethra
This approach aims to reduce bladder injury risk compared to TVT.
Anesthesia And Access:
Procedures can be performed under local anesthesia with sedation, regional anesthesia (spinal or epidural), or general anesthesia
Access is typically via vaginal and suprapubic/groin incisions
Sterile technique and meticulous hemostasis are essential.
Postoperative Care
Pain Management:
Postoperative pain is typically managed with oral analgesics, often including NSAIDs and opioids as needed
Local anesthetic infiltration at incision sites can also provide relief.
Urinary Management:
Indwelling urinary catheter is usually placed postoperatively
Patients are monitored for urine retention
Voiding trials are initiated once initial swelling subsides
Prolonged catheterization may be necessary if voiding dysfunction persists
Patients are instructed on self-catheterization if required long-term.
Monitoring And Discharge:
Monitoring for signs of infection, bleeding, or urinary retention
Patients are typically discharged within 24-48 hours if stable, with instructions on wound care, activity restrictions, and follow-up appointments
Avoidance of strenuous activity and heavy lifting for 4-6 weeks.
Follow Up Schedule:
Routine follow-up appointments at 2-4 weeks, 3-6 months, and then annually are recommended to assess for recurrence of SUI, complications, and overall functional outcome
Urodynamic re-evaluation may be considered if symptoms recur.
Complications
Early Complications:
Pain (groin, pelvic, vaginal), urinary retention, acute urinary tract infection, bleeding, hematoma formation, wound infection, nerve injury (obturator nerve), and injury to adjacent organs (bladder, bowel).
Late Complications:
Chronic pelvic pain, vaginal erosion of mesh, dyspareunia, de novo urgency or urge incontinence, recurrent SUI, urinary tract infections, fistula formation, and mesh migration or extrusion
Bladder outlet obstruction is rare but possible with overtightening.
Prevention And Management:
Meticulous surgical technique, proper mesh placement, and tensioning are key to prevention
Aggressive pain management, prompt diagnosis and treatment of infections, and early recognition of mesh-related issues are important
Vaginal erosion may require conservative management, partial or complete mesh excision, or flap repair
Recurrent SUI may necessitate further investigation and alternative management strategies.
Key Points
Exam Focus:
Understand the different types of slings (TVT, TOT, autologous), their indications, contraindications, and relative advantages
Recognize common early and late complications and their management
Be prepared to discuss urodynamic findings in the context of SUI diagnosis.
Clinical Pearls:
Adequate urethral support is achieved by proper sling tensioning
too tight leads to retention, too loose leads to recurrence
Urodynamics are essential to confirm SUI and rule out significant detrusor overactivity, which can be worsened by sling placement
Differentiate SUI from urge incontinence and mixed incontinence.
Common Mistakes:
Over-reliance on subjective history without urodynamic confirmation
Inadequate counselling of patients regarding potential complications, especially mesh erosion and dyspareunia
Incorrect tensioning of the sling leading to voiding dysfunction
Failure to address co-existing pelvic organ prolapse or detrusor overactivity.