Surgery for stress incontinence: suburethral tapes and slings

Types of sling

• Synthetic tapes 
• monofilamentous polypropylene mesh
• Retropubic tape (TVT) 
• Transobturator tape (TOT) 
• Autologous 
• Rectus fascia, fasica lata, vaginal wall 
• Non-autologous 
• Fascia lata from cadaveric tissue

Retropubic tapes (TVT): 

• Midline anterior vaginal incision over the mid-urethra 
• Trocars inserted either side of the urethra and perforate through the endopelvic fascia into the lower abdominal wall in the midline, just above the pubic bone
• Success rates 90% at 1 y 80% at 5 y 
• TVT vs colposuspension 
• Ward Hilton studies, similar efficacy at 5y. 
• TVT have lower OAB symptoms and prolapse (1.8% vs 7.5%) 

Transobturator tapes (TOT, TVTO)  

• Midline anterior vaginal incision over the mid-urethra 
• Two small incisions lateral to labia majora at level of clitoris 
• Trocar passed through skin incision, downwards though obturator foramen, exiting alongside urethra on each side (outside to inside) 
• In TVTO, trocar passes from (inside to outside) 
• TOT vs TVT: 
• Similar subjective cure rates at 1 y
• TVT better objective cure rates (88% vs 84%) 
• TOT less voiding dysfunction, blood loss, bladder perforation, shorter operating time
• TOT higher vaginal injuries/erosion and pain in the groin/thigh 
• TVTO vs TVT:
• Similar objective cure rates 
• Increased risk of leg pain

Mini tapes 

• Self retaining, inserted via a single vaginal incision 
• short-term success 80-90% 
• results may not be sustained over time 

General complications of tapes 

• Voiding dysfunction (retention, de novo bladder overactivity)
• Vaginal, urethra, and bladder perforation or erosions
• Pain (groin/thigh with TO route) 
• Damage to bowel or blood vessels (rare) 

Pubovaginal (autologous) slings 

• Not commonly used as a first line surgical procedures for SUI
• Commonly a segment of rectus fascia (10-20 cm) is harvested and sutured placed on both ends  
• Sling placed under mid urethra though endopelvic fascia 
• Suture ends tied 
• Autologous slings vs colposuspension 
• Autologous slings have better outcome 
• Autologous slings have higher complications (UTI, Voiding dysfunction, urge incontinence) 

Pubovaginal (autologous) slings