Many women deal with bladder leaking with cough, laugh, sneeze or activities. After trying kegel exercises or pelvic floor exercises, many women seek answers in the form of surgery. Midurethral slings specifically treat this type of leaking. Over 95% of women who have a sling placed see significant improvement in their quality of life due to improvement in bladder leaking
This topic can be scary and confusing for many people. Your physicians may not even fully understand some of these differences. Mesh surgeries existed in two main forms during the 2000's and 2010's.
Treatment of SUI (stress urinary incontinence) with mesh based slings began in the middle part of the 1990's and continue in very similar form today with only minor changes. Although like any surgery, there can be problems with midurethral sling, they are not common. There are still many FDA approved slings on the market and they remain the gold standard to treat SUI.
A completely separate type of mesh based surgery became popular among gynecologists and urologists during the early part of the 2000's and continued in some form until 2016 to treat vaginal prolapse. Unlike the slings for SUI, vaginal mesh treated prolapsing walls of the vagina by placing a larger sheet of mesh to provide extra support and decrease the chances that the prolapse would return. Although some women had excellent results with their vaginal mesh based surgery, other women developed pain or problems with the mesh. For this reason, these products were slowly removed from the market over the years. Currently, there are no FDA approved vaginal meshes on the market. Many of the commercials and lawsuits are directly related to these products.
Many times, women develop leaking with cough, sneeze or activity due to loss of support of the urethra or bladder neck. This is not the same as prolapse. Without support at the urethra, the urethra drops during cough and there is nothing there to help the urethra close to prevent leaking. This condition, urethral hyper mobility, allows for bladder leaking. When a sling is placed, it sits loosely at the level of the urethra so that it does not make voiding difficult. But when a stress event occurs like a cough, it "catches" the urethra and causes it to close enough that urine does not escape.
Two main types of slings for treatment of SUI exist. A biologic sling called a pubovaginal sling, utilizes either a patient's own tissue (fascia) or a biologic graft (non-mesh based) to build a sling. These slings successfully treat leaking in about 90% of women but can have a higher risk of difficulty with bladder emptying. These also involve more surgery and a lengthier recovery.
Midurethral slings made of mesh comprise the vast majority of slings placed in current practice. There are three main types of midurethral slings each of which uses a similar type of polypropylene mesh. The sling discussed here, specifically refers to the retropubic type of sling. The other two types, transobturator and mini-sling, have slightly different placement techniques.
The surgeon makes a 1 inch incision in the vagina under the bladder neck. Small tunnels beside the urethra on each side allow the surgeon to pass specially designed needles on both sides to carry the sling. These needles pass between the bone and the bladder then emerge in the front, just above the pubic bone, in the hair area. The surgeon then looks in the bladder to make sure the needle did not pass through the bladder. The sling then gets advanced by elevating the two arms through the skin until the sling lays directly against the urethra. Once the sling sits correctly, the surgeon removes the plastic covers and removes any extra mesh from the skin area. Skin glue is applied to these small punctures in the skin. Absorbable suture or stitches then get placed to close the vaginal incision. No mesh can be seen or felt after a sling placement.
On the day of the surgery, you will arrive at the hospital or surgery center and get checked in at admissions. When the nurses bring you to the preoperative area, they will get vital signs and update their records. After you change into a gown, you will begin to meet the surgical team including the anesthesia team and other members of the OR team. You will also get to visit with Dr. Parnell and he will answer questions and pray with you before the surgery.
When the nurse takes you to the operating room, the entire team will make sure you are comfortable before going to sleep. Once asleep, the nurse and scrub tech prepare you for surgery and Dr. Parnell begins the surgery. A sling procedure takes approximately 15 minutes to perform. Once complete, the anesthesia team will awaken you and take you to the recovery room. You will spend about 1 hour in the recovery room. Dr. Parnell will update your family member or support person at this time.
After the recovery room, you will return to the holding area and the nurses will make sure you are comfortable prior to giving you an opportunity to empty your bladder. Approximately, one out of every four patients will have a "lazy bladder" after surgery and be unable to empty their bladder. In this situation, you would go home with a bladder catheter and return 3 days later to the office to have it removed.
Dr. Parnell will send you home with a pain medication and ibuprofen. Women generally consider this surgery to have mild to moderate pain that typically only requires pain medication for the first 1-2 days. Each patient's individual experience will be different.
Most women report a very reasonable postoperative recovery experience. Postoperative pain is usually very manageable with ibuprofen and some pain medication. Typically, women resume routine activities the day after surgery with limitations including no heavy lifting or straining, nothing in the vagina and no soaking in water. We encourage women to resume activities that they feel comfortable doing within the limitations provided. There may be a small amount of blood but generally that is only a small amount the first few days or week. The stitch inside the vagina dissolves so there can sometimes be drainage as it dissolves. The glue on the incisions in the hair area in the front can be removed after a week.