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The evolution of midurethral slings

Nature Clinical Practice Urology volume 5, pages 194–201 (2008)Cite this article

Abstract

Use of urethral slings in the treatment of incontinence started in the early 20th century. An evolution in understanding the pathogenesis of urinary incontinence led to development of the midurethral sling, which was designed to replace the natural suburethral vectors of support, as described in the integral theory. Since the introduction of tension-free vaginal tape in 1995, multiple other commercially available types of midurethral sling have been introduced. In general, these sling types share the common characteristics of using a thin, type I synthetic mesh inserted at a midurethral level and applied without tension. The midurethral sling procedure has subsequently undergone multiple technical modifications, predominantly alterations to the technique and route used for sling insertion. Despite the variety in techniques, available evidence suggests that all sling types provide efficacious and durable outcomes. Several adverse effects have been reported that are specific to certain techniques, and include the risk of vascular, enteric or nerve injury, lower urinary tract injury, urinary retention or voiding dysfunction, and vaginal erosion. Nonetheless, the midurethral sling provides a safe surgical option overall, and represents a notable advance in the treatment of stress urinary incontinence.

Key Points

  • The urethral sling has undergone a considerable evolution since its introduction in the early 20th century

  • Introduction of the integral theory advanced our understanding of incontinence, and led to the era of the midurethral sling

  • Multiple midurethral sling types are available, which share the common characteristics of a monofilament mesh placed in a tensionless fashion at a midurethral level

  • Significant data suggest excellent outcomes after sling placement, irrespective of midurethral sling type chosen

  • Specific adverse events are reported, including vascular and enteric injury, urinary voiding dysfunction, and vaginal erosion

  • The midurethral sling represents a notable advance in the treatment of stress urinary incontinence

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Acknowledgements

Désirée Lie, University of California, Irvine, CA, is the author of and is solely responsible for the content of the learning objectives, questions and answers of the Medscape-accredited continuing medical education activity associated with this article.

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Authors and Affiliations

  1. DE Rapp is a Fellow in incontinence and pelvic floor reconstruction, and KC Kobashi is Head of the Section of Urology at Virginia Mason Medical Center, Seattle, WA, USA.,

    David E Rapp & Kathleen C Kobashi

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  1. David E Rapp
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Correspondence to David E Rapp.

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Competing interests

DE Rapp declared no competing interests.

KC Kobashi is a member of the speaker's bureaus and receives honoraria from Astellas and Novartis. She also works as a consultant for Coloplast.

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Rapp, D., Kobashi, K. The evolution of midurethral slings. Nat Rev Urol 5, 194–201 (2008). https://doi.org/10.1038/ncpuro1052

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