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Carolina Continence Center

​Sling Procedures: An Overview


What is a sling?
Patients who have stress incontinence are recommended to have a sling procedure.  This procedure involves placing material around the urethra and attaching it to the abdominal wall or laterally to ligaments of the pelvic bone.  The type of sling material can effect long term complications. There are currently two classes of slings: synthetic and biologic.  The benefit of the synthetic sling is that the material is consistent and patients who become dry tend to stay this way for a long time (>10 years).  The tradeoff is a higher rate of erosion of the material into the urethra, bladder or vagina, although this rate is very low (< 1%).  The benefit of a biologic sling is that fewer types of erosion occur; however, long term durability is less with biologic grafts (the graft dissolves and the leaking returns.)   Natural/biologic grafts that are not harvested from you (either from an animal or other person) can be rejected by some patients and this may take months to resolve.  If you would like a biologic sling, we strongly recommend you consider having your own fascia harvested and inserted for your sling. The sling procedure is performed primarily from the vagina and takes less than thirty minutes to complete.  The procedure is usually done with the patient under twilight anesthesia if this is the only procedure you are having; otherwise, you may undergo spinal anesthesia or be put to sleep (general anesthesia.)  Known complications from this procedure are bladder perforation (putting a hole in the bladder) and bleeding in the short term and erosion of the material into the urethra, bladder and vagina in the long term.  The surgical sites can also become infected or have excessive bleeding that may cause a large bruise.  There are a few reports of major a vascular injury when attempting to place a sling, one which necessitated a blood transfusion and grafting of the artery damaged.  While these complications are rare, they can be life threatening, requiring blood transfusions and the possibility of poor outcomes and morbidity.   It should be noted that most severe complications occurred in cases where the physician was inexperienced. Patients typically have to relearn how to void with the sling in place and intermittent self catheterization is taught prior to a sling procedure (this will necessitate the patient learning how to insert a catheter into the bladder in order to void.)  You can expect the stream of your urine to be less.  Some patient (up to 25%) can develop irritative voiding symptoms (frequency/urgency); however, this usually subsides with time.  In less than 1% of cases, patients will have to use the catheter for the rest of their life; most patients (>99%) will not go home with a catheter.   For the few patients who are unable to void long term after a sling, you may have the sling divided in the operating room.  While this usually allows you to void again, it may result in leaking (approximately 40% risk.) The benefit of this procedure is that it provides the best cure rate for patients who are at high risk for failure from standard incontinence procedures.  Options to this therapy include periurethral injections or older open urethropexies (bladder tacks.)  Artifical urethral sphincters are another option, but are rarely used in women because of the high rate of erosion of the device, and the need to replace the device after ten years (a second surgery).  The complication rate of the sling procedure ranges from 5 to 22% (higher complications with synthetic material), and is related to the number of prior surgeries and the amount of scarring.  Long term risks of slings include more urinary tract infections and pain around the area where the sling has been placed.  These issues may persist even if the sling is removed at a later date.


What is sling revision?

Patients with problems voiding after a sling may be offered a sling revision or division of the sling.  The success of this procedure is greater than 95%, but can be associated with a hole in the bladder or communication from the bladder to the vagina (fistula, approximately 5%.)  There is also the possibility that urine loss with stress can occur (approx. 20%.) Patients who are having pain from a sling may have the sling explanted in order to relieve this discomfort.  Be aware that removing a sling may be successful, but the pain may persist.  Depending on the type of sling that was placed, you may have incisions in the vagina, on the outside of your vulva or on the lower part of your abdomen.  Any and all of these sites may become infected and require long term treatment.  In some cases, the sling may not be completely removed, requiring additional surgery.  Some slings are placed through the obturator foramen and may be close to nerves that innervate the leg.  This can be damage leaving you with nerve pain or leg pain that may be permanent.  

 If you have had an adjustable sling, the sling revision involves making an incision over where the initial incision was made.  The tensing device will have another adjuster attached and this will be tightened to the point where you will become dry again.  There is alway risk of infection of the wound that may require removal of the tensing device.  The device may not become tight enough to make you dry, and you may continue to leak, or require further adjustments in the future.  You will be required to void after the sling adjustment, and if unable, the sling will be loosened.

What is an adjustable suburethral sling?
Patients who have stress incontinence are recommended to have a sling procedure.  This procedure involves placing material around the urethra and attaching it to the abdominal wall or laterally to ligaments of the pelvic bone.  The type of sling material can effect long term complications. There is a higher complication when synthetic material is used, and some problems, namely erosion of the material into the urethra or vagina, is more frequent with some materials.  Fewer erosion complications occur when a natural graft of fascia (tough connective tissue) is used as sling material; however, long term durability is less with natural grafts.   Natural/biologic grafts can be rejected by some patients and this may takes months to resolve. Current studies have shown that some patients are at higher risk of failure from a traditional sling.  These include patients that have had a prior sling and are now leaking again as well as patients with poor urethral muscle strength, also called intrinsic sphincteric deficiency.  A newer sling has been recommended that can be adjusted after placing this surgically in the body.  This sling has been recommended for you because you meet one of these high risk categories. The sling procedure is performed primarily from the vagina and takes less than an hour to complete.  Known complications from this procedure are bladder perforation (putting a hole in the bladder) and bleeding in the short term and erosion of the material into the urethra, bladder and vagina in the long term.  The abdominal device can also get infected or create a foreign body reaction resulting in a seroma.  The surgical sites can also become infected or have excessive bleeding that may cause a large bruise.  There are a few reports of major a vascular injury when attempting to place a sling, one which necessitated a blood transfusion and grafting of the artery damaged.  While these complications are rare, they can be lifethreatening, requiring blood transfusions and the possibility of poor outcomes and morbidity. With the adjustable sling, the sling is placed in a tension free environment and you will need to return to the office within one week to have this adjusted.  You will most likely leak prior to the adjustment time.   Patients typically have to relearn how to void with the sling in place.  You can expect the stream of your urine to be less once the sling is adjusted.  Once adjusted, you will need to void (go to the bathroom) to make sure you are emptying properly.  If you are unable to successfully empty your bladder, the sling will need to be loosened which involves instrumenting your urethra.  Some patient (up to 25%) can develop irritative voiding symptoms (frequency/urgency); however, this usually subsides with time. The benefit of this procedure is that it provides the best cure rate for patients who are at high risk for failure.  Artifical urethral sphincters are another option, but is rarely used in women because of the high rate of erosion of the device, and the need to replace the device after ten years (a second surgery).  The complication rate of the sling procedure ranges from 5 to 22% (higher complications with synthetic material), and is related to the number of prior surgeries and the amount of scarring.