Mid-urethral Slings in the Treatment of Female Stress Incontinence – What is Known and What is Not

European Urological Review, 2005:1-6

Sub-urethral and sub-cervical slings have been used for many years to cure female stress urinary incontinence. These surgical techniques were renowned to have an obstructive effect on bladder outlet. This is why autologous and heterologous, pediculated or free fascial slings were only used in selected cases.

In the early 1990s, a new physiological concept of urinary continence was described. This new concept emphasises the main role of sub-urethral support or, more precisely, of mid-urethral support. In the mid 1990s, surgical techniques based on these theories were developed. Soon afterwards, the mid-urethral slings became the standard surgical treatment of female stress incontinence. Today, the tension-free vaginal tape (TVT) and TVT-like techniques are increasingly frequently performed as a first-line treatment.1,2

The Physiological and Anatomical Rationale

Although still incompletely known, the mechanism of urinary continence is better understood today, thanks to the works of Petros and Ulmsten, confirmed by anatomical dissection by DeLancey. In the view of these authors, several muscular and ligamentar structures contribute to either fix the urethra (the pubo-urethral ligament and the connective tissue around) or actively or passively support urethra and bladder neck.

The tissue supporting the urethra in its middle and proximal portions is a sling-shaped segment of the anterior vaginal wall, attached to the muscles of the pelvic floor (principally the levator ani) inserted on the arcus tendineus fascia pelvis.

The tension in the pubo-urethral ligaments ensures a normal interaction between the muscular and vaginal components – forward contraction of pubococcygeus muscles and backward contraction through the levator ani lead to closure of urethra and bladder neck. The position of pubo-urethral ligaments can be seen by lateral urethrocystography and presents like a kink in the mid-urethral portion (‘the urethral knee’). Based on this hammock theory, the urethra and bladder neck do not have to be elevated like with older operative techniques. Surgery should only provide an underlying support to the urethra, palliating the lack of tension of pubo-urethral ligaments. Clinically, the deficiency of the pubourethral ligaments results in urethral hypermobility.

The Surgical Technique

The initial TVT technique described by Ulmsten less than 10 years ago is still used, with very few modifications.3,4 The procedure can be performed under general, regional or local anaesthesia, without affecting the efficacy and safety rate. If the hydrodissection of the Retzius space is contested and does not offer any benefit to the operation, the hydrodissection of the space between urethra and vaginal wall prior to any incision seems, in the authors’ experience, to be a safe gesture in order to prevent accidental urethral injury.5

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