What is the Mesh Sling Procedure for Stress Urinary Incontinence in Women?
SUI is a problem when the pelvic muscles that support the bladder and urethra, or the urethral sphincter are weak. Support problems can start from pressure on these muscles with pregnancy and childbirth, chronic constipation, extra body weight, smoking, coughing and certain activities like heavy lifting that are repeated often.
The female bladder is behind the pubic bone and on top of the vagina. It is in the pelvis, the lowest part of the body between the hips.
The bladder muscle squeezes to empty urine through a short tube called the urethra. This tube lies under the pubic bone and in front of the vagina.
The urethral sphincter is a muscle at the opening to the bladder. You control urination by relaxing and squeezing this muscle.
Stress urinary incontinence, SUI (say S-U-I) is uncontrolled urine leaking from pressure on the bladder and urethra. This pressure happens with sneezing, coughing, laughing and exercise.
SUI is a problem when the pelvic muscles that support the bladder and urethra, or the urethral sphincter are weak.
Support problems can start from pressure on these muscles with pregnancy and childbirth, chronic constipation, extra body weight, smoking, coughing and certain activities like heavy lifting that are repeated often.
- Other risks for female SUI include
- low estrogen and menopause
- genetics, meaning a woman can be born at risk for weak tissue
- and it can be an occasional side effect of pelvic surgery
Some changes can make leaking better without surgery, drink smaller amounts at a time, quit smoking if you smoke and work to get to a healthy weight if you are overweight.
Another way to help stop leaking without surgery is to make pelvic muscles stronger with Kegels, also called pelvic floor exercise. These exercises can help before and after incontinence surgery.
Physical therapists can help with these exercises. They will sometimes use biofeedback therapy to test if you are exercising the right muscles. Other tools for this therapy are electrical stimulation and vaginal weights.
If exercise and other changes have not helped stop the leaking then bulking agents may be an option. Silicone microbeads or another material is injected into the urethra to make the wall thicker so that it closes more tightly. Many patients are better after this but the leaking eventually returns for most. The injection may be repeated.
Bulking agents are most helpful for people with mild SUI, for patients not ready for surgery and patients that cannot or should not have surgery.
The sling procedure is a permanent surgical treatment option for women with problem leaking from SUI.
A sling is a ribbon which can be made of human tissue or plastic fabric called mesh. The ribbon is looped under the urethra during surgery, to create a sling or hammock. This adds support for the weak tissues and urethral sphincter and helps stop leaking for most patients.
Your surgeon has recommended a mesh sling for you. This means that your sling will be made of a ribbon of plastic fabric called polypropylene.
The main benefits to using mesh instead of human tissue are
- mesh slings are faster and easier to place
- less time is spent in surgery
- incisions are smaller
- so healing is faster than if the sling was made from your own tissue.
- Mesh slings have been used to treat SUI for over 15 years. About 8 out of 10 women have no leaking or are drier after this procedure. As with any surgery, there can be problems or complications for some patients.
Mesh exposure in the vagina is one problem that can affect about 3 percent or 3 in 100 women after a mesh sling. This is when a piece of the mesh is not completely covered by the vaginal wall after healing.
A small edge of the mesh can be felt by the patient or their partner as a screen or gritty patch in the vagina. This can usually be fixed with a minor procedure to trim and cover the mesh. If the exposed mesh is not causing the patient any problems, it can be safe to leave untreated, and repair if new problems develop.
Mesh exposure is more common in patients that have thin delicate vaginal tissue from low estrogen. You may be advised to use estrogen vaginal cream before or after surgery.
Rarely, the mesh causes painful scar tissue, erosion or damage to the bladder or urethra. Some problems, especially pain are not able to be fixed with surgery.
There are three main types of mesh sling procedure: mini sling, retropubic and transobturator. Each way of placing the mesh has its own risks and benefits.
Mini Slings are the newest procedure. They use the smallest size mesh and only need one small vaginal incision to place. But we are still learning about how well these work and the problems that patients may have.
The retropubic sling procedure guides the mesh using the pubic bone in front of the bladder. This has the highest risk of a small hole being poked in the bladder. These injuries usually heal quickly if seen and treated at the time of surgery. This type of sling is the best-studied with proven long-term benefits.
The transobturator procedure guides the mesh in from the side and bottom of the pubic bone. This is away from the bladder so there is less risk of bladder damage. Two small incisions are needed in the groin or leg crease to place this mesh. A risk of this procedure is pain from these groin incisions for some patients.
Mesh is permanent. During healing your tissues grow into the mesh. Surgery to remove it can be difficult or impossible to do.
Experts haven’t agreed that any one sling procedure is the best. The procedure recommended for you depends on your surgeon’s experience and training and your individual situation. Be sure you understand which procedure and sling material is planned for you.
Let’s talk about what happens during a Mesh sling procedure.
To start, you are given anesthesia to keep you free of pain during the procedure.
You are positioned carefully.
A thin soft tube called a Foley may be placed in your bladder.
A tool called a retractor is gently used to enable the surgeon to reach and operate on the front wall of the vagina.
Here an incision is made.
If you are having a mini mesh procedure, this will be the only incision. The small piece of mesh is gently positioned under the urethra and the incision is closed.
If you are having a retropubic mesh procedure, the vaginal incision is made followed by 2 small skin incisions above the pubic bone.
If a trans-obturator procedure is done, the vaginal incision is made, followed by 2 small skin incisions in the groin-crease of the upper-thighs.
For the retropubic and trans-obturator procedures, special tools are used to guide the sling into position under the urethra. The tools and the way they are used vary for the different procedures and kits.
The mesh is gently positioned to support the urethra without crushing or pressing on it. This is called tension free. The ends of the mesh are cut to the needed length. The mesh holds itself in position.
A cystoscope is gently placed thru the urethra to the bladder and the bladder is filled with water or saline.
This scope has a light and a camera and is used to help the surgeon see the inside of the urethra and bladder during the procedure and after the sling is placed. The surgeon checks for bleeding, holes in the bladder and for mesh or tools where they should not be. At the end of the procedure, a foley may be placed.
The vaginal incision and skin incisions are closed.