Fascial sling surgery is also known as pubovaginal sling or rectus fascial sling. This surgery is a procedure performed to treat stress urinary incontinence in women, which occurs when intra-abdominal pressure increases, such as coughing and sneezing. Unlike other similar surgeries, no foreign or synthetic object is used, the patient’s own tissue is used. The success rate is 95%.

This sling acts as a hammock, supporting the urethra during moments of increased abdominal pressure, such as coughing, sneezing, or physical exertion, to prevent involuntary leakage of urine. The surgery is typically minimally invasive and performed under anesthesia. It offers a long-term solution for stress urinary incontinence, improving the quality of life for affected women by reducing or eliminating episodes of leakage.

In this article, I will give general information about the surgery with the help of my own experiences and literature.

What is “fascial sling operation”?

A fascial sling operation for stress incontinence in women is a surgical procedure used to treat stress urinary incontinence, a condition where there is involuntary leakage of urine during physical activities such as coughing, sneezing, laughing, or exercising. This type of incontinence is often caused by weakened or damaged pelvic floor muscles and tissues, which fail to support the bladder and urethra adequately.

During the fascial sling operation, a supportive sling is surgically implanted beneath the urethra to provide additional support and help prevent urine leakage. This sling is typically made from natural tissue (such as fascia harvested from the patient’s own body) or synthetic materials. The sling acts like a hammock, supporting the urethra and helping to keep it closed when pressure is exerted on the bladder. The procedure is usually performed under anesthesia and can be done through minimally invasive techniques, such as laparoscopic or vaginal approaches.

It is considered an effective treatment option for women with stress urinary incontinence who have not responded to non-surgical treatments like pelvic floor exercises or medication. Following the procedure, most women experience significant improvement or resolution of their urinary incontinence symptoms, leading to an improved quality of life. However, as with any surgical procedure, there are potential risks and complications that should be discussed with a healthcare provider prior to undergoing the surgery.

How to do operation?

Performing a fascial sling operation for stress incontinence in women involves several key steps. Here is a general overview of the procedure:

• Preoperative Evaluation: Before the surgery, the patient undergoes a thorough evaluation, including medical history, physical examination, and diagnostic tests such as urodynamic studies, to confirm the diagnosis of stress urinary incontinence and assess the severity of the condition.
• Anesthesia: The patient is placed under anesthesia, which may be general anesthesia or regional anesthesia, depending on the surgeon’s preference and the patient’s medical condition.
• Incision: The surgeon makes a small incision in the lower abdomen (suprapubic approach) or the vaginal wall (transvaginal approach) to access the pelvic area.
• Harvesting Fascia: If using the patient’s own tissue for the sling, the surgeon may harvest a strip of fascia from the patient’s abdominal wall or thigh. Alternatively, synthetic materials may be used for the sling.
• Sling Placement: The surgeon positions the sling material underneath the urethra to provide support. The sling is placed in a way that it provides the necessary support to the urethra during moments of increased abdominal pressure, such as coughing or sneezing.
• Attachment: The ends of the sling are secured to nearby pelvic structures, such as the pubic bone or the fascia of the abdominal muscles, using sutures or other fixation devices.
• Closure: The incisions are closed with sutures or surgical staples, and sterile dressings may be applied to the surgical site.
• Postoperative Care: After the surgery, the patient is monitored in a recovery area until they wake up from anesthesia. Pain medications and antibiotics may be prescribed to manage discomfort and prevent infection. The patient may need to limit physical activity and avoid heavy lifting for a few weeks following the procedure. We discharge our patients on the same day or we keep them at the hospital for one day and remove the catheter and discharge them the next day.

• Follow-Up: The patient will have follow-up appointments with their surgeon to monitor their progress, assess any complications, and make adjustments to their treatment plan if necessary.

It’s important to note that the specific details of the procedure may vary depending on the surgeon’s experience, the patient’s individual anatomy, and other factors. Patients should discuss the procedure in detail with their healthcare provider to understand what to expect before, during, and after the surgery.

Indications

The fascial sling operation for stress incontinence in women is typically indicated for cases where conservative treatments have failed to adequately manage stress urinary incontinence (SUI). Here are some common indications for this surgical procedure:

• Persistent Stress Urinary Incontinence: Women who continue to experience stress urinary incontinence symptoms despite trying conservative treatments such as pelvic floor exercises (Kegel exercises), bladder training, lifestyle modifications, and medications may be candidates for a fascial sling operation.
  • Severe Symptoms: Women with severe stress urinary incontinence symptoms that significantly impact their quality of life, causing embarrassment, social isolation, or disruption of daily activities, may benefit from surgical intervention.
  • Failed Previous Surgeries: Women who have undergone previous surgeries for stress urinary incontinence, such as bladder neck suspension procedures or synthetic midurethral sling placement, and have experienced treatment failure or recurrence of symptoms may require a fascial sling operation as a secondary surgical intervention.
  • Urethral Hypermobility: Urethral hypermobility, which is characterized by excessive movement or descent of the urethra during periods of increased abdominal pressure, is a common cause of stress urinary incontinence. Women with significant urethral hypermobility may benefit from a fascial sling procedure to provide additional support to the urethra and reduce urinary leakage.
  • Intrinsic Sphincter Deficiency (ISD): In cases where stress urinary incontinence is primarily due to intrinsic sphincter deficiency, characterized by weakness or dysfunction of the urethral sphincter muscles, a fascial sling operation may be indicated to improve urethral closure and reduce urinary leakage.
  • Desire for Surgical Intervention: Some women may opt for a fascial sling operation due to personal preference or lifestyle factors, especially if they are dissatisfied with the limitations of conservative treatments and desire a more permanent solution for their stress urinary incontinence.

Contraindications

While the fascial sling operation for stress incontinence in women is a generally safe and effective procedure, there are certain contraindications that may preclude some individuals from undergoing this surgery. Contraindications may include:

• Active Urinary Tract Infection (UTI): Patients with an active urinary tract infection are typically not considered candidates for elective surgery. UTIs can increase the risk of postoperative complications such as wound infection and urinary retention.
  • Untreated Pelvic Organ Prolapse: Women with significant pelvic organ prolapse, where one or more pelvic organs (such as the bladder, uterus, or rectum) protrude into the vaginal canal, may require treatment for prolapse before considering a fascial sling operation. Addressing pelvic organ prolapse may improve the success and durability of the sling procedure.
  • Uncontrolled Medical Conditions: Patients with uncontrolled medical conditions such as diabetes, hypertension, or heart disease may have an increased risk of surgical complications. Optimization of these conditions is important before undergoing elective surgery to minimize risks.
  • Pregnancy: Pregnancy is a contraindication for a fascial sling operation. Women who are pregnant or planning to become pregnant in the near future should postpone surgery until after childbirth and completion of the postpartum period, as pregnancy and childbirth can affect the outcomes of the sling procedure.
  • Coagulopathy: Patients with bleeding disorders or those taking anticoagulant medications may have an increased risk of bleeding during and after surgery. Adequate control of coagulopathy or adjustment of medications may be necessary before proceeding with a fascial sling operation.
  • Unrealistic Expectations: Patients who have unrealistic expectations regarding the outcomes of the surgery or who are not fully committed to postoperative care and rehabilitation may not be suitable candidates for a fascial sling operation. It’s important for patients to have a clear understanding of the potential benefits, risks, and limitations of the procedure.
  • Severe Cognitive or Physical Impairment: Patients with severe cognitive impairment or physical disabilities that would limit their ability to participate in postoperative care, such as bladder training or pelvic floor exercises, may not be suitable candidates for surgery.

These contraindications may vary depending on individual patient factors and surgical considerations. It’s essential for patients to undergo a comprehensive evaluation by a urologist to determine their suitability for a fascial sling operation and to discuss any potential contraindications or concerns before proceeding with surgery.

Complications

While a fascial sling operation for stress incontinence in women is generally considered safe and effective, like any surgical procedure, it carries potential risks and complications. These can include:

• Urinary Retention: Some women may experience difficulty emptying their bladder completely after surgery, leading to urinary retention. This can result from temporary swelling or inflammation around the urethra or bladder neck, or it may be due to sling placement affecting bladder function.
• Urinary Tract Infection (UTI): UTIs are a common complication following any urological procedure. Symptoms may include burning with urination, urgency, frequency, and fever. Prompt treatment with antibiotics is necessary to prevent complications.
• Urinary Urgency or Overactive Bladder: Some women may experience an increase in urinary urgency or frequency after the procedure. This may be temporary and resolve as the body adjusts to the sling, but in some cases, it may persist as a long-term issue.
• Bladder Injury: During sling placement, there is a risk of unintentional injury to the bladder or nearby structures. This risk is generally low but may occur, particularly in cases where there is anatomical variation or scarring from previous surgeries.
• Voiding Dysfunction: In some cases, the sling may cause obstruction of the urethra or affect bladder function, leading to voiding difficulties. This can manifest as hesitancy, weak urine stream, or incomplete bladder emptying.
• Sling Erosion or Extrusion: Rarely, the sling material may erode through the vaginal wall or cause irritation or discomfort. This can require additional surgery to remove or revise the sling.
• Pelvic Pain: Some women may experience pelvic pain or discomfort after the procedure, which may be temporary or persistent. This can be due to nerve irritation, scar tissue formation, or other factors.
• Bleeding or Hematoma: Bleeding during or after surgery can occur, leading to the formation of a hematoma (a collection of blood) around the surgical site. Severe bleeding may require additional intervention to control.
• Sling Failure or Recurrence: While fascial sling procedures are generally effective in treating stress urinary incontinence, there is a risk of recurrence of symptoms over time. This may necessitate additional treatments or procedures.
• Anesthesia Risks: As with any surgery, there are risks associated with anesthesia, including allergic reactions, respiratory complications, and cardiovascular events.

Advantages

The fascial sling operation for stress incontinence in women, also known as the mid-urethral sling procedure, offers several advantages:

• Effective Treatment: This procedure is highly effective in treating stress urinary incontinence (SUI), which is a common condition among women. It provides long-term relief from symptoms such as urine leakage during activities like coughing, sneezing, or exercising.
• Minimally Invasive: Compared to older surgical techniques, fascial sling operations are minimally invasive. They usually involve smaller incisions and less tissue disruption, leading to reduced postoperative pain, shorter hospital stays, and quicker recovery times.
• Low Complication Rates: When performed by experienced surgeons, the fascial sling operation generally has low complication rates. Complications such as urinary tract infections, bladder or urethral injury, or sling erosion are relatively rare.
• Outpatient Procedure: In many cases, the fascial sling operation can be performed as an outpatient procedure, meaning patients can go home the same day as surgery. This reduces healthcare costs and minimizes disruption to daily routines.
• Minimal Alteration of Anatomy: The procedure typically involves placing a supportive sling beneath the urethra to provide added support. Unlike some other surgical interventions, it does not significantly alter the anatomy of the pelvic region, which may be advantageous for some patients.
• Improved Quality of Life: Successful treatment of stress urinary incontinence can lead to significant improvements in a woman’s quality of life. It can restore confidence, reduce anxiety related to leakage, and allow individuals to engage in activities they may have previously avoided due to fear of embarrassment.
• Customization: Fascial sling operations can be tailored to meet the specific needs of each patient. Surgeons can adjust the tension of the sling or choose different materials based on factors such as the severity of incontinence and the patient’s anatomy.
• High Success Rates: Overall, fascial sling operations have been shown to have high success rates in resolving stress urinary incontinence symptoms. Many patients experience significant improvement or complete resolution of their symptoms following the procedure.
• Long-Term Durability: Studies have demonstrated that the benefits of fascial sling operations can be durable over the long term, providing sustained relief from stress urinary incontinence for many years after the procedure.
• Minimal Impact on Sexual Function: Unlike some other surgical interventions for stress incontinence, the fascial sling operation typically has minimal impact on sexual function. This can be an important consideration for many women when choosing a treatment option.
• The patient’s own tissue is used: The sling material is not synthetic material. Since the patient’s own tissue is used, no foreign body reaction is observed.

Success rate

The success rate of fascial sling operation for stress incontinence in women varies depending on factors such as patient selection, surgical technique, and follow-up duration. Overall, fascial sling procedures have been shown to be effective in treating stress urinary incontinence (SUI) in a significant percentage of patients. Success rates are typically defined in terms of improvement or resolution of urinary incontinence symptoms following surgery.

Several studies have reported success rates ranging from 70% to 90% or higher for fascial sling procedures in women with stress urinary incontinence. These rates indicate that a majority of patients experience significant improvement or complete resolution of their urinary incontinence symptoms following surgery.

Factors that may influence the success rate of fascial sling operations include:

• Severity of Incontinence: Patients with milder forms of stress urinary incontinence may have higher success rates compared to those with more severe symptoms.
• Type of Sling: Different types of sling materials and surgical techniques may have varying success rates. Fascial slings made from the patient’s own tissue or synthetic materials have been shown to be effective in treating SUI.
• Surgeon Experience: Success rates may be influenced by the experience and expertise of the surgeon performing the procedure.
• Patient Factors: Individual patient characteristics such as age, overall health, pelvic anatomy, and presence of other medical conditions may impact surgical outcomes.
• Follow-Up Duration: Success rates may vary depending on the duration of follow-up after surgery. Longer-term studies may provide more accurate assessments of the durability of treatment outcomes.

Despite the high success rates reported for fascial sling operations, it’s important to note that no surgical procedure is without risks or guarantees of success. Some patients may experience complications or recurrence of symptoms following surgery, and additional treatments or interventions may be necessary in these cases.

Summary

A fascial sling operation for stress incontinence in women is a surgical procedure aimed at treating urinary incontinence caused by weakened pelvic floor muscles. During the procedure, a supportive sling made of natural or synthetic material is placed beneath the urethra to provide additional support and improve its function. This helps to prevent involuntary urine leakage during activities such as coughing, sneezing, or physical exertion.

The surgery is typically minimally invasive and offers a long-term solution for stress urinary incontinence, with success rates ranging from 70% to 90% or higher. We have achieved 95% or more success in our cases. While generally effective, patients should discuss potential risks, benefits, and expected outcomes with their healthcare provider before undergoing the procedure.

Prof. Dr. Emin ÖZBEK

Urologist

Istanbul- TURKIYE