What is it?
The Mid Urethral Sling (MUS) is a synthetic mesh tape or sling inserted for the treatment of Urinary Stress Incontinence.
What is Stress Incontinence?
Stress incontinence refers to leakage of urine associated with activities like coughing, sneezing, laughing, lifting or even walking or standing. Stress incontinence results from either weakness of the supports of the urethra (urethral hypermobility – Type II Stress Incontinence) or an actual weakness of the sphincter muscle in the wall of the urethra (Intrinsic Sphincter Deficiency – Type III Stress Incontinence). Which type you have is determined by your history, examination finding and the results of Fluoroscopic Urodynamic Studies. Stress incontinence is different to incontinence due to urgency (Urge Incontinence). Urinary urgency is a strong desire to pass urine that is difficult to postpone. You may have a combination of different types of incontinence.
What does the MUS procedure involve?
Three small cuts/incisions are made to place the tape/sling, each cut is about 1-1.5cm in length. Two of these are located just above the pubic bone on the lowest part of the abdominal wall (for the retropubic sling), and the third is inside the vagina. Through the vaginal incision the tape/sling is passed around the mid urethra and up through the pelvis behind the pubic bone to the lower abdominal wall. The urethra is the tube leading from the bladder through which urine passes to the outside of the body. After placement of the tape/sling, the small incisions are stitched closed with a dissolvable suture or closed with tissue glue. The tape/sling itself doesn’t need to be stitched into place as the properties of the tape/sling cause it to knit with the surrounding tissues and maintain its position.
What sort of anaesthesia is involved?
A MUS procedure can be done under either a local, regional (e.g. spinal anaesthetic) or general anaesthetic. In addition, sedation can be given in combination with local anaesthetic.
What is the usual Post-operative course?
Usually patients spend one night in hospital. A catheter in the bladder and a pack in the vagina are placed in theatre and this is removed the next morning. Following this if you are passing your urine freely you can go home. Patients can return to light duties within 1 week and normal daily activities after two weeks. It is recommended to wait 4-6 weeks from surgery before doing any heavy lifting, straining or strenuous exercise. Most patients (80%) notice a difference in the way they pass their urine after the procedure. It may be slower to start and slower to empty out.[1] There may be some discharge from the vagina until this wound in the vagina heals, about 2 weeks. Do not have intercourse or use tampons until 4 weeks after surgery.
Who is the MUS procedure suitable for?
It works best for patients with Type II Stress Incontinence with about a 90% cure rate of their stress incontinence. [2] It doesn’t work as well in patients with Type III Stress Incontinence, only about a 70% cure rate. [3, 4] Also for patients who have had previous surgery for stress incontinence cure rates as low as 40% have been reported.[5]
What about urgency symptoms?
The operation will also cure urgency symptoms in 30-50%, but 5-15% of patients who didn’t have urgency beforehand will develop it afterwards and some patients can develop urge incontinence. This can usually be controlled with medication.
What are the alternatives?
There are non-operative treatments for stress incontinence such as bladder training and pelvic floor exercises. If these have failed surgery is considered. Operations for stress incontinence include minor procedures such as ‘injectables’ and standard operations such as the Pubo-vaginal Sling or Burch Procedures.
Is the MUS as good as the other operations?
For Type II Stress Incontinence results with this procedure are comparable to the standard operations for stress incontinence such as the Burch or Sling Procedures. 90% of patients who have the operation are satisfied with the results.[7] The MUS is the stress incontinence operation with the most research and longest follow up data.
What are the advantages then of the MUS?
- Short operating time – about 1/2 an hour
- Short hospital stay – 1 night
- Quick recovery – return to most activities by 4 weeks
- Small incisions (cut)
What are the risks and complications?
There are very small risks (0.7/1000) of damaging nearby structures such as a major blood vessel, a nerve, the bowel or the urethra when the tape is inserted, which may require conversion to an open operation to repair [8]. If significant difficulty is encountered when passing the tape, conversion to an open operation may also be needed. This is more likely to occur in patients who have had previous pelvic surgery.
If there was damage to the bladder or bowel or urethra a fistula could result here bladder or bowel contents leak out the vagina. This is very rare. Further surgery would be required to manage it. If there was damage to the bowel or urethra this would be repaired and the MUS procedure aborted. An alternative procedure may be considered at a later date. The risk of making your incontinence is very rare.
It is often not possible to warn patients of every possible risk or potential complication with surgery especially if very rare. Yet it is important that you are aware of what risks are involved, especially the more common ones. This information is not meant to alarm you but allow you to make an informed consent to have surgery. It is very rare but unfortunately some patients can suffer complications and end up worse off as a result of their surgery.
There is a 5% risk of bladder perforation and this is more likely in patients who have had previous pelvic surgery. Fortunately, if this does occur the tape can usually be repositioned without much difficulty but a catheter may need to remain in the bladder for up to 5 days after the surgery. [2]
There is a small (6%) risk of a urine infection. The risks of bleeding (> 200 ml) or a pelvic haematoma (collection of blood) are 2%, and of a wound infection, only1%.
A few patients may experience minor difficulties passing their urine after this procedure, 7.6% [8]. Some (2.8%) may not be able to pass any urine, requiring a catheter to drain the urine or they may have significant problems passing their urine (hesitancy, straining to void or feeling of incomplete emptying) that suggest obstruction. These patients may require another minor operation to cut the tape through a vaginal incision (urethrolysis, 1.5%), which will usually relieve their symptoms without the return of incontinence.[9] The risk of persisting retention that cannot be fixed with further surgery resulting in the need for permanent catheter is very rare.
There is a risk of the tape/sling eroding through into either the vagina or the urethra. Although this is rare (<1%) it would require removal of that part of the tape/sling, [1]. There is probably a lifelong risk of erosion. There is about a 2% risk of the tape becoming infected which would then need to be surgically removed.
Any significant long term physical, emotional, mental, social, sexual or other problems following this procedure have not been fully studied. Pain during intercourse is reported in 3% of patients following the procedure but in most cases this resolves within 3 months of surgery. Up to 14% of patients have been reported to have a loss of libido after the MUS procedure.[7] Pain from the tape can occur requiring tape removal. In some patients tape removal does not resolve their pain.
There are also general medical risks of abdominal, cardiovascular (heart), and pulmonary (lung) illnesses; about 2%. These include Deep Vein Thrombosis (blood clots in deep leg veins), Pulmonary Embolus (these clots dislodging and going to the lungs), pneumonia, Myocardial Infarction (heart attack) and Cerebro-Vascular Accident (stroke).
There is a small risk of death; 1 in 100,000.
Follow-op
An appointment will be made for you to see your surgeon in the rooms about six weeks after discharge.
Pelvic Floor Exercises.
You should learn pelvic floor exercise and optimize your pelvic floor muscle strength prior to surgery. Pelvic floor exercises can cure stress incontinence in some women and avoid the need for surgery. Learning to contract you pelvic floor during activities will help protect your pelvic floor for life and is useful after surgery especially in the first 4-6 weeks whilst the tissues are healing. Physiotherapists or continence nurses can assist with pelvic floor education and an exercise programme.
Childbirth
It is possible to have children after this procedure but we just don’t really know the risk of your incontinence returning after pregnancy and childbirth. If you are planning to have children it is important you inform your surgeon so the time of your surgery can be planned to optimize the results. If you get pregnant after a MUS you and you Obstetrician would decide of the best type of delivery after weighing up the various pros and cons as other factors need to be taken into account. Generally a caesarean is recommended as a vaginal delivery can cause severe damage to the bladder after a MUS procedure.
References
1. Sander, P., et al., Does the tension-free vaginal tape procedure affect the voiding phase? Pressure-flow studies before and 1 year after surgery. BJU Int, 2002. 89(7): p. 694-8.
2. Boustead, G.B., The tension-free vaginal tape for treating female stress urinary incontinence. BJU Int, 2002. 89(7): p. 687-93.
3. Rezapour, M., C. Falconer, and U. Ulmsten, Tension-Free vaginal tape (TVT) in stress incontinent women with intrinsic sphincter deficiency (ISD)--a long-term followup. Int Urogynecol J Pelvic Floor Dysfunct, 2001. 12 Suppl 2: p. S12-14.
4. Jacquetin, B., [Use of "TVT" in surgery for female urinary incontinence]. J Gynecol Obstet Biol Reprod (Paris), 2000. 29(3): p. 242-7.
5. Bakas, P., A. Liapis, and G. Creatsas, Q-tip test and tension-free vaginal tape in the management of female patients with genuine stress incontinence. Gynecol Obstet Invest, 2002. 53(3): p. 170-3.
7. Maaita, M., J. Bhaumik, and A.E. Davies, Sexual function after using tension-free vaginal tape for the surgical treatment of genuine stress incontinence. BJU Int, 2002. 90(6): p. 540-543.
8. Kuuva, N. and C.G. Nilsson, A nationwide analysis of complications associated with the tension-free vaginal tape (TVT) procedure. Acta Obstet Gynecol Scand, 2002. 81(1): p. 72-7.
9. Klutke, C., et al., Urinary retention after tension-free vaginal tape procedure: incidence and treatment. Urology, 2001. 58(5): p. 697-701.
Version: V3, July 2017
