Last updated: 02/17/2009

Anti-incontinence surgery is used to address the failure of two parts of female urinary continence: loss of support to the bladder neck or central urethra and intrinsic sphincter deficiency (ISD). The surgery does not restore function to the urethra...

or to the ability for closure to the sphincter. It replaces the mechanism for continence with supporting and compressive aids. Stabilizing the supporting elements of the urethra (ligaments, fascia, and muscles) was thought for many years to be the most important factor in curing incontinence. Called anatomic or genuine stress urinary incontinence (SUI), retropublic procedures, like the Burch procedure, sought only to restore the urethra to a fixed position. However, it became clear with the high failure rate of these procedures that ISD was present and unless surgery could confer some added compressive ability to the closure of the bladder, SUI would persist.

The urethral sling procedure is effective in the treatment of the severest types of incontinence (Types II and III) by re-establishing the "hammock effect" of the proximal or central point of the urethra during abdominal straining. The surgery involves the placement of a piece of material under the urethra at its arterial or vesical juncture and anchoring it on either side of the pubic bone or to the abdominal wall or vaginal wall. This technique involves the creation of a sling from a strip of tissue from the patient's own abdominal fascia (fibrous tissue) or from a cadaver. Synthetic slings also are used, but some are prone to break down over time.

The urethral sling procedure is most often performed as open surgery, which involves entering the pelvic area from the abdomen or from the vagina while the patient is under general or regional anesthesia. Broad-spectrum antibiotics are offered intravenously. If the patient is fitted with a urethral catheter, ampicillin and gentamicin are administered instead. The patient is placed in stirrups. Surgery takes place as a 6-to-9-cm by 1.5-cm sling is harvested from rectal tissue and sutured under the urethra at each end within the retropubic space (the area that undergirds the urethra). Synthetic tissue or fascia from a donor may also be used.

The goal of the surgery is to create a compression aid to the urethra. This involves an individualized approach to the tension needed on the sling. While the sling procedure is relatively easy to complete, the issue of tension on the sling is hard to determine and involves the use of tests during surgery for determining the compression effect of the sling on the urethra. Some manual tests are performed or a more sophisticated urodynamic test, like cystourethrography, may determine tension. It is important for the surgeon to test tension during surgery because of the high rate of retention of urine (inability to void) after surgery associated with this procedure and the miscalculation of the required tension.