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Pelvic slings for stress urinary incontinence: Are all created equal?

Procedure choice must consider balance of efficacy and safety based on patient characteristics

Dr. Nikolavsky
In the 1990s, the pubovaginal sling (PVS) became the most widely utilized procedure for female stress urinary incontinence (SUI). This was due to the development of "off-the-shelf" graft material, which decreased the morbidity, complexity, operative time, and convalescence of the procedure while treating all types of SUI, including intrinsic sphincter deficiency (ISD) (J Urol 2002; 167:608-12).

Dr. Flynn
In 1996, Ulmsten introduced the tension-free vaginal tape ([TVT] Ethicon Inc., Somerville, NJ) as a novel treatment for all types of SUI (Br J Obstet Gynaecol 1999; 106:345-50). The original TVT™ is a polypropylene mesh sling placed at the mid-urethra and tunneled by a trocar retropubically. It became the predicate device for subsequent sling kits. In fact, since 2002, Chapple and others have considered a tension-free mid-urethral sling (MUS) such as the TVT™ the gold standard for SUI due to a superior balance of efficacy, safety, and morbidity (Curr Opin Urol 2003; 13:301-7).

Christopher M. Gonzalez
Several other MUS designs followed the introduction of the TVT™ sling. In this article, we discuss the evolution of MUS kits, outline the advantages and disadvantages of three distinct approaches to MUS placement, and provide an overview of our algorithm for procedure selection. (Note: We will use the abbreviation TVT generically to refer to all kits that contain a full-length polypropylene mesh sling tunneled retropubically with a trocar, unless labeled with a trademark symbol. We will use the abbreviation TOT generically to refer to all kits that contain a full-length polypropylene mesh sling tunneled through the obturator foramen with a trocar, unless labeled with a trademark symbol.)

Mid-urethral sling kits

A variety of MUS kits have evolved since the advent of the original TVT™ sling, including the suprapubic arc (SPARC) sling system (American Medical Systems, Minnetonka, MN), which is a retropubic MUS placed using a "top-down" approach. Transobturator tapes (TOT) are the most popular type of MUS and may be placed from an "inside-out" technique, using the TVT-O™ (Ethicon), or an "outside-in" approach, using the Monarc (AMS).

In 2006, even less-invasive, single-incision kits such as the Gynecare TVT SECUR (Ethicon) and later, the MiniArc (AMS), were introduced. This latest innovation allows the MUS to be placed through a single vaginal incision.

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