Correspondence *Virginia Mason Medical Center, C-7 URO, 1100 Ninth Avenue, Seattle, WA 98111, USA

Email derapp@yahoo.com

Introduction

At the beginning of the 20^th century, VonGiordano described the first urethral sling, which used gracilis muscle.¹ Modifications to the technique were subsequently described that predominantly used other muscle bodies, such as a pyramidalis muscle flap and plication of the perivesical muscular structures.^{2, 3, 4} Common to these techniques was the belief that muscle placed around the bladder neck would provide a sphincteric function.

As sling techniques evolved, a variety of materials came into use. Price⁵ described the first fascia lata sling in 1933. The origin of the contemporary pubovaginal sling may be found in the classic technique described by Aldridge in 1942,⁶ in which a strip of rectus fascia was secured beneath the urethra to provide increased resistance at times of heightened abdominal pressures. This technique was later modified to leave the external oblique aponeurosis attached to the pubic tubercle and suture the fascial ends beneath the proximal urethra.⁷

This era of sling development was also notable for the popularity of abdominal retropubic and transvaginal suspension procedures, characterized by techniques to suspend the bladder neck by fixation of surrounding tissues. Accordingly, in 1949, Marshall et al.⁸ pioneered a technique for bladder-neck suspension through the fixation of perivesical bladder-neck tissue to the pubic symphysis. Rare but severe bony complications were attributed to pubic symphyseal fixation, however, and consequently Burch⁹ described a modified retropubic suspension in which the fixation point was positioned laterally along Cooper's ligament.

Although satisfactory continence rates were achieved by retropubic procedures, the invasive nature of the abdominal approach and consequently long durations of hospital stay and postoperative convalescence rendered them less ideal than the vaginal approach. Additionally, perioperative morbidity was notable. Despite the reduced morbidity associated with the transvaginal needle suspensions, however, the effects of these procedures on stress urinary incontinence (SUI) were not durable.

In an effort to improve the efficacy of surgical treatment of SUI, McGuire and Lytton¹⁰ revived, in 1978, the use of the pubovaginal sling. They described a combined abdominovaginal approach with complete detachment of the rectus fascia, which was repositioned suburethrally as a sling. The morbidity associated with autologous graft harvesting led, eventually, to exploration of the use of allografts and xenografts, for example, the use of cadaveric fascia lata anchored over the rectus fascia or via transvaginal bone anchors. Irrespective of allograft type or fixation method, however, early reports of isolated failure were attributed to weak tensile strength and suture pull-out.¹¹ Continued refinements in materials were sought to identify an ideal compound for use in transvaginal slings that would be inert, sterile, noncarcinogenic, and mechanically durable. In this Review we provide an overview of the pathogenesis of SUI and of the evolution of the midurethral sling, with a focus on the types of slings currently available and the outcomes of this therapy.

Theories of continence and the pathogenesis of incontinence

Development of midurethral sling types and insertion procedures

Expanding on the integral theory, Ulmsten and Petros¹⁴ first described outcomes of 50 patients after intravaginal sling placement performed via a minimally invasive technique in 1995. In addition to its midurethral anatomic location, their procedure had a further novel modification, a tensionless sling placement that minimized direct urethral pressure. The resultant effect was an emulation of the backboard feature of the integral theory. The original midurethral sling model of Ulmsten and Petros led to the development of tension-free vaginal tape (TVT), which was introduced as a commercially available kit by Gynecare^® Inc., Menlo Park, CA.¹⁵

As introduced, the TVT sling comprised a narrow polypropylene strip, housed within a plastic sheath to aid in retropubic sling passage. The sling was placed by specially designed trocars that were passed retropubically from a small vaginal incision to a suprapubic exit site at the skin surface. Importantly, passage in this fashion was described as a bottom-to-top technique.

Several modifications have been applied to the initial technique for TVT insertion. To overcome complications associated with the blind passage of the TVT through the retropubic space, the SPARC^® or suprapubic arc system (American Medical Systems Inc., Minnetonka, MN) was developed. This system comprises a polypropylene sling of similar characteristics to the TVT, but which is inserted via a top-to-bottom approach. In theory, the greatest control of the trocar occurs at the beginning of the passage arc. Accordingly, a top-to-bottom insertion approach theoretically allows the greatest control to occur during passage through the retropubic space, while the device is in proximity to the vascular and enteric structures of the pelvis.

A transobturator approach was described by Delorme.¹⁶ This approach was introduced in the US for use with the commercially available ObTape^® (Mentor Corporation, Santa Barbara, CA) transobturator sling. The transobturator approach, initially described as 'outside-in', preserved the principles of previous midurethral sling procedures but altered the route of needle passage. Trocar placement was initiated via an incision lateral to the labium majus and continued though the obturator foramen to a vaginal exit site at the midurethral position. While the transobturator technique theoretically minimizes the risk of complications involving enteric and vascular structures of the pelvis, this approach involves navigation of the obturator foramen, through which passes the obturator artery, vein and nerve. Nonetheless, because of the lateral position of these structures within the foramen, trocar passage should theoretically occur well medial to these structures. The sling trajectory specific to this approach does, however, raise the risk of groin or adductor tendon pain.

Similarly to the evolution of the technique described with the retropubic midurethral sling, subsequent modifications to the transobturator approach were described. De Leval¹⁷ reported an 'inside-out' transobturator technique, and commercially available kits using this design were subsequently introduced (Table 1). Assuming that maximum control of the needle path occurs at the point of entry, the outside-in approach theoretically affords greatest control in the proximity of the obturator structures, while the inside-out route would be most precise in the vicinity of the urethra. Importantly, the available data do not generally suggest significant differences in outcomes between these midurethral sling types. Moreover, the wide variety in sling procedures will probably continue, because it is driven by the large number of commercial manufacturers that participate in this market and, subsequently, by surgeons' preferences for the available products.

Table 1 Commercial kits available for midurethral sling placement.

Full tableFigures & Tables indexDownload Power Point slide (264K)

Finally, two further midurethral sling types have been introduced, but limited data are so far available on their safety and efficacy. The first type is a shortened sling placed via a vaginal incision. The design allows for sling fixation to the pubic ramus. Sling deployment may be achieved in either a U-shaped or hammock-shaped fashion, and separate incisions are not, therefore, needed for trocar exit sites. In addition, complications associated with trocar passage through either retropubic or obturator sites are avoided. This sling type is now commercially marketed by two different manufacturers: MiniArc^® by American Medical Systems Inc., Minnetonka, MN, and Secur^® by Gynecare^® Inc.

The second type of sling was described by Daher et al.¹⁸ in 2003 and involves a prepubic approach. Again, this approach was designed to minimize the complications associated with retropubic or transobturator passage. Accordingly, trocar passage is directed from a vaginal incision to an exit site anterior to the pubic bone. Theoretically, this approach allows for avoidance of not only vascular and enteric structures, but the bladder as well. However, there is an added risk of injury to the neurovascular supply of the clitoris. This sling type is now commercially marketed as the Prefyx PPS^® system (Boston Scientific Scimed Inc., Maple Grove, MN).

Many descriptions of polypropylene mesh slings placed without the use of the popular proprietary midurethral sling kits exist in the literature. Despite the variety of sling placement techniques, it must be emphasized that the concept of the midurethral sling has undergone minimal changes since its description by Ulmsten and Petros in 1995.¹⁴

Outcomes after midurethral sling placement

A complete review of published outcomes is beyond the scope of this article. We attempt, therefore, to provide representative data on outcomes, with a focus on the series that have reported the longest follow-up. Comparison of outcomes data remains extremely difficult, however, owing to the variation in outcome measures and definitions of success that have been used by different reporting centers.

The greatest body of outcomes data is available for TVT. Combined, these data demonstrate this sling type to be highly efficacious. In general, cure rates of 80–89% are reported.^{16, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33} Outcomes seem to remain stable over the observed follow-up periods, and several centers have reported updated outcomes.^{15, 19, 20, 21, 22} Cure rates of 91%, 84% and 86% have been reported at minimum follow-up periods of 1, 2 and 3 years, respectively.^{15, 19, 20} The effects seem to be durable: reports with 6–8 years of follow-up demonstrate persistent cure rates of 80–81%.^{22, 25} Finally, successful outcomes have been achieved by use of TVT to treat recurrent SUI after failure of a previous midurethral sling placement.³⁴

Similar data are available for the SPARC^® sling, albeit from studies with limited follow-up.^{26, 27, 28, 29} One study with follow-up of longer than 1 year demonstrated subjective and objective cure rates of 75–95% (Table 2). Again, outcomes seem to remain stable over this period.

Table 2 Clinical outcomes in patients undergoing midurethral sling placement.

Full tableFigures & Tables indexDownload Power Point slide (267K)

For the transobturator technique, outcome data are mainly available only for short-term and intermediate-term experiences. Given the smaller quantity of data, we present combined outcomes for both transobturator techniques here. In general, objective and subjective cure rates range from 80% to 92% and seem to be similar for both techniques. Outcomes with a minimum of 3 years' follow-up were reported by Waltregny and colleagues³³ following transobturator TVT placement in 91 patients with SUI. In this patient cohort, 88% of patients were cured, and a further 9% improved. Again, these outcomes remained stable, with no significant differences in the cure rate being observed when compared with outcomes seen at 1 year follow-up.

Numerous sling techniques have been described in the literature, and the focus of research has accordingly turned to elucidating which of these give the best results. Included in this body of literature are large numbers of not only retrospective comparisons, but also prospective, randomized, controlled clinical trials. In a comparison of the retropubic techniques, several series demonstrated no difference in cure rates between TVT and SPARC^® procedures.^{27, 35} A comparison of outside-in with inside-out transobturator techniques also demonstrated similar success rates at 1 year.³⁶ Furthermore, comparisons of retropubic versus transobturator approaches reveal similar improvements in the severity of incontinence.^{37, 38} Finally, Ward and Hilton³⁹ reported comparable efficacies for TVT versus Burch colposuspension in a prospective, randomized trial.

Novara et al.⁴⁰ performed a meta-analysis to evaluate retropubic and transobturator sling procedures, as well as retropubic colposuspension. Their findings suggested similar efficacies for retropubic and transobturator approaches. Interestingly, TVT was more efficacious than use of the SPARC^® system with Burch colposuspension. However, the authors note that caution should be exercised in extrapolating these data, given the poor methods of most of the studies used in their analysis. Despite these conclusions, analyses of comparable studies suggest that there is little difference in clinical outcomes between techniques.

Complications associated with midurethral slings

Voiding dysfunction is a common concern after sling surgery. In contrast to the often prolonged period of incomplete bladder emptying observed after retropubic colposuspensions, spontaneous voiding is generally achieved rapidly with midurethral sling placement.⁴¹ Urinary retention requiring catheterization occurs in 2–20% of patients, although its duration is generally limited.⁴¹ Levin et al.⁴² reported a 2.5% rate of urinary retention requiring catheterization for a period of longer than 7 days; only one patient failed to void spontaneously by 1 month after surgery. Apart from the risk of overt urinary retention, the development of either objective changes to voiding patterns or debilitating obstructive symptoms is possible after sling placement.^{43, 44, 45} Klutke et al.⁴⁶ noted a 2.8% rate of obstructive symptoms that ultimately required transvaginal sling release in a series of 600 patients who underwent TVT.

The development of de novo urgency following midurethral sling placement is a concern. This symptom is reported in 0–26% of patients, and is attributed to obstructive or locally irritative causes.⁴¹ Midurethral sling placement is, however, more likely than traditional sling procedures to alleviate preoperative urgency and irritative symptoms. For example, in one review, nearly 9% of patients required anticholinergic therapy for de novo urgency, whereas 58% of the patients (in the same cohort) who required anticholinergic drugs before surgery were able to stop this therapy after sling placement.⁴⁷ When de novo urgency does occur, it is typically treated with dietary and behavioral modification and anticholinergic therapy.

Bladder perforation is a relatively common occurrence during sling placement, seen in 1–10% of cases.^{21, 48} A combined experience of 92 surgeons indicated a 7% bladder perforation rate in a study population of over 12,000 patients.⁴⁹ Despite the theoretically improved control obtained through top-to-bottom passage during placement, no difference in bladder perforation rates has been noted between the use of SPARC^® and TVT.²⁶ Unsurprisingly, however, bladder perforation rates are substantially lower with the transobturator approach, although urethral perforation has been reported.⁵⁰ Given these data, we believe that cystourethroscopy should be performed intraoperatively following sling placement, irrespective of technique.

Vascular injury and hemorrhage are arguably the most feared complications of any sling placement, despite their rarity; hemorrhagic complications have occasionally resulted in death.⁵¹ Abouassaly et al.⁵² report blood loss of greater than 250 ml in 5% and 500 ml in 3% of patients undergoing TVT, with only 2% of patients developing retropubic hematoma.⁵² Few data exist on the relative frequencies of hemorrhagic complications after retropubic versus transobturator sling insertion, although reported trends seem to favor the transobturator approach. Anatomical studies in cadavers have suggested a worse vascular safety margin with an inside-out approach than with outside-in transobturator techniques.

Similarly, bowel perforation is a rare but potentially devastating complication.⁵³ In contrast to other types of complication, there is a definite advantage to the transobturator approach with respect to the avoidance of bowel injury.

Finally, mesh erosion and vaginal extrusion exist as notable concerns related to the use of synthetic slings. Use of polypropylene mesh has become standard, because of the increased erosion rates associated with other synthetic fibres, such as polyester.^{54, 55} Erosion and vaginal extrusion are seen not only with midurethral sling techniques, but also with most types of anti-incontinence and vaginal reconstructive surgeries that employ synthetic materials in general. Despite the common use of polypropylene, differences in sling characteristics, such as pore size and weave characteristics, could theoretically yield differences in erosion or extrusion rates. For example, our experience suggests an unacceptably high incidence of vaginal extrusion associated with use of ObTape^®, despite its polypropylene makeup, which might be attributable to the small pore size of its mesh.⁵⁶

Vaginal extrusion rates of 0–6% are reported.^{24, 26, 30, 50} A trend towards increased extrusion rates might be associated with the transobturator approach, although further data are needed to confirm this finding. Of importance, while erosion and extrusion can present with bleeding, pain, or recurrent incontinence, these complications may also be asymptomatic. Accordingly, a thorough postoperative examination and high index of suspicion for these sequelae is necessary following sling placement.

Conclusions

Advances in the treatment of female SUI have been seen over recent decades. The emergence of the integral theory and the midurethral sling has resulted in an evolution of the theory and treatment of this disorder. Multiple midurethral sling types exist and seem to provide safe, efficacious, and durable treatment options. Further investigation is necessary to confirm long-term outcomes and to determine whether sling-specific outcomes vary over time.

Acknowledgments

Désirée Lie, University of California, Irvine, CA, is the author of and is solely responsible for the content of the learning objectives, questions and answers of the Medscape-accredited continuing medical education activity associated with this article.

References

1. Ridley JH (1985) The Goebell-Stoeckel sling operation. In TeLinde's operative gynecology (Eds Mattingly RF and Thompson JP). Philadelphia: Lippincott Williams & Wilkins
2. Goebell R (1910) Zur operativen Beseitgung der angeborenen Incontinentia Versicae [German]. Dtschr Gynakol Urol 2: 187–191
3. Frangenheim P (1914) Zur operativen behandlung der Inkontinenz der mannlichen Harnrohe [German]. Verh Dtsch Ges Chir 43: 149–156
4. Stoeckel EP (1921) Treatment of incontinence of urine in traumatic injuries of the sphincter muscle. Zentralbl Gynakol 45: 17–19
5. Price PB (1933) Plastics operations for incontinence of urine and feces. Arch Surg 26: 1043–1048
6. Aldridge AH (1942) Transplantation of fascia for the relief of urinary incontinence. Am J Obstet Gynecol 44: 398–411
7. Narik G and Palmrich AH (1962) A simplified sling operation suitable for routine use. Am J Obstet Gynecol 84: 400–405 | PubMed | ChemPort |
8. Marshall FV et al. (1949) The correction of stress incontinence by simple vesicourethral suspension. Surg Gynecol Obstet 88: 509–518 | PubMed |
9. Burch JC (1961) Urethrovaginal fixation to Cooper's ligament for the correction of stress incontinence, cystocele and prolapse. Am J Obstet Gynecol 81: 281–290 | PubMed | ChemPort |
10. McGuire EJ and Lytton B (1978) Pubovaginal sling for stress incontinence. J Urol 119: 82–84 | PubMed | ChemPort |
11. Chaikin DC and Blaivas JG (1998) Weakened cadaveric fascial sling: an unexpected cause of failure. J Urol 160 (Pt 1): 2151 | Article |
12. Delancey JO (1994) Structural support of the urethra as it relates to stress urinary incontinence: the hammock hypothesis. Am J Obstet Gynecol 170: 1713–1723 | PubMed | ChemPort |
13. Petros PE and Ulmsten UI (1997) An integral theory of female urinary incontinence: experimental and clinical considerations. Acta Obstet Gynecol Scand 166 (Suppl): 3–8
14. Ulmsten U and Petros P (1995) Intravaginal slingplasty (IVS): an ambulatory surgical procedure for treatment of female urinary incontinence. Scand J Urol Nephrol 29: 75–82 | PubMed | ChemPort |
15. Ulmsten U et al. (1998) A multicenter study of tension-free vaginal tape (TVT) for surgical treatment of stress urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunct 9: 210–213 | Article | PubMed | ChemPort |
16. Delorme E (2001) Transobturator urethral suspension: mini-invasive procedure in the treatment of stress urinary incontinence in women [French]. Prog Urol 11: 1306–1313 | PubMed | ISI | ChemPort |
17. de Leval J (2003) Novel surgical technique for the treatment of female stress urinary incontinence: transobturator vaginal tape inside-out. Eur Urol 44: 724–730 | Article | PubMed | ISI |
18. Daher N et al. (2003) Pre-pubic TVT: an alternative to classic TVT in selected patients with stress incontinence. Eur J Obstet Gynecol Reprod Biol 107: 205–207 | Article | PubMed | ChemPort |
19. Ulmsten U et al. (1996) An ambulatory surgical procedure under local anesthesia for treatment of female urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunct 7: 81–85 | Article | PubMed | ChemPort |
20. Ulmsten U et al. (1999) A three-year follow-up of tension-free vaginal tape for surgical treatment of female stress urinary incontinence. Br J Obstet Gynecol 106: 345–350 | ChemPort |
21. Nilsson CG et al. (2001) Long-term results of the tension-free vaginal tape (TVT) procedure for surgical treatment of female stress urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunct 12 (Suppl 2): S5–S8 | Article |
22. Nilsson CG et al. (2004) Seven-year follow-up of the tension-free vaginal tape procedure for treatment of urinary incontinence. Obstet Gynecol 104: 1259–1262 | PubMed |
23. Jeffry L et al. (2001) Objective and subjective cure rates after tension-free vaginal tape for treatment of urinary incontinence. Urology 58: 702–706 | Article | PubMed | ISI | ChemPort |
24. Rezapour M and Ulmsten (2001) Tension-free vaginal tape (TVT) in women with mixed urinary incontinence—a long-term follow-up. Int Urogynecol J Pelvic Floor Dysfunct 12 (Suppl 2): S15–S18 | Article |
25. Deffieux X et al. (2007) Long-term results of tension-free vaginal tape for female urinary incontinence: follow-up of over 6 years. Int J Urol 14: 521–526 | Article | PubMed |
26. Andonian S et al. (2005) Randomized clinical trial comparing suprapubic arch sling (SPARC) and tension-free vaginal tape (TVT): one-year results. Eur Urol 47: 537–541 | Article | PubMed |
27. Tseng LH et al. (2005) Randomized comparison of suprapubic arc sling procedure vs tension-free vaginal taping for stress incontinent women. Int Urogynecol J Pelvic Floor Dysfunct 16: 230–235 | Article | PubMed |
28. Dalpiaz O et al. (2006) SPARC sling system for treatment of female stress urinary incontinence in the elderly. Eur Urol 50: 826–830 | Article | PubMed |
29. Primus G (2006) One year follow-up on the SPARC sling system for the treatment of female urodynamic stress incontinence. Int J Urol 13: 1410–1414 | Article | PubMed |
30. Deval B et al. (2006) Objective and subjective cure rates after trans-obturator tape (OBTAPE) treatment of female urinary incontinence. Eur Urol 49: 373–377 | Article | PubMed |
31. Spinosa JP and Dubuis PY (2005) Suburethral sling inserted by the transobturator route in the treatment of female stress urinary incontinence: preliminary results in 117 cases. Eur J Obstet Gynecol Reprod Biol 123: 212–217 | Article | PubMed |
32. Giberti C et al. (2007) Transobturator tape for treatment of female stress urinary incontinence: objective and subjective results after a mean follow-up of two years. Urology 69: 703–707 | Article | PubMed |
33. Waltregny D et al. (2007) TVT-O for the treatment of female stress urinary incontinence: results of a prospective study after a 3-year minimum follow-up. Eur Urol 563: 401–410
34. Lee KS et al. (2007) Outcomes following repeat mid urethral synthetic sling after failure of the initial sling procedure: rediscovery of the tension-free vaginal tape procedure. J Urol 178: 1370–1374 | Article | PubMed |
35. Gandhi S et al. (2006) TVT versus SPARC: comparison of outcomes for two midurethral tape procedures. Int Urogynecol J Pelvic Floor Dysfunct 17: 125–130 | Article | PubMed |
36. Liapis A et al. (2007) Monarc vs TVT-O for the treatment of primary stress incontinence: a randomized study. Int Urogynecol J Pelvic Floor Dysfunct 19: 185–190 | PubMed |
37. Barry C et al. (2007) A multi-centre, randomised clinical control trial comparing the retropubic (RP) approach versus the transobturator approach (TO) for tension-free, suburethral sling treatment of urodynamic stress incontinence: the TORP study. Int Urogynecol J Pelvic Floor Dysfunct 19: 171–178 | PubMed |
38. Zhu L et al. (2007) Comparing vaginal tape and transobturator tape for the treatment of mild and moderate stress incontinence: a prospective randomized controlled trial. Int Urogynecol J Pelvic Floor Dysfunct 99: 14–17
39. Ward KL and Hilton P (2004) A prospective multicenter randomized trial of tension-free vaginal tape and colposuspension for primary urodynamic stress incontinence: two-year follow-up. Am J Obstet Gynecol 190: 324–331 | Article | PubMed | ISI |
40. Novara G et al. (2007) Tension-free midurethral slings in the treatment of female stress urinary incontinence: a systematic review and metaanalysis of randomizd controlled trials of effectiveness. Eur Urol 52: 663–678 | Article | PubMed |
41. Bullock TL et al. (2006) Advances in female stress urinary incontinence: mid-urethral slings. BJU Int 98 (Suppl 1): 32–40 | Article |
42. Levin I et al. (2004) Surgical complications and medium-term outcome results of tension-free vaginal tape: a prospective study of 313 consecutive patients. Neurourol Urodyn 23: 7–9 | Article | PubMed |
43. Lukacz ES et al. (2004) The effects of the tension-free vaginal tape on voiding function: a prospective evaluation. Int Urogynecol J Pelvic Floor Dysfunct 15: 32–38 | Article | PubMed |
44. Sander P et al. (2002) Does the tension-free vaginal tape procedure affect the voiding phase? Pressure-flow studies before and 1 year after surgery. BJU Int 89: 694–698 | Article | PubMed |
45. Dietz HP et al. (2004) Voiding function after tension-free vaginal tape: a longitudinal study. Aust NZ J Obstet Gynaecol 44: 152–155 | Article |
46. Klutke C et al. (2001) Urinary retention after tension-free vaginal tape procedure: incidence and treatment. Urology 58: 697–701 | Article | PubMed | ChemPort |
47. Segal JL et al. (2004) Prevalence of persistent and de novo overactive bladder symptoms after the tension-free vaginal tape. Obstet Gynecol 104: 1263–1269 | PubMed |
48. Haab F et al. (2001) Results of the tension-free vaginal tape procedure for the treatment of type II stress urinary incontinence at a minimum follow-up of 1 year. J Urol 165: 159–162 | Article | PubMed | ChemPort |
49. Agonstini A et al. (2005) Immediate complications of tension-free vaginal tape (TVT): results of a French survey. Eur J Obstet Gynecol Reprod Biol 124: 237–239 | Article | PubMed |
50. Costa P et al. (2004) Surgical treatment of female stress urinary incontinence with a trans-obturator-tape (T.O.T.) Uratape: short term results of a prospective multicentric study. Eur Urol 46: 102–107 | Article | PubMed | ChemPort |
51. Bemelmans BL and Chapple CR (2003) Are slings now the gold standard treatment for the management of female urinary stress incontinence and if so which technique. Curr Opin Urol 13: 301–307 | Article | PubMed |
52. Abouassaly R et al. (2004) Complications of tension-free vaginal tape surgery: a multi-institutional review. BJU Int 94: 110–113 | Article | PubMed |
53. Kobashi KC and Govier FE (2003) Perioperative complications: the first 140 polypropylene pubovaginal slings. J Urol 170: 1918–1921 | Article | PubMed |
54. Comiter CV and Colegrove PM (2004) High rate of vaginal extrusion of silicone-coated polyester sling. Urology 63: 1066–1070 | Article | PubMed |
55. Young SB et al. (2001) Mersilene mesh sling; short- and long-term clinical and urodynamic outcomes. Am J Obstet Gynecol 185: 32–40 | Article | PubMed | ChemPort |
56. Yamada BS et al. (2006) High rate of vaginal erosions associated with the mentor ObTape. J Urol 176: 651–654 | Article | PubMed |

Contact the journal about this article

Subject areas under which this article appears: Urinary incontinence, urodynamics and lower urinary tract dysfunction