Vaginal Slings

How I Practice Video Series
Cheryl B. Iglesia, MD, FACOG

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When the patient has made the decision for surgery for stress urinary incontinence and you want to talk about midurethral slings, sometimes that concept is very difficult for patients to visualize. So what I usually do is I take a few props, something that's on my desk is a piece of tape and I ask the patient to put her hand out with the fist being the bladder and the index finger being the urethra. The pubic bone is right here above the urethra, the vagina is beneath the urethra, so we have to make a little incision in the vagina underneath the midurethra. Then I take a piece of tape and I demonstrate that the sling is going on either side of the urethra behind the pubic bone, like this, in a "U-shaped" fashion. So, it doesn't have to be stitched to anything, it exits that, and the sling, at rest, is under no tension. But when you cough, laugh, and sneeze, there's more pressure and that's when the sling activates, that's the most common type of sling, it's a retropubic midurethral sling. But in some patients with inherent voiding dysfunction or more mixed incontinence symptoms, we'll do a transobturator sling. And, to explain that I say that instead of having a "U-shaped" sling, we have an "H-shaped" sling with the incision exiting, it's the same as just along the vagina, but the sling exits on either side of the lips. Again, under relaxation there's no tension, but when the patient coughs, laughs, sneezes, it takes effect, but it's not as tight.

Now there is one other sling that's available, it's the mini sling (these have no exit wounds), it's the same incision, but instead the sling just sticks behind the pubic bone or the sling can get inserted into either side of the muscle. That can be used but the jury's still out on it, we don't have a lot of data on it. So I find with just a few props, some tape and the patient's finger, we get the concept of a midurethral sling explained in a relatively simple easily to visualize fashion. That is how I practice.


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