Suburethral slings
When perineal rehabilitation (pelvic floor physiotherapy) or other conservative methods (e.g. incontinence pessary) have failed and urinary stress incontinence is very uncomfortable for women, a procedure to install a suburethral sling may be offered. Suburethral slings have been approved by Health Canada and have been used by physicians to treat their patients since the early 2000s.
Definition
A suburethral sling is a small polypropylene mesh (looks like a net) used in surgery to correct stress urinary incontinence, a type of leakage that occurs during an activity such as laughing, coughing or exercising. The suburethral sling is put in place to prevent or significantly reduce urine loss during these activities. The sling stays in the body permanently.
This procedure can greatly improve the health of patients, and especially their quality of life.
The beneficial effects of the surgery last five years after surgery in 75-80% of women; this rate decreases to 60% after five years.
As with any type of surgery, women are informed of the risks of complications beforehand by their doctor. This procedure is not necessarily suitable for all women. The decision must be made jointly by the patient and her doctor after discussing other non-surgical treatment options and the risks associated with the procedure.
The most severe complication is the development of chronic disabling pain (groin, thighs, pubic area, abdomen, back, vagina and perineum). The risk of this complication varies between 4 and 12% depending on the studies.
The scientific literature is vast on this subject. The insertion of a sling, which is a foreign body, is not harmless. The insertion of a sling is permanent. Not all women react to it in the same way.
In the presence of complications, it will be possible, after rigorous evaluation in an expert centre, to proceed to the partial or total removal of the sling, but this corrective surgery does not guarantee the end of undesirable effects felt. The removal of the sling could even lead to the return or even exacerbation of urinary stress incontinence.
Some 80,000 Quebec women have had suburethral slings installed since the early 2000s, greatly improving their health and quality of life.
In the event that a woman needs to have the sling removed, this procedure can be performed in Quebec. Expertise centres will be designated in the near future.
In recent years, there has been a movement to question these procedures because of the disabling pain observed in some patients. This movement includes patients from several countries, including Canada.
In 2019, the leaders of a Facebook group of approximately 800 women in Quebec who have suffered disabling pain due to a sling have led media offensives. This group represents approximately 1% of patients operated on, in Quebec. Following media reports and open letters in 2019, the President of the Urologists Association of Quebec responded to the media and published a response to these criticisms in the form of an open letter « Une main tendue et des faits » (in French only).
At the same time, the Collège des médecins du Québec (CMQ) mandated a committee of experts to evaluate this case. The CMQ's recommendations on the medical practice of suburethral sling insertion were the subject of an official report presented on June 16, 2020. The FMSQ favorably approved this report.
Stress urinary incontinence can significantly affect quality of life, but is not a medical condition requiring mandatory treatment.
Surgical treatment options other than the synthetic suburethral sling have been available for over 100 years. Suburethral slings have been used in Canada since 1999.
In general, the suburethral sling has been found to be as effective or more effective than any of these procedures and as durable (the favorable effects of the surgery last over a longer period of time). In addition, the pain associated with the procedure, the recovery time from surgery and the time needed before resuming normal activities, including work, is less for the suburethral sling than for these other surgical procedures.
Other treatments that exist to correct stress leaks include :
Aponeurotic sling
A sling made of your own tissue, taken from the abdomen and placed under the urethra. This is done through open surgery by making an incision in the lower abdomen and vagina under general anesthesia. The surgery lasts from 2 hours to 2h30. The adjustment of the sling (tight enough to stop leaking, but not so tight that you are always able to urinate) is more complex. You will have to stay in the hospital for 1 to 3 days after the surgery. The recovery time is about 6 weeks. Between 1 to 5 years after surgery, about 75% of women have an improvement in their symptoms, and 25% do not.
Colposuspension
This involves tying the tissue around the bladder to suspend it with stitches. This can be done either through open surgery or laparoscopy (using a camera through small incisions), under general anesthesia. You will need to stay in the hospital for 1 to 2 days after the operation. The recovery time is about 6 weeks. Between 1 to 5 years after surgery, about 70% of women have an improvement in their symptoms, and 30% do not.
Fillers
A synthetic substance is injected into the walls of the urethra via a small camera (cystoscopy) in order to narrow the urethra and help it to close. The agent remains in the body permanently. This is usually done under local anesthesia with a recovery time of 1 or 2 days. Although not as effective (~50%) or as durable as surgical treatments, it is useful as an alternative in some circumstances.
It may be necessary to repeat the injections or one may decide to opt for surgery later if the injections are not or no longer effective.
Do you have incontinence problems?
See your family doctor or a general practitioner.
Do you have a test sling and are experiencing pain?
Consult the Questions and Answers of the Collège des médecins (in French only) and consult a physician if necessary.