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Sling Surgery Techniques & Post-Op Management

Author Ishaan Sangwan covers Sling Surgery Techniques & Post-Op Management on BackTable Urology

Ishaan Sangwan • Jul 7, 2021 • 78 hits

Sling surgery is the most common type of surgery to treat female stress incontinence. There are several types of slings that can be used, including TOTs, TVTs, and mini-slings, all with their risks and benefits.

Dr. Yahir Santiago-Lastra shares her approach to sling surgery and post-op management. We’ve provided the highlight reel in this article, but you can listen to the full podcast below.

The BackTable Urology Brief

• Of the different types of urethral sling surgery, Dr. Silva and Dr. Santigo-Lastra prefer TVT slings over TOT slings in their practices due to the risk of severe groin pain with TOTs.

• When inserting a “tension-free” sling, Dr. Santiago-Lastra recommends erring on the side of making it more loose in order to avoid putting undue pressure on the urethra.

• Dr. Santiago-Lastra prefers not to proceed with the procedure if the urethra or bowel are perforated or damaged.

• During sling surgery recovery, both doctors recommend a period of severe activity restriction, during which patients avoid heavy lifting, exercise, and penetrative sex, for 6-8 weeks.

Boston Scientific’s Advantage Fit sling device for TVT sling surgery

Table of Contents

(1) Types of Sling Surgery: TVTs, TOTs & Mini-Slings

(2) Sling Surgery Tensioning Technique

(3) Sling Surgery Contraindications

(4) Sling Surgery Post-Op Recovery

Types of Sling Surgery: TVTs, TOTs & Mini-Slings

Dr. Silva and Dr. Santiago-Lastra discuss the pros and cons of various types of urethral sling surgery, including TVTs, TOTs, and mini-slings. During a TVT, a mesh sling is passed through the retropubic space to support the bladder and urethra, whereas during a TOT, the sling is passed through the obturator space. A mini-sling is similar to a TOT, but it is performed with a single incision and the mesh arms do not pass all the way through the groin.

Dr. Santiago-Lastra states that her preferred type of sling is the retropubic sling, or the TVT sling, because TOTs come with the risk of severe groin pain. Mini-slings are also a viable option, especially for younger women, as the recovery can be easier for these patients. However, they may not be an option for women with larger pelvises.

[Dr. Jose Silva]
Let's talk about sling surgery. Are you doing TBTs, TOTs, mini-sling? What are you doing? Are you doing different procedures depending on the patient and also for residents to learn? What are you doing?

[Dr. Yahir Santiago-Lastra]
I have trained to do TVTs, TOTs, mini-slings from bottom up, top down... all different kinds of slings, I've seen them all. My preferred route for sling is the retropubic sling. The reason that I like the retropubic sling, again this sling surgery is the most common surgery that I do and so, for me, the retropubic sling has the best results and it also keeps the arms of the sling within the retropubic compartment, which I think is the urologist's domain.

TOT, on the other hand, involves placement of the sling through the obturator and involves the groin and I do think that, when patients develop really severe groin pain after a TOT, it can be really debilitating to their quality of life. For me, that is prohibitive and places the TOT in a category of a type of procedure that I prefer not to perform.

That said, there is also the mini-sling, which is similar to a TOT except that the mesh arms don't go all the way through into the groin. A lot of my colleagues in pelvic medicine place mini-slings and do think that the recovery from the mini-sling is a lot easier for women, especially for younger women. I, again, have not had any difficulty with the retropubic sling and its recovery and so that tends to be my sling of choice. But I also think that a TOT, especially for example a robotic procedure or a pelvic organ prolapse procedure when you are doing these things in combination, can be a really nice short bookend to a long case. I don't disavow it or think that it is not a great option. TOTs, however, I'm slightly biased again, just because of that potential for the groin pain.

[Dr. Jose Silva]
Yeah, I personally have the same side. I haven't done mini-slings, especially for big women that have a big pelvis. Sometimes you struggle putting the trocar in. I don't know but for now I continue using the TVTs.

Listen to the Full Podcast

Management of Pelvic Floor Dysfunction with Dr. Yahir Santiago-Lastra and Dr. Jose Silva on the BackTable Urology Podcast)
Ep 4 Management of Pelvic Floor Dysfunction with Dr. Yahir Santiago-Lastra and Dr. Jose Silva
00:00 / 01:04

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Sling Surgery Tensioning Technique

It’s important to create a tension-free sling to avoid putting undue pressure on the urethra. This can be achieved placing an 8 Hegar dilator between the sling and urethra tensioning. It is difficult to make a sling too loose, as the vaginal epithelium still needs to be closed over the sling.

[Dr. Jose Silva]
You always hear that the sling has to be retained to be tension-free. What does that mean?

[Dr. Yahir Santiago-Lastra]
The mesh does have to be placed in a tension-free manner, which means that you don't want it to be abutting the urethra directly. You want it to have some space between the urethra and the sling, where it is located. That can mean different things to different people. Everyone has their style of tensioning. I tend to use the style that was used back when the mesh was described, the first sling cases were described, which was a placement of an 8 Hegar dilator in between the sling and the urethra, while you're tensioning. So, I'm always, whenever I'm tensioning and pulling the sheaths off the sling, I have the 8 Hegar and I take it out and put it back in and make sure that it fits there snugly but without putting any undue pressure on the urethra and I do this tensioning with the 16 Fr Foley in place, I don't take it out. That has tended to go pretty well. I have only had three cases of retention in my career and those three women were all women who already had some incomplete bladder emptying, so I suspect that they had some intrinsic properties of their bladder that already predisposed them to being in retention. I actually haven't had a woman have a sling be placed too tightly who did not have some predisposition.

[Dr. Jose Silva]
I also use the Hegar but some people say that it needs to be not touching the urethra, so it is a little bit floating around. I mean it is interesting that is the same thing that I do but what would be the difference, I'm not sure. Do you know if there is a difference between letting it a little more loose. Definitely, the important part is to not strangle the urethra, but in terms of how loose is too loose. So you don't want to just not do anything.

[Dr. Yahir Santiago-Lastra]
One of my colleagues, Charlie Negar. He is this wonderful urogynecologist. He was the chair of OB/GYN when I started my career. He always tells us that you can almost never make a sling too loose. I think that that's true. It is always better to err on the side of making it more loose and it is very difficult to actually make it so loose that the patient doesn't get a good result and the reason for that is that you still have to close this very small incision. So, if the sling is a little too loose, then it is going to be really hard for you to close the vaginal epithelium over the sling, so it always ends up being in that sweet spot where it is easy to close but not too close to the urethra is what I've seen in my experience.

Sling Surgery Contraindications

While sling surgery has a high success rate for treating female incontinence, it is dangerous to proceed if the urethra or bowel are damaged. Excessive bleeding is also a risk, especially in younger women. In these cases Dr. Santiago-Lastra recommends holding pressure on the closed incision while the patient is prepped to go to recovery, with a possible ultrasound if the patient is unstable.

[Dr. Yahir Santiago-Lastra]
The nice thing about the sling surgery is that it really is the kind of surgery where you can do it the exact same way each and every time and it is very easy to become an expert and master the technique because there is very little variability in what you do. That said, I can think of two instances in which I would not proceed with the surgery. One would be if the urethra is injured during the dissection or also if you injure the urethra with the trocar when you're trying to pass the trocar. So those two instances... There's a third instance, actually, that is extremely rare and, full disclosure, I've never actually witnessed it in my career, but it has been reported in the literature, is if you have a bowel injury during trocar passage, for obvious reasons. So, those two scenarios, urethral injury or bowel injury, I think would be a moment to abort the surgery. Another thing that can happen with the sling operations, more so with the autologous slings but also for the synthetic slings is bleeding, especially if you are operating on a very young woman. I have had very young women who have very well estrogenized vaginas, where they have lost a significant amount of blood during the surgery. So whenever I'm thinking of a patient that is younger who is interested in undergoing the surgery, I definitely keep that in the back of my mind, because some of these patients will bleed quite a bit before the incision is closed.

[Dr. Jose Silva]
Do you do anything different in those cases? I mean, after you close, do you do any ultrasound or do you just wait and see how it goes.

[Dr. Yahir Santiago-Lastra]
That is a great question. I have thought about that a bunch and really what I do and it is the same for each case. For those young women, this would definitely be a case where I am not teaching during the case and I am really the one that is taking it from point A to point B completely independently. But, in addition, for all of my cases, when the vaginal incision is closed, I will actually take a lap or a Raytec and I will hold pressure while the suprapubic perforation sites are closed with Dermabond and everyone is getting the patient cleaned up and extubated in order to go to the recovery area. That will probably be about five minutes of pressure in the vagina with a Raytec or a lap sponge and then they go to the recovery with a Foley. I don't do an ultrasound. I don't necessarily admit them for observation. I definitely would if I were concerned about a lot of bleeding or if the patient were unstable, but luckily that has been a very rare occurrence.

Sling Surgery Post-Op Recovery

Dr. Santiago-Lastra recommends a six week period of restrictions after bladder sling surgery, during which she recommends no heavy lifting and no intercourse. While there’s some debate and ongoing clinical trials regarding whether these restrictions are necessary, she feels that they are, even if it’s for a shorter period of time. Dr. Silva recommends two months of the same restrictions to his patients, and warns that the recovery period will be longer for patients with impaired healing, such as diabetics and smokers.

[Dr. Jose Silva]
In terms of post-operative care, what do you tell a patient about when they can start doing exercise, lifting, having sex... What do you tell a patient or what do you do?

[Dr. Yahir Santiago-Lastra]
So, I think this paradigm may change, but currently what I and a lot of my colleagues will recommend is six weeks of no heavy lifting more than 10 pounds, nothing in the vagina during that time, so no intercourse for six weeks, and no soaking or bathing or bathing in the ocean, etc.

There are currently some clinical trials that are actually looking at whether we need to be having those restrictions present for the patient. I think that some restrictions are going to be necessary whether it is six weeks, or maybe less, I think remains to be seen. I bet you it is probably not necessary for it to be six weeks, but I don't want to take that chance. Most women are pretty happy doing that because they want their sling to work. If you think about how the sling works, since it is tension-free, it actually has to scar at the endopelvic fascia right in that position and you don't want it to stretch out because then it is not going to be effective for them when they have moments of effort or coughing or sneezing. So I think it is a good investment of their time to follow the restrictions, but I bet maybe in a few years, we'll be counseling them that maybe it needs to be four weeks or three weeks instead of six.

[Dr. Jose Silva]
Yes, I usually do two months just to be on the safe side and definitely in diabetic patients and people who are still smoking, I tell them it is going to be a lot longer, just because the healing will be less.

Podcast Contributors

Dr. Yahir Santiago-Lastra discusses Management of Pelvic Floor Dysfunction on the BackTable 4 Podcast

Dr. Yahir Santiago-Lastra

Dr. Yahir Santiago-Lastra is an associate professor of urology and the director of the Women's Pelvic Medicine Center at UC San Diego in California.

Dr. Jose Silva discusses Management of Pelvic Floor Dysfunction on the BackTable 4 Podcast

Dr. Jose Silva

Dr. Jose Silva is a board certified urologist practicing in Central Florida.

Cite This Podcast

BackTable, LLC (Producer). (2021, April 21). Ep. 4 – Management of Pelvic Floor Dysfunction [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.

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