Surgical Techniques

Which sling for which patient?

This roundtable is the first of a series on persistent questions in urogynecology. Future topics: lower urinary tract injury, hysterectomy routes, vaginal vault prolapse.



  • How preop evaluation guides the decision
  • Intrinsic sphincter deficiency: What it is and what to make of it
  • Why the Burch procedure isn’t obsolete


  • Mickey Karram, MD, the moderator of this discussion, is director of urogynecology at Good Samaritan Hospital in Cincinnati and professor of obstetrics and gynecology at the University of Cincinnati.
  • Jerry Blaivas, MD, is clinical professor of urology, Weill Cornell Medical Center, New York City.
  • Mark Walters, MD, is head of the section of urogynecology and reconstructive pelvic surgery, Cleveland Clinic Foundation, Cleveland.

Slings abound, entering the market faster than research can evaluate every new modification as exhaustively as we would like. How should we determine what is best for a particular patient? That is the question we examine in this discussion—the first in a series of roundtables, Controversies in Pelvic Surgery.

Future topics in the series focus on other unsettled issues:

  • Preventing and managing lower urinary tract injury
  • How best to correct vaginal vault prolapse
  • Choosing the right hysterectomy route
  • Mesh augmentation in prolapse repair

We decided on a roundtable format for the series because it seems well suited to a review of sometimes spotty data, not to mention the onslaught of new products and procedures that, ironically enough, are intended to simplify our lives.

Choosing a sling for “uncomplicated” cases

DR. KARRAM: What is your sling procedure of choice for the uncomplicated patient who has primary stress urinary incontinence (SUI), urethral hypermobility, and what appears to be a healthy urethra?

DR. BLAIVAS: I prefer an old-fashioned, autologous, rectus fascial sling, or one made of soft prolene mesh, as described by Rodriguez and Raz1—although I place the sling a bit more proximal than most and dissect into the retropubic space. The autologous rectus fascial sling has a long-term success rate at least as good as any other procedure. Even though it requires at least a small suprapubic incision, the possibility of serious complication (vascular or bowel injury, urethral or vaginal erosion) is almost nil.

Allograft and xenograft slings do not have as good a long-term success rate, but the chance of serious complication is nearly nil. If I do use a synthetic, I prefer the technique developed by Dr. Raz because it utilizes a time-honored, safe technique and avoids the unnecessary expense of the disposable midurethral sling kits.

I place the autologous sling at the bladder neck because long-term studies confirm its safety and efficacy.

DR. WALTERS: I use the literature as a guide and perform either Burch colposuspension or a synthetic midurethral sling procedure.Although its popularity has waned slightly, the Burch operation—either open or laparoscopic—is very effective.

My midurethral sling of choice for the simplest cases, as well as those with coexistent prolapse, is the Monarc transobturator sling (American Medical Systems, Minnetonka, Minn). The outcome data for this procedure are preliminary, and it has not yet been shown to equal a classic tension-free vaginal tape (TVT) technique, but I find that it causes less voiding dysfunction and urgency in my hands.

KARRAM: I would probably use a conventional TVT sling procedure. The reason: There is a tremendous amount of data to support the use of TVT for all types of SUI. The data and our experience supports a very low erosion or excursion rate with the TVT tape. Since it is really the only synthetic midurethral sling that has been shown to be as effective as—if not more effective than—conventional repairs, it remains my procedure of choice in uncomplicated cases.

Preop evaluation

KARRAM: Do you use the same sling procedure for all patients? If so, do you test preoperatively to help determine appropriate tension? If not, how do you decide which sling to use on which patient?

WALTERS: I use 3 types of slings:

  • the Monarc transobturator sling for simple primary SUI, SUI with prolapse, and potential SUI,
  • TVT placed very loosely for recurrent SUI with leak point pressures over 60 cm H2O, and
  • TVT placed with a little more tension under the urethra for patients who have recurrent SUI with leak point pressures under 60 cm H2O, but who lack a complete “drainpipe” urethra.