By Chiara Ghetti, MD
Associate Professor, Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Washington University School of Medicine, St. Louis
SYNOPSIS: The controversy surrounding polypropylene mesh use has confused and discouraged women from seeking surgical treatment for stress urinary incontinence. Midurethral slings remain the standard of care for the surgical treatment of stress urinary incontinence.
SOURCE: [No authors listed]. Joint position statement on midurethral slings for stress urinary incontinence. Female Pelvic Med Reconstr Surg 2021;27:707-710.
The purpose of this joint statement of the American Urogynecologic Society (AUGS) and Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction (SUFU) is to support the use of a midurethral sling (MUS) for the surgical management of stress urinary incontinence. Following the 2011 U.S. Food and Drug Administration (FDA) notification regarding adverse events with the use of transvaginal mesh and the subsequent 2019 restriction on mesh products for transvaginal repair of pelvic organ prolapse, confusion has arisen regarding the difference between the use of transvaginal mesh for prolapse and stress urinary incontinence. Negative perceptions of MUS have discouraged women from seeking treatment despite the well-established safety and efficacy of the full-length MUS.
COMMENTARY
AUGS and SUFU have come together with endorsing organizations (American College of Obstetricians and Gynecologists, American Urological Association, and International Urogynecological Association) and supporting organizations (American Association of Gynecologic Laparoscopists, National Association for Continence, and Society of Gynecologic Surgeons) to recognize again the importance of the MUS in the management of stress urinary incontinence in women.
Stress urinary incontinence is the “involuntary loss of urine on effort or physical exertion (e.g., sporting activities) or on sneezing or coughing” and it is distinguished from urgency incontinence, or overactive bladder, in which leakage is associated with a strong urge to void that is difficult to defer.1,2 The estimated lifetime risk of stress urinary incontinence for women in the United States is 20%, and leakage is known to have a significant negative effect on a woman’s quality of life.3
The evaluation of urinary leakage is similar between stress and urge incontinence. Initial treatment options of lifestyle/behavioral modification and pelvic floor physical therapy can be employed for both types of incontinence. Subsequent treatment options diverge. There are no current pharmacotherapies for stress urinary incontinence.
The nonsurgical treatment options for stress urinary incontinence include vaginal inserts and incontinence pessaries. The MUS is the standard of care for women with documented stress urinary incontinence desiring surgical management and it provides an efficacious and durable treatment. Pelvic examination and office testing to demonstrate stress incontinence and document bladder emptying is recommended prior to performing a MUS.
The joint task force that developed this statement presents five main justifications for the position statement:
- Polypropylene is safe and effective as a surgical implant. Polypropylene material has been used extensively in numerous surgical subspecialties and is used widely as both suture material and as knitted graft material to augment surgical repairs throughout the body. The polypropylene knitted material used for MUS is type 1, microporous, monofilament, and lightweight; studies have supported its long-term durability, safety, and efficacy up to 17 years.4
- The MUS has been studied extensively and, in fact, is the most highly studied surgical treatment for stress urinary incontinence. These studies have contributed to the rigorous evidence supporting the use of MUS for the treatment of stress urinary incontinence.
- With the publication of level 1 data, MUS has become the standard of care for the surgical treatment of stress urinary incontinence. When compared to the numerous other surgeries for stress urinary incontinence, MUS is associated with less pain, faster recovery, and reduced cost.
- The FDA updated its 2019 statement regarding surgical mesh to include the well-established safety and efficacy of MUS. They reported vaginal mesh exposure as the most common complication, occurring at a rate of 2% in one year.
- The Scientific Committee on Emerging and Newly Identified Health Risks concluded in 2015 that when used by trained surgeons, the MUS is an accepted procedure with proven efficacy and safety in most patients with moderate-to-severe stress urinary incontinence.
As with any surgical procedure, informed consent and joint decision-making are essential. In our practice, we review different treatment options for stress urinary incontinence and describe the procedure in its entirety. We explicitly review the indication for surgery and counsel patients to clarify and align expectations. Specifically, we review that the MUS is performed to treat stress urinary incontinence and not to treat other urinary symptoms, such as urgency, frequency, urge incontinence, nocturia, etc. Although some of these symptoms may change, patients should not expect a resolution of these other urinary symptoms. We review the efficacy of the procedure and the risks of sling placement, including urethral, bladder, bowel, and vascular injury; the possible need for transfusion; and mesh complications. We also discuss the risk of infection, incomplete bladder emptying, and a possible increase in urgency symptoms. We discuss some of the key points the task force addressed in this statement and point out explicitly that the MUS is not the transvaginal procedure fraught with complications that they may have heard about on television or in the news.
Because of the adverse events associated with transvaginal mesh kits, many women have been reluctant to consider surgical treatment for stress urinary incontinence. The purpose of this statement is to highlight once again the important role that MUS play in the treatment of stress urinary incontinence and in improving the lives of women with stress urinary incontinence.
REFERENCES
- D’Ancona C, Haylen B, Oelke M, et al. The International Continence Society (ICS) report on the terminology for adult male lower urinary tract and pelvic floor symptoms and dysfunction. Neurourol Urodyn 2019;38:433-477.
- Abrams P, Andersson KE, Birder L, et al. Fourth International Consultation on incontinence recommendations of the International Scientific Committee: Evaluation and treatment of urinary incontinence, pelvic organ prolapse, and fecal incontinence. Neurourol Urodyn 2010;29:213-240.
- Wu JM, Matthews CA, Conover MM, et al. Lifetime risk of stress urinary incontinence or pelvic organ prolapse surgery. Obstet Gynecol 2014;123:1201-1206.
- Nilsson CG, Palva K, Aarnio R, et al. Seventeen years’ follow-up of the tension-free vaginal tape procedure for female stress urinary incontinence. Int Urogynecol J 2013;24:1265-1269.
