Urethral Slings for Incontinence during Vaginal Prolapse Repair

It often happens that new bladder overactivity appears after surgical correction of vaginal prolapse. The bladder neck is kinked by the prolapse, and straightening that kink with surgery can make a woman who was continent newly incontinent because that kink was helping them stay dry with a retentive effect. When the kink is gone, the muscular sphincter is left on it’s own to maintain dryness.

Some surgeons recognize this and place a mid-urethral sling on all of these patients at surgery, presuming that it is needed in case incontinence may develop. In the CARE trial, this reduced the posoperative risk of stress incontinence from 44.1 to 23.8%. In the more recent OPUS trial, similar numbers were seen with mid-urethral slings lowering the rate of stress incontinence from 43 to 27.3%.

However, we must ask ourselves is putting a sling in 100% of patients to achieve a 16% benefit is really cost-effective and worth the possible complications of sling placement. Many experts, and myself, believe that it is better to complete the prolapse surgery and the subsequent recovery. For those women who have new-onset stress incontinence we can return to surgery for a sling, and the large majority of women who do not need one can be spared the potential complications. This reduces the number of slings placed by 60 to 80%, which is considerable.

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