The evolution of midurethral slings

Use of urethral slings in the treatment of incontinence started in the early 20th century. An evolution in understanding the pathogenesis of urinary incontinence led to development of the midurethral sling, which was designed to replace the natural suburethral vectors of support, as described in the integral theory. Since the introduction of tension-free vaginal tape in 1995, multiple other commercially available types of midurethral sling have been introduced. In general, these sling types share the common characteristics of using a thin, type I synthetic mesh inserted at a midurethral level and applied without tension. The midurethral sling procedure has subsequently undergone multiple technical modifications, predominantly alterations to the technique and route used for sling insertion. Despite the variety in techniques, available evidence suggests that all sling types provide efficacious and durable outcomes. Several adverse effects have been reported that are specific to certain techniques, and include the risk of vascular, enteric or nerve injury, lower urinary tract injury, urinary retention or voiding dysfunction, and vaginal erosion. Nonetheless, the midurethral sling provides a safe surgical option overall, and represents a notable advance in the treatment of stress urinary incontinence.