Mid-Urethral Slings (MUS) & Autologous Fascial Slings (AFS) for Female Stress
Urinary Incontinence Urology
What is Stress Urinary Incontinence (SUI)?
SUI is the leakage of urine with exercise or exertion that increases intraabdominal pressure. This can occur during everyday activities such as coughing, sneezing and exercising. SUI can be mild but may also cause significant difficulty with daily activities. Management of SUI starts with nonsurgical treatments such as weight loss, smoking cessation as well as pelvic floor muscle exercises.
Indications for Surgery
Patients with bothersome symptoms who have failed non-surgical management should consider surgical options for treatment. Surgical options for SUI include Mid-Urethral Slings (MUS) or Autologous Fascial Slings (AFS).
What are Mid-Urethral Slings (MUS)?
MUS is a relatively safe, effective and minimally invasive procedure designed to treat women with SUI, improving their quality of life. This has been performed since the early 1990s. The procedure involves the placement of a small synthetic mesh made of polypropylene between the urethra and vagina. Small incisions are made for placement of the sling to reduce urine leakage. This helps to support the pelvic floor muscles, hence reducing SUI. (Fig 1). A urinary catheter (tube inserted into the bladder) is usually required post-surgery for a short period of time.
Vagina Vagina Retropubic Sling Transobturator Sling Figure 1. Mid-urethral sling¹Advantages of MUS
Proven long-term efficacy, quick recovery with minimal downtime and a shorter hospital stay.
Disadvantages of MUS
As a synthetic mesh is utilised, there are potential risks of mesh infection, mesh erosion and chronic pain. These may require subsequent removal of the mesh via surgery.
What are Autologous Fascial Slings (AFS)?
AFS is a surgical treatment for women with SUI who are unsuitable for MUS or prefer AFS. AFS is made from your own connective tissue (fascia), taken from the lower abdomen. Similar to a MUS, the AFS creates a sling that is placed under the urethra. The operation is done through a small incision across the abdomen where a thin ribbon of fascia is taken from one of the abdominal wall layers and placed underneath the urethra. A small cut is made in the vagina, under the urethra and the strip of tissue is threaded on either side of the bladder to create a sling. A urinary catheter is usually required post-surgery for a short period of time.
Advantages of AFS
Similar effectiveness as MUS. As there is no synthetic material used, it avoids the risks of mesh-related complications.
Disadvantages of AFS
As it requires a slightly larger incision on abdomen, it could potentially have a higher risk of post-operative pain, and wound-related complications (seroma, hematoma).
Cut on tummy Strip of tissue Figure 2. Autologous fascial sling²What tests may be done prior to the surgery?
• Urodynamic study to evaluate your urinary tract function
• 24-hour pad test to identify the number of pads utilised and amount of urine leaked
• Cystoscopy to evaluate your bladder
• Pre-operative investigations (blood tests, ECG, chest x-ray) depending on your anaesthetist’s assessment
Are there any risks involved with MUS and AFS?
Complications are not commonly seen but the procedure carries risks of:
• Pain at site of operation
• Wound infection
• Difficulty passing urine, requiring a urinary catheter
• Pain during sexual intercourse
• Urinary urgency and/or frequency post-surgery, which may be worsened if already present before surgery
• Bladder, bowel or urethral injury
• Mesh erosion (with MUS)
• Chronic pain
• Recurrence of stress urinary incontinence
What are the alternatives?
• Continence pads
• Pelvic floor exercises
• Lifestyle measures e.g. Smoking cessation, weight loss
• Continence pessaries
• Artificial Urinary Sphincter (AUS)
Preparation
for the surgery
You may be instructed as below:
• Do not take any blood thinning medications, such as Aspirin, one week prior to the procedure
• Please inform your Urologist regarding any blood-thinning or anti-clotting medications you may have
What do I have to expect after surgery?
• This is performed either as a day or overnight procedure
• You will have a urinary catheter post-surgery
• You will be given a course of oral antibiotics to complete upon hospital discharge
• You may resume your regular diet after the procedure
• It is not unexpected to have some bleeding from the vagina post-surgery
• During recovery, avoid excessive straining, strenuous exercise or heavy lifting to allow for wound healing
• Avoid constipation during this period as well
• Sexual intercourse can be resumed 6-8 weeks after the surgery, depending on assessment by your surgeon
When should I seek medical attention after surgery?
Please seek medical attention if you experience:
• Significant pain at the operative site
• Difficulty passing urine
• Persistent blood or clots in the urine
• Persistent bleeding from the vagina
• High fever
Contact Information
Please contact our Customer Contact Centre at 6555 8828 for an urgent appointment to return to the Urology Clinic during Office Hours.
For any emergency after office hours, please proceed to the KTPH Acute and Emergency Department (A&E).
References
1. CHI St Vincent, “Mid-urethral sling”, https://www.chistvincent.com/clinical-services/urogynecology/ mid-urethral-sling
2. British Society of Urogynaecology, “Autologous fascial sling to treat stress urinary incontinence”, https://bsug.org.uk/budcms/includes/kcfinder/upload/files/Autologous%20fascial%20sling%20BSUG% 20Mar%202018-2.pdf