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Female Slings & Suspensions

Synthetic midurethral sling (MUS) surgery is the most commonly performed and most extensively studied operation for female stress urinary incontinence (SUI). It is a minimally invasive outpatient procedure in which a type I macroporous monofilament polypropylene tape is placed under the midurethra as a tension-free backstop.[1][2][3][13]

The three contemporary MUS families are:

Sling familyCommon namesTrajectoryMain tradeoff
Retropubic MUSTVT, RMUSVaginal incision to suprapubic skin through the retropubic spaceHighest long-term evidence base; more bladder perforation and voiding dysfunction[8][9]
Transobturator MUSTOT, TVT-O, TMUSVaginal incision to groin skin through the obturator foramenLess bladder / vascular injury; more groin or thigh pain[8][9]
Single-incision slingMini-sling, SIMS, SISSingle vaginal incision with lateral anchoring, usually into obturator internus or obturator membraneLess dissection and early pain; longer-term durability data still maturing[7][12][18]

Multiple professional societies, including AUA/SUFU, ACOG, AUGS, and EUGA, continue to support MUS as an appropriate primary surgical option for index patients with SUI after counseling about alternatives, mesh-specific risks, and the different risk profiles of retropubic, transobturator, and single-incision routes.[3][4][5][6] A 2018 position statement from the International Urogynecological Community, reaffirmed in September 2025, and a 2014 statement from RANZCOG and the Urogynaecological Society of Australasia (UGSA) also support monofilament polypropylene MUS for SUI and distinguish it from vaginal mesh for prolapse. The international statement describes full-length retropubic and transobturator slings as the current "gold standard" for SUI surgery and is an ungraded position statement. RANZCOG C-Gyn 32 gives an evidence-based Grade A recommendation for MUS in routine SUI, but limits transobturator slings to exceptional circumstances after multidisciplinary or peer review and single-incision slings to trials.[34][35] The earlier joint AUGS/SUFU position statement on mesh midurethral slings makes the same distinction. It calls polypropylene MUS the standard of care and cites up to 17 years of TVT follow-up, but its evidence and its FDA discussion end at 2013, so it predates later data and current regulatory context.[36] The 2021 AUGS/SUFU joint position statement, which AUGS reaffirmed in 2026, describes full-length polypropylene MUS as a standard of care for the surgical treatment of SUI and discusses the FDA's 2019 communication on surgical mesh for SUI.[43][44] NICE NG123 is more restrictive: it offers a retropubic mesh sling alongside colposuspension and an autologous rectus fascial sling, advises the transobturator route only when the retropubic approach should be avoided, and limits single-incision and top-down retropubic slings to clinical trials.[31]

See also: Female Stress Urinary Incontinence, Female Urethra, The Retropubic Space, and Polypropylene Mesh.

Procedure-specific pages​

PageUse it for
Retropubic Mid-Urethral SlingTVT / RMUS route, cystoscopy requirement, retropubic complications
Transobturator Mid-Urethral SlingTOT / TVT-O routes, groin-pain tradeoff, obturator passage
Single-Incision Mini-SlingSIMS / SIS device selection, 3-year evidence, durability counseling

Shared Mechanism​

MUS operations restore continence by recreating a suburethral hammock at the midurethra. During cough, sneeze, lifting, or exertion, abdominal pressure compresses the urethra against the tape rather than allowing the urethra to descend away from its support.[1][13]

The tape should not be tied down or actively tensioned. It functions as a passive backstop while connective tissue grows through the mesh pores over the first several postoperative weeks, fixing the tape in position.[13]

Preoperative Evaluation​

For an index patient with uncomplicated SUI, ACOG and AUGS describe a basic office evaluation before primary sling surgery:[14][15]

  1. History to distinguish stress, urgency, and mixed symptoms.
  2. Urinalysis to exclude infection or hematuria.
  3. Physical examination, including assessment for pelvic organ prolapse.
  4. Objective demonstration of SUI with cough stress testing.
  5. Assessment of urethral mobility, by Q-tip test, pelvic exam, or ultrasound.
  6. Postvoid residual measurement.

Multichannel urodynamics are not required before primary surgery for an otherwise uncomplicated index patient with demonstrable SUI. Urodynamics become more useful for non-index scenarios: prior failed continence surgery, suspected obstruction or incomplete emptying, elevated PVR, neurogenic lower urinary tract dysfunction, predominant urgency incontinence, severe prolapse, or symptoms that do not match the exam.[3][14][15]

Conservative management should be offered before surgery, including pelvic floor muscle training, behavioral modification, weight loss when relevant, pessary or continence insert, and treatment of genitourinary syndrome of menopause when it is contributing to symptoms.[4]

Technique Selection​

Sling route selection depends on the patient's anatomy, goals, and risk tolerance.

Patient / operative factorOften favorsRationale
Desire for the longest evidence base and slightly higher efficacy signalRetropubic MUSTOMUS and meta-analyses support similar overall cure, with some analyses suggesting a modest retropubic efficacy advantage[9][11][16]
Intrinsic sphincter deficiency or fixed urethraRetropubic MUS or autologous fascial slingRetropubic route may provide more vertical urethral support than transobturator tape. For a fixed, immobile urethra AUA/SUFU lists PVS, retropubic MUS, bulking or an adjustable retropubic sling, with PVS the panel's preferred approach; excessive tension on a mesh sling should be avoided[3]
High concern for bladder perforation, retropubic bleeding, or difficult retropubic passageTransobturator MUS or SIMSAvoids the retropubic space; bladder perforation is substantially lower than with RMUS[8][9]
Chronic groin pain, obturator neuralgia, major adductor pain syndromeRetropubic MUS or non-mesh optionTMUS traverses the obturator compartment and has higher groin / thigh pain rates[8][9]
Need to minimize dissection, skin incisions, and early postoperative painSIMSA pooled analysis found shorter operative time and less early pain; the SIMS RCT found noninferior patient-reported success through 3 years[17][12]
Patient declines synthetic meshAutologous fascial pubovaginal sling, Burch colposuspension, or bulkingMesh-free options remain valid but have different morbidity and durability profiles[3][11]

Mesh contraindications and cautions. AUA/SUFU advises against placing a synthetic MUS after intraoperative urethral injury or with concomitant urethral diverticulectomy, urethrovaginal fistula repair, or urethral mesh excision (Clinical Principles). Prior radiation, substantial scarring, or poor tissue quality warrants strong consideration of a non-mesh approach .[3]

Retropubic MUS (TVT / RMUS)​

Ulmsten introduced the tension-free vaginal tape in 1996. In a retropubic MUS, the tape is passed from a midurethral vaginal incision through the retropubic space and out through two small suprapubic incisions, forming a U-shaped support behind the urethra.[8][9]

Route​

Retropubic passage may be bottom-to-top (vaginal incision to suprapubic incision) or top-to-bottom. Bottom-to-top passage is the classic TVT route and has generally shown better efficacy than top-to-bottom techniques in comparative evidence.[8]

Key steps: bottom-to-top TVT​

  1. Place the patient in dorsal lithotomy and insert a Foley catheter.
  2. Mark two suprapubic exit sites just above the pubic symphysis, lateral to midline.
  3. Make a small midline vaginal incision over the midurethra, roughly 1 cm proximal to the external meatus.
  4. Develop bilateral paraurethral tunnels toward the inferior pubic ramus and endopelvic fascia.
  5. Pass the trocar along the posterior surface of the pubic bone through the retropubic space.
  6. Bring the trocar out through the suprapubic skin incision and repeat contralaterally.
  7. Perform cystoscopy after passage to rule out bladder or urethral perforation.
  8. Adjust the tape with a spacer between tape and urethra; the tape should lie flat and tension-free.
  9. Remove the plastic sheaths, trim excess tape at the skin, and close vaginal and suprapubic incisions.

Technical rules​

  • Keep the trocar on the posterior pubic bone during retropubic passage; lateral deviation increases vascular and visceral risk.
  • Cystoscopy is mandatory after retropubic passage because bladder perforation is the signature intraoperative complication.
  • Do not "cinch" the tape. Over-tensioning converts a support operation into obstruction and postoperative retention.

Outcomes and complications​

Retropubic MUS has short-term subjective cure rates broadly in the 71-97% range and long-term subjective cure rates in the 51-88% range across trials and reviews.[1][8][11] Compared with TMUS, RMUS has higher bladder perforation and voiding dysfunction rates, but lower groin / thigh pain.[8][9]

Transobturator MUS (TOT / TVT-O / TMUS)​

Transobturator MUS was developed to avoid retropubic trocar passage. The tape passes through the obturator foramen and exits through two groin crease incisions, creating a more transverse support under the urethra.[8]

Routes​

RouteDirectionPractical note
Outside-in TOTGroin incision to vaginal incisionDelorme-style route; trocar enters through the obturator foramen and emerges at the vaginal incision
Inside-out TVT-OVaginal incision to groin incisionde Leval-style route; comparative data show similar efficacy and fewer vaginal perforations than outside-in passage in some analyses[11]

Key steps: inside-out TVT-O​

  1. Place the patient in dorsal lithotomy and insert a Foley catheter.
  2. Make a midurethral vaginal incision.
  3. Develop lateral paraurethral tunnels toward the inferior pubic ramus and obturator membrane.
  4. Make bilateral groin crease exit incisions at the intended trocar exit sites.
  5. Pass the helical trocar from the vaginal incision through the obturator membrane and obturator foramen to the groin incision.
  6. Repeat contralaterally.
  7. Adjust the tape tension-free under the midurethra.
  8. Perform intraoperative cystoscopy after transobturator tape passage to inspect the bladder and urethra for injury, including when passage appears uncomplicated.[3]
  9. Trim the tape at the skin and close vaginal and groin incisions.

Technical rules​

  • The dissection is lateral, not retropubic; avoid unnecessary deep cephalad dissection.
  • Confirm the tape lies flat and symmetric before sheath removal.
  • Counsel patients preoperatively about transient groin or thigh pain; persistent pain is uncommon but more characteristic of TMUS than RMUS.

Outcomes and complications​

TMUS short-term subjective cure rates overlap with RMUS, but some network meta-analyses rank retropubic tape slightly higher for cure.[8][11][16] TMUS lowers bladder perforation risk compared with RMUS, but increases groin / thigh pain and may have a higher long-term reoperation signal in some population cohorts.[8][9][21]

Single-Incision Mini-Sling (SIMS / SIS)​

Single-incision slings use a shorter piece of polypropylene mesh placed through one vaginal incision, with no suprapubic or groin exit incisions. The sling arms are fixed laterally, commonly into the obturator internus muscle or obturator membrane.[7][12]

Key steps​

  1. Make a single midurethral vaginal incision.
  2. Develop short bilateral paraurethral tunnels toward the obturator internus / obturator membrane.
  3. Deploy the sling anchors laterally according to the device-specific system.
  4. Confirm symmetric tape position under the midurethra.
  5. Adjust tension according to the device design; avoid urethral compression.
  6. Perform cystoscopy to check for bladder perforation .[41]
  7. Close the vaginal incision.

Evidence position​

The UK SIMS randomized trial randomized 600 women (596 included after four post-randomization exclusions) across 21 hospitals and found the pooled adjustable anchored mini-sling group (primarily Ajust and Altis) noninferior to standard MUS for patient-reported success at 15 and 36 months.[12][19][41] A 2025 meta-analysis of 24 RCTs (3,687 women; mean follow-up 13.4 months) found no statistically significant difference in patient-reported cure between SIMS and standard MUS.[17] It reported shorter operative time and stay, lower day-1 pain, and less organ injury and groin pain with SIMS.[17]

The caution is that SIMS has less long-term evidence than RMUS and TMUS. In the SIMS trial, mesh exposure was 3.3% with mini-slings versus 1.9% with standard MUS, further surgery for SUI was 2.5% versus 1.1%, and dyspareunia among questionnaire responders was 11.7% versus 4.8%.[12]

General sexual-function outcome after standard midurethral sling. A meta-analysis of studies using validated questionnaires found no change or improvement in overall sexual function in about 67% of midurethral sling procedures analyzed, but improvement in orgasmic function specifically in only about 33% of studies, a smaller fraction. By route, both overall sexual function and orgasm scores improved after retropubic (TVT) slings; after transobturator (TOT) slings, overall sexual function improved but the mean orgasm score did not. The authors noted heterogeneous transobturator data and proposed periurethral neural injury only as a hypothesis.[37] Persistent postoperative sexual dysfunction can also reflect incompletely treated stress incontinence.[37]

Comparative Outcomes​

RMUS vs TMUS​

TOMUS randomized 597 women, with 565 assessed at 12 months. Objective composite success was 80.8% after RMUS versus 77.7% after TMUS and met the prespecified equivalence criterion; subjective composite success was 62.2% versus 55.8% and did not meet that criterion.[9]

OutcomeRetropubic MUSTransobturator MUSInterpretation
Short-term subjective cure71-97%62-98%Broadly similar across trials[8][11]
Long-term subjective cure51-88%43-92%EAU recommends informing women that longer-term retropubic MUS outcomes are superior , whereas AUA/SUFU considers the route comparison inconclusive[8][11][3][41]
Bladder perforation~4.5%~0.6%Higher with RMUS in pooled trials[8]; TOMUS reported 15/298 (5.0%) with RMUS and 0/299 with TMUS[9]
Voiding dysfunctionReferenceRR 0.53Higher with RMUS; in TOMUS, voiding dysfunction requiring surgery, catheter use, or both occurred in 8/298 (2.7%) versus 0/299 during 12 months[8][9]
Groin pain~1.3%~6.4%Higher with TMUS; usually short-lived[8][9]
Mesh exposureSimilarSimilarNo consistent route-specific difference[8]

The BMJ network meta-analysis of 175 randomized trials ranked retropubic MUS near the top for cure probability, with transobturator MUS showing a modestly lower odds of cure compared with RMUS (OR 0.74; 95% CrI 0.59-0.92).[16] AUA/SUFU notes that although some data suggest less durability with TMUS, other long-term studies show similar outcomes; the evidence is not conclusive enough to declare one route universally superior.[3]

Mixed incontinence​

In the MUSA superiority trial, 150 women with mixed incontinence were randomized and 137 contributed to the primary analysis. At six months, the between-group difference in total UDI change (onabotulinumtoxinA minus sling) was 18.1 points (95% CI -4.6 to 40.7; P=.12); equivalence was not tested. The sling improved the stress subscore more, and no statistically significant irritative-subscore difference was detected.[30] Counsel on which symptom bothers the patient most.

Long-term reoperation rates​

Population cohorts report nonzero sling reintervention risk.[10][23] In a 2025 French observational target-trial emulation of 215,141 first implants, the weighted five-year incidence of sling removal or section was 3.25% after TOT and 4.13% after TVT; second-sling implantation for recurrent SUI was less frequent after TVT.[10]

StudyCohortMain long-term signal
Gurol-Urganci et al.95,057 womenAt 9 years: mesh sling removal 3.3%, recurrent-SUI reoperation 4.5%, any reoperation 6.9%[20]
Tulokas et al.3,531 womenCumulative SUI re-procedure 3.2% at up to 17 years (median follow-up 13 years RMUS, 11 years TMUS); re-procedure was more common after TMUS, but only 245 TMUS recipients were included[21]
Berger et al.17,030 patientsOverall reoperation 6.0% at 9 years; mesh revision / removal 1.1% at 9 years; recurrent-SUI reoperation more common after single-incision slings than RMUS[22]

In the Gurol-Urganci cohort, the 9-year removal risk was lower after transobturator insertion (2.7%) than after retropubic insertion (3.6%; subdistribution hazard ratio 0.72, 95% CI 0.62-0.84), consistent with the route-specific complication pattern described above.[20]

Pregnancy and childbirth after a sling​

Two registry cohorts give limited counseling data on childbirth after a midurethral sling. In a Norwegian cohort, 72 women with a delivery after MUS were compared with 156 women without, at a median 10-year follow-up; subjective SUI cure was 82% versus 75% (p=0.31) and delivery mode did not affect outcomes, but women with more than one delivery after the sling had a significantly lower cure rate than those with one (50% vs 88%, p=0.006).[38] Among questionnaire respondents in a Swedish cohort, 163 women with childbirth after MUS were compared with 374 women without; SUI was reported in 22% versus 17% (OR 1.2, 95% CI 0.7-2.0), and vaginal delivery was not associated with higher observed SUI than cesarean delivery.[39] Neither registry cohort randomized patients or measured predelivery continence.

Complications​

ComplicationTypical patternManagement principle
Bladder perforationRMUS ~4-5%; TMUS ~0.6%Recognize with cystoscopy, remove and repass trocar, leave catheter based on injury size and surgeon judgment[8][9]
Voiding dysfunction / retentionMore common after RMUS than TMUSShort-term catheterization; persistent obstruction may require sling loosening, incision, or lysis
Postoperative urgencyReview-reported ranges: 5.9–25% after retropubic and 0–15.6% after transobturator slings[42]Exclude obstruction and UTI; treat persistent OAB medically or procedurally
Groin / thigh painMore common after TMUSUsually self-limited; persistent focal pain requires evaluation for mesh arm pain or obturator neuralgia[8][9]
Vaginal tape erosion / exposure / extrusionPooled trials: 2.1% after retropubic versus 2.4% after transobturator slings[8]Observation for small asymptomatic exposure; topical estrogen, trimming, or excision for symptomatic exposure
DyspareuniaHigher signal in SIMS trialEvaluate for exposure, focal tenderness, tape tension, and pelvic floor myalgia[12]
Bladder / urethral mesh erosionRareEndoscopic or open / vaginal excision depending on site and extent
Vascular injury / retropubic hematomaRare, RMUS > TMUSPrevention is midline bone-hugging trocar passage; manage by observation, packing, embolization, or exploration as severity dictates

FDA and Mesh Counseling​

Transvaginal mesh for pelvic organ prolapse is not the same product category as midurethral sling mesh for SUI.

  • In April 2019, the FDA ordered manufacturers to stop selling and distributing transvaginal mesh products intended for pelvic organ prolapse repair.[24][26]
  • That FDA action did not remove midurethral slings for SUI from the US market, and it did not apply to transabdominal mesh used for sacrocolpopexy.[6][25][26]
  • The FDA evaluates SUI slings separately from POP mesh. In 2024, it reported that mini-slings studied under its 522 orders had comparable effectiveness, adverse events, and re-surgery to traditional midurethral slings through 36 months; its completed review of 30 RCTs supported comparable clinical performance. The agency continues to consider surveillance for novel mini-sling designs.[26]
  • After the 2011 FDA warning concerning POP mesh, a New York State observational analysis found a 43% decline in SUI sling placement from 2011 to 2015, especially among non-FPMRS providers.[27]

The counseling sentence should be explicit: "The FDA POP mesh order does not apply to the midurethral sling being discussed for SUI, but the sling is still a permanent polypropylene implant with risks of exposure, pain, erosion, urinary symptoms, and possible revision."

Concomitant Sling at Prolapse Repair​

For women undergoing vaginal prolapse repair with symptomatic SUI, concomitant MUS may reduce postoperative SUI (RR 0.30; 2 trials, 319 women; low certainty); for those with occult SUI, it probably reduces SUI (RR 0.38; 5 trials, 369 women; moderate certainty) and later continence surgery.[28] The 2026 Cochrane review found adverse effects unclear. In OPUS, a separate randomized trial of women without preoperative SUI symptoms, prophylactic sling increased bladder perforation (6.7% versus 0%) and urinary tract infection (31.0% versus 18.3%) after vaginal prolapse repair.[28][40] Delaying the sling and operating only if needed is also feasible, because some patients will not need one after prolapse correction.[28] For women with SUI undergoing prolapse repair, AUA/SUFU permits any continence procedure (MUS, PVS or Burch) .[3] NICE NG123 advises considering concurrent surgery for women with anterior or apical prolapse and SUI, explaining that benefit beyond one year is uncertain, but advises against surgery to prevent incontinence in women without it.[3][31]

For women with objectively confirmed SUI undergoing native-tissue vaginal prolapse repair, a 2024 randomized trial found an Altis single-incision sling noninferior to a retropubic sling for a 12-month composite of bothersome SUI, SUI retreatment, or treatment for retention (29 [25%] versus 24 [20%] among evaluable patients).[45]

The decision is preference-sensitive:

StrategyBest fitTradeoff
Concomitant slingSymptomatic SUI, strongly positive prolapse-reduced stress test, high priority on avoiding a second operationLess postoperative SUI; sling-related adverse effects remain incompletely defined
Selective prophylactic slingOccult SUI with positive reduced cough stress testOne-year retropubic-sling model: selective prophylaxis was cost-effective; staged surgery had the lowest cost[29]
Staged slingUncertain bother, high concern for retention / mesh, or negative reduced stress testAvoids unnecessary sling in patients who become continent after prolapse repair

Mesh-Free and Lower-Mesh Alternatives​

ProcedureRoleAdvantagesTradeoffs
Autologous fascial pubovaginal slingMesh-free durable outlet procedure; useful for complex SUI, ISD, failed MUS, or patient preferenceNo synthetic mesh; strong salvage roleLonger operation, fascial harvest morbidity, more voiding dysfunction than MUS[3][11]
Burch colposuspensionMesh-free retropubic suspensionDurable historical data; useful when already operating abdominallyMore invasive recovery; less commonly performed than MUS[11]
Urethral bulkingOffice-based or low-morbidity optionLocal anesthesia, rapid recovery, no sling dissectionLower cure rate and frequent need for repeat injection[3]

Operative Pearls​

  • Confirm the diagnosis: the best sling operation fails when urgency-predominant leakage, overflow, fistula, or urethral diverticulum is mistaken for SUI.
  • Put the tape at the midurethra, not the bladder neck.
  • Retropubic sling: hug the back of the pubic bone and always cystoscope.
  • Transobturator sling: respect the obturator compartment and counsel about groin pain.
  • Single-incision sling: understand the device-specific anchoring and tensioning system; the operation is shorter.
  • Do not over-tension any MUS. A flat, tension-free tape is the point of the operation.
  • Document the exact product, route, cystoscopy findings, and postoperative voiding result.
  • Postoperative activity: in a multicenter noninferiority RCT (158 randomized), liberal activity instructions were noninferior to avoiding strenuous exercise and heavy lifting for satisfaction with the instructions among those assessed at 2 weeks (54 [80.6%] versus 48 [73.9%]).[32] Recurrent or persistent SUI (18.52% versus 23.53%, P = 0.635) and complication rates did not differ significantly, but these were secondary outcomes.[32] The 2025 AUGS consensus statement found that traditional 6-week restrictions did not improve continence after midurethral sling; it notes that the sling may shift before tissue incorporation, and that about 2 weeks of light activity is often advised on expert opinion.[33]

Key Takeaways​

  1. Midurethral mesh sling surgery is the most commonly performed operation for female SUI; it is minimally invasive and highly effective.[1][2][3][16]
  2. Retropubic and transobturator slings have broadly similar cure rates, but different complications: RMUS has more bladder perforation and voiding dysfunction; TMUS has more groin / thigh pain.[8][9]
  3. Single-incision slings are acceptable in AUA/SUFU guidance for index patients (NICE limits them to clinical trials) and supported by randomized data through 3 years, but counseling should acknowledge less mature long-term evidence and the SIMS trial signals for dyspareunia, exposure, and further SUI surgery.[3][12][17][31]
  4. The 2019 FDA order applied to transvaginal mesh for POP, not to midurethral slings for SUI.[6][26]
  5. Urodynamics are not required for uncomplicated index SUI when history, exam, cough stress test, urethral mobility, urinalysis, and PVR support the diagnosis.[14][15]
  6. In the two cohorts above, any reoperation at nine years was 6.0% in Berger et al. and 6.9% in Gurol-Urganci et al.; mesh revision or removal was 1.1% in Berger et al., whereas mesh removal was 3.3% in Gurol-Urganci et al.[20][22] Different endpoints and populations preclude pooling.[20][22]

Podcasts​

Midurethral Slings vs Bulkamid: What Clinicians Need to Know
BackTable Urology, Ep. 140 (2023) · Tamsin Greenwell, Suzette Sutherland
backtable.com

References​

1. Wu JM. "Stress Incontinence in Women." N Engl J Med. 2021;384(25):2428-2436. doi:10.1056/NEJMcp1914037

2. Lukacz ES, Santiago-Lastra Y, Albo ME, Brubaker L. "Urinary Incontinence in Women: A Review." JAMA. 2017;318(16):1592-1604. doi:10.1001/jama.2017.12137

3. Kobashi KC, Vasavada S, Bloschichak A, et al. "Updates to Surgical Treatment of Female Stress Urinary Incontinence (SUI): AUA/SUFU Guideline (2023)." J Urol. 2023;209(6):1091-1098. doi:10.1097/JU.0000000000003435

4. ACOG Practice Bulletin No. 155: "Urinary Incontinence in Women." Obstet Gynecol. 2015;126(5):e66-e81. doi:10.1097/AOG.0000000000001148

5. Ruffolo AF, Frigerio M, Barba M, et al. "European Urogynaecological Association Position Statement: Implantable Devices for Female Stress Incontinence Surgery." Eur J Obstet Gynecol Reprod Biol. 2025;309:175-185. doi:10.1016/j.ejogrb.2025.03.049

6. American Urogynecologic Society. "FAQ document by Patients on Mesh Midurethral Slings for Stress Urinary Incontinence." 2021.

7. Carter E, Johnson EE, Still M, et al. "Single-Incision Sling Operations for Urinary Incontinence in Women." Cochrane Database Syst Rev. 2023;10:CD008709. doi:10.1002/14651858.CD008709.pub4

8. Ford AA, Rogerson L, Cody JD, Aluko P, Ogah JA. "Mid-Urethral Sling Operations for Stress Urinary Incontinence in Women." Cochrane Database Syst Rev. 2017;7:CD006375. doi:10.1002/14651858.CD006375.pub4

9. Richter HE, Albo ME, Zyczynski HM, et al. "Retropubic versus Transobturator Midurethral Slings for Stress Incontinence." N Engl J Med. 2010;362(22):2066-2076. doi:10.1056/NEJMoa0912658

10. Guillot-Tantay C, Guillo S, Tran MHTD, et al. "Long-Term Safety of Mid-Urethral Sling for Stress Urinary Incontinence in Women: An Emulated Trial Using French National Health Data System." EClinicalMedicine. 2025;87:103411. doi:10.1016/j.eclinm.2025.103411

11. Fusco F, Abdel-Fattah M, Chapple CR, et al. "Updated Systematic Review and Meta-Analysis of the Comparative Data on Colposuspensions, Pubovaginal Slings, and Midurethral Tapes in the Surgical Treatment of Female Stress Urinary Incontinence." Eur Urol. 2017;72(4):567-591. doi:10.1016/j.eururo.2017.04.026

12. Abdel-Fattah M, Cooper D, Davidson T, et al. "Single-Incision Mini-Slings for Stress Urinary Incontinence in Women." N Engl J Med. 2022;386(13):1230-1243. doi:10.1056/NEJMoa2111815

13. American Urogynecologic Society. "Midurethral Sling Supplemental Information Checklist." 2021.

14. ACOG Committee Opinion No. 603: "Evaluation of Uncomplicated Stress Urinary Incontinence in Women Before Surgical Treatment." Obstet Gynecol. 2014;123(6):1403-1407. doi:10.1097/01.AOG.0000450759.34453.31

15. American College of Obstetricians and Gynecologists. "Evaluation of Uncomplicated Stress Urinary Incontinence in Women Before Surgical Treatment." 2018.

16. Imamura M, Hudson J, Wallace SA, et al. "Surgical Interventions for Women With Stress Urinary Incontinence: Systematic Review and Network Meta-Analysis of Randomised Controlled Trials." BMJ. 2019;365:l1842. doi:10.1136/bmj.l1842

17. Zhou Y, Chai Y, Zhang Y, Zhou Z. "Application of Single-Incision Mini-Sling Surgery Versus Standard Mid-Urethral Sling Surgery in Female Stress Urinary Incontinence: A Systematic Review and Meta-Analysis of Randomized Controlled Trials." Int J Surg. 2025. doi:10.1097/JS9.0000000000002584

18. Gallo K, Weiner H, Mishra K. "An Update on Surgical Management for Stress Urinary Incontinence." Curr Opin Obstet Gynecol. 2024;36(6):433-438. doi:10.1097/GCO.0000000000000989

19. Abdel-Fattah M, Cooper D, Davidson T, et al. "Single-Incision Mini-Slings Versus Standard Synthetic Mid-Urethral Slings for Surgical Treatment of Stress Urinary Incontinence in Women: The SIMS RCT." Health Technol Assess. 2022;26(47):1-190. doi:10.3310/BTSA6148

20. Gurol-Urganci I, Geary RS, Mamza JB, et al. "Long-Term Rate of Mesh Sling Removal Following Midurethral Mesh Sling Insertion Among Women With Stress Urinary Incontinence." JAMA. 2018;320(16):1659-1669. doi:10.1001/jama.2018.14997

21. Tulokas S, Rahkola-Soisalo P, Gissler M, Mikkola TS, Mentula MJ. "Long-Term Re-Procedure Rate After Mid-Urethral Slings for Stress Urinary Incontinence." Int Urogynecol J. 2020;31(4):727-735. doi:10.1007/s00192-019-04223-1

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