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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]

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] This is why the operation is a support procedure, not a urethral strangulation procedure.

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​

The practical decision is not "which sling is best for everyone?" but "which route best matches this 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
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 painSIMSContemporary SIMS trials show shorter operative time and less early pain, with noninferior patient-reported success through 3 years[12][17]
Patient declines synthetic meshAutologous fascial pubovaginal sling, Burch colposuspension, or bulkingMesh-free options remain valid but have different morbidity and durability profiles[3][11]

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. Consider cystoscopy based on surgeon practice, difficult passage, hematuria, prior surgery, or concern for urinary tract injury.
  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. Close the vaginal incision.

Evidence position​

The UK SIMS randomized trial enrolled 596 women across 21 hospitals and found mini-slings noninferior to standard MUS for patient-reported success at 15 months, with durability of the patient-reported result through 36 months.[12][19] A 2025 randomized-trial meta-analysis similarly found SIMS noninferior to standard MUS for patient-reported cure, with shorter operative time, shorter stay, lower postoperative day-1 pain scores, less organ injury, and less groin pain.[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] That does not make SIMS experimental, but it does make the long-term counseling different.

Comparative Outcomes​

RMUS vs TMUS​

The Trial of Mid-Urethral Slings (TOMUS) randomized 597 women and established the modern comparison between retropubic and transobturator approaches.[9]

OutcomeRetropubic MUSTransobturator MUSInterpretation
Short-term subjective cure71-97%62-98%Broadly similar across trials[8][11]
Long-term subjective cure51-88%43-92%Similar overall; durability advantage remains debated[8][11]
Bladder perforation~4.9%~0.6%Higher with RMUS[8][9]
Voiding dysfunction~7.2%~3.8%Higher with RMUS[8][9]
Groin / thigh pain~1.1%~4.4%Higher with TMUS[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]

Long-term reoperation rates​

Population-level data are reassuring but not zero-risk.[10][23]

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 womenRe-procedure for SUI 3.2% at 17 years; re-procedure more common after TMUS than RMUS[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]

Complications​

ComplicationTypical patternManagement principle
Bladder perforationRMUS ~4-5%; TMUS ~0.4-0.6%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
De novo urgency / UUIUsually 5-15% range in reviewsExclude 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 mesh exposureUsually 1-5%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​

The most important counseling distinction is that 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 has continued to evaluate SUI sling evidence separately from POP mesh and describes ongoing review of mini-slings and traditional midurethral slings as a distinct SUI device category.[26]
  • POP mesh complications and litigation nevertheless changed patient perception and practice patterns; one New York State 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 pelvic organ prolapse repair with symptomatic or occult SUI, concomitant MUS reduces postoperative SUI but increases adverse events. A 2026 Cochrane review found that concomitant MUS probably reduces postoperative SUI in this setting, while also reinforcing that staged continence surgery remains feasible because some patients will not need a sling after prolapse correction.[28]

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; more perioperative adverse events
Selective prophylactic slingOccult SUI with positive reduced cough stress testCost-effective balance in modeling studies[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, but not technically casual.
  • 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.

Key Takeaways​

  1. MUS remains the reference operation for index female SUI because it combines high efficacy, short operative time, outpatient recovery, and the largest evidence base of any continence procedure.[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 now guideline-acceptable 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]
  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. Long-term reoperation rates after MUS are low but real: roughly 6-7% for any reoperation and 1-3% for mesh revision / removal by 9 years in large cohorts.[20][22]

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

22. Berger AA, Tan-Kim J, Menefee SA. "Long-Term Risk of Reoperation After Synthetic Mesh Midurethral Sling Surgery for Stress Urinary Incontinence." Obstet Gynecol. 2019;134(5):1047-1055. doi:10.1097/AOG.0000000000003526

23. Chughtai B, Mao J, Matheny ME, et al. "Long-Term Safety With Sling Mesh Implants for Stress Incontinence." J Urol. 2021;205(1):183-190. doi:10.1097/JU.0000000000001312

24. ACOG Practice Bulletin No. 214: "Pelvic Organ Prolapse." Obstet Gynecol. 2019;134(5):e126-e142. doi:10.1097/AOG.0000000000003519

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

26. US Food and Drug Administration. "FDA's Activities: Urogynecologic Surgical Mesh." 2024. https://www.fda.gov/medical-devices/urogynecologic-surgical-mesh-implants/fdas-activities-urogynecologic-surgical-mesh

27. Siegal AR, Huang Z, Gross MD, et al. "Trends of Mesh Utilization for Stress Urinary Incontinence Before and After the 2011 Food and Drug Administration Notification Between FPMRS-Certified and Non-FPMRS-Certified Physicians: A Statewide All-Payer Database Analysis." Urology. 2021;150:151-157. doi:10.1016/j.urology.2020.06.053

28. Baessler K, Christmann-Schmid C, Haya N, et al. "Surgery for Women With Pelvic Organ Prolapse With or Without Stress Urinary Incontinence." Cochrane Database Syst Rev. 2026;2:CD013108. doi:10.1002/14651858.CD013108.pub2

29. Mou T, Cadish LA, Gray EL, Bretschneider CE. "Cost-Effectiveness of Prophylactic Retropubic Sling at the Time of Vaginal Prolapse Surgery." Am J Obstet Gynecol. 2022;227(3):471.e1-471.e7. doi:10.1016/j.ajog.2022.05.044