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Retropubic Mid-Urethral Sling

The retropubic mid-urethral sling (RMUS, TVT) is the classic synthetic sling for female stress urinary incontinence (SUI). A type I macroporous monofilament polypropylene tape is placed under the midurethra and passed through the retropubic space to two small suprapubic exit sites.[1][2][3]

This page focuses on the retropubic route. For shared counseling across all midurethral sling types, see Female Slings & Suspensions. For anatomy, see The Retropubic Space and Female Urethra.

Indications​

Retropubic MUS is most useful for an index patient with demonstrable SUI who wants the most established synthetic sling route and accepts the retropubic risk profile.[3][4]

ScenarioWhy RMUS fits
Hypermobility-predominant SUIRestores a midurethral backstop at the functional support zone
Intrinsic sphincter deficiency concernOften favored over transobturator tape when urethral closure is weak or mobility is limited
Need for strongest long-term evidence baseTOMUS, Cochrane reviews, and large cohorts anchor most long-term counseling[2][3][5]
Avoidance of obturator-groin pain riskDoes not traverse the obturator compartment

Relative reasons to choose another option include hostile retropubic anatomy, major prior retropubic surgery, high concern for bladder perforation or retropubic bleeding, inability to tolerate transient retention, or patient preference for a non-mesh operation.

Mechanism​

The RMUS is a tension-free support operation, not a constricting operation. During stress events, the urethra compresses against the tape. Over the first postoperative weeks, tissue ingrowth through the polypropylene pores fixes the tape in place.[1][6]

The retropubic route creates a more vertical U-shaped vector than the transobturator route. That vector may explain why RMUS often performs better in patients with weaker sphincteric coaptation, while also explaining the higher risk of bladder injury and voiding dysfunction.

Technique​

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, about 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 trocar passage.
  8. Adjust the tape with a spacer between tape and urethra so the sling lies flat and tension-free.
  9. Remove the plastic sheaths, trim excess tape at the skin, and close vaginal and suprapubic incisions.

Technical rules​

  • Hug the posterior pubic bone during trocar passage.
  • Avoid lateral deviation, which increases vascular and visceral risk.
  • Cystoscopy is mandatory after retropubic passage because bladder perforation is the signature intraoperative complication.
  • Do not cinch the tape; obstruction and retention are usually technical failures of tensioning.

Outcomes​

Across trials and systematic reviews, retropubic MUS short-term subjective cure rates are generally reported in the 71-97% range, with long-term subjective cure rates roughly 51-88%.[1][2][7]

OutcomeRMUS counseling point
EfficacyComparable to TMUS in TOMUS, with some meta-analyses showing a modest retropubic advantage[3][7]
Bladder perforationAbout 4-5%; much higher than TMUS but usually recognized and managed intraoperatively[2][3]
Voiding dysfunctionMore common than TMUS; usually transient but may require sling loosening or lysis
Groin / thigh painLess common than TMUS because the obturator compartment is avoided[2][3]
Mesh exposureSimilar to other full-length MUS routes in comparative reviews[2]

Operative Pearls​

  • Confirm SUI objectively before surgery; urgency-predominant leakage will not be fixed by a sling.
  • Put the tape at the midurethra, not the bladder neck.
  • Use cystoscopy deliberately: bladder, urethra, trigone, and trocar path all matter.
  • If the trocar perforates bladder, remove it, repass it correctly, and re-cystoscope.
  • A flat loose tape is better than a perfect-looking tight tape.

References​

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

2. 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

3. 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

4. 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

5. 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

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

7. 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