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Single-Incision Mini-Sling

Single-incision mini-slings (SIMS, SIS) are short polypropylene slings placed through one vaginal incision without suprapubic or groin exit incisions. The sling anchors laterally, usually into the obturator internus muscle or obturator membrane, to support the midurethra while avoiding full retropubic or transobturator trocar passage.[1][2][3]

For shared midurethral sling counseling, see Female Slings & Suspensions.

Indications​

SIMS is most attractive when the patient values less dissection, no skin exit incisions, shorter operative time, and lower early postoperative pain, while accepting less mature long-term durability data than standard full-length MUS.[2][3][4]

AUA/SUFU 2023 says clinicians may offer a single-incision sling to index patients selecting midurethral sling surgery , while NICE NG123 limits single-incision short mesh slings to clinical trials.[2][6] Device-specific evidence and local guidance must shape this choice.[2][6]

ScenarioWhy SIMS fits
Uncomplicated index SUIThe SIMS trial supports noninferior patient-reported success through 3 years after randomization for the adjustable anchored devices studied, in selected patients[3][5]
Need to reduce early pain / recovery burdenNo retropubic or full obturator exit passage
Local or limited anesthesia strategySmaller dissection can support lower-intensity anesthesia pathways in selected patients
High concern for organ injuryAvoids retropubic trocar passage; a pooled organ-injury signal favors SIMS, but events are uncommon and the estimate depends on the comparator and included devices[4][5]

Relative reasons to choose standard MUS instead include severe SUI, high concern for durability, complex recurrent SUI, prior failed sling, marked ISD, or need for the longest available follow-up evidence. For Altis specifically, the manufacturer's April 2024 brief statement lists pregnancy or desire for future pregnancy, potential for further growth (for example, adolescents), known active urinary tract or operative-field infection, anticoagulant therapy, abnormal urethra (for example, fistula or diverticulum), conditions that could compromise the implant or its placement, and documented hypersensitivity or allergic reaction to polypropylene or polyurethane as contraindications. Check the selected device's current IFU.[13]

Mechanism​

SIMS uses the same midurethral support concept as RMUS and TMUS but with a shorter implant and device-specific lateral anchors. The operation depends on:

  • accurate midurethral placement,
  • symmetric lateral anchoring,
  • avoidance of urethral compression,
  • tissue ingrowth into macroporous polypropylene.

Because each SIMS device has a specific anchor and tensioning system, follow its current package instructions. The broad sequence below is illustrated by the Ajust/Altis methods in the SIMS trial.[5]

Technique​

  1. Make a single midurethral vaginal incision.
  2. Develop short bilateral paraurethral tunnels toward the obturator internus / obturator membrane. Older SIMS literature described vaginal-wall perforation during trocar passage in rates as high as 2%, without a device-specific estimate; a described countermeasure for one anchored device guides the delivery trocar with the surgeon's index finger placed through the vaginal incision, directing the trocar tip toward the obturator internus once it is felt near the vaginal fornix.[8][9]
  3. Deploy the sling anchors laterally according to the device-specific system. One chapter author's sequence for an anchored device opens the endopelvic fascia for a direct route, aims the trocar toward the superior-medial obturator foramen, advances it beyond the inferior pubic ramus, and rotates it so the anchor enters obturator internus perpendicular to the muscle surface; purchase is tested by pulling on the deployed anchor, repositioning deeper at 90 degrees if it does not hold.[10] Coloplast cautions that a deployed Altis anchor is not designed to be retracted or advanced further after placement; follow the selected device's current IFU.[13]
  4. Confirm symmetric tape position under the midurethra.
  5. Adjust the sling so it supports without compressing the urethra. The shorter implanted mesh length places more tension on a mini-sling at insertion than on a full-length MUS; one description frames a correctly placed implant as closely apposed to the urethra without laxity or redundant tape, which should be distinguished from tensioning the sling more tightly to compensate for its short length.[9]
  6. Perform cystoscopy to check the bladder and urethra for intraoperative injury. If urethral injury is identified, do not place a synthetic mesh sling .[2] If bladder perforation is found, the chapter author recommends removing the SIMS without a second insertion during the same operation.[9]
  7. For Altis, cut the adjustment suture close to the pelvic sidewall without injuring the sling or urethra, then close the vaginal incision.[13][5]

Technical rules​

  • Avoid aggressive tensioning to compensate for a short implant.
  • Confirm that the tape lies flat and centered before closure.
  • Counsel that dyspareunia, exposure, and recurrent SUI remain possible despite the smaller implant.

Evidence Position​

The UK SIMS trial randomized 600 women across 21 hospitals; 596 remained after four post-randomization exclusions. It compared adjustable anchored Ajust/Altis devices with a mix of retropubic and transobturator standard MUS. Patient-reported success was 79% (212/268) versus 76% (189/250) at 15 months and 72% (177/246) versus 67% (157/235) at 3 years after randomization, meeting the prespecified 10% noninferiority margin at both times.[5] The UK SIMS trial excluded prior incontinence surgery, substantial anterior or apical prolapse, and concomitant surgery.[3][5] A separate 2024 randomized trial enrolled women with stage II or greater prolapse and objectively confirmed SUI undergoing reconstructive or obliterative native-tissue vaginal repair; 126 were randomized to Altis and 129 to a retropubic sling. At 12 months, the composite of bothersome SUI, SUI retreatment, or treatment for retention occurred in 29 (25%) versus 24 (20%) evaluable women and met the prespecified 12-percentage-point noninferiority margin.[12]

The 2023 Cochrane review found little or no difference in 12-month subjective cure or improvement versus retropubic slings (RR 0.99, 95% CI 0.91–1.07; 2 trials, 297 women; low-certainty evidence) or transobturator slings (RR 1.00, 95% CI 0.97–1.03; 17 trials, 2,359 women; high-certainty evidence), while device heterogeneity and uncertainty about long-term adverse events and durability limit interpretation.[1] A later 2025 meta-analysis abstract reports 24 trials (3,687 women; mean follow-up 13.4 months), no statistically significant patient-reported cure difference, and lower day-1 pain and organ-injury signals.[4]

EAU 2026 (a reprint of the 2025 guideline with minor formatting updates) rates Ajust and Altis noninferior to conventional MUS at 15 and 36 months (level 1b) but reports higher mesh exposure, repeat SUI surgery and dyspareunia at 3 years (level 1b). Its network meta-analysis (ESTER, low-quality evidence) found retropubic and transobturator MUS more effective than single-incision slings at 12 months (OR 0.50 for TVT, 0.68 for TOT), and it notes that most single-incision data come from the withdrawn TVT Secur device. Two strong recommendations apply: tell women that short-term efficacy of Ajust and Altis appears equivalent to conventional MUS, and that long-term efficacy of any single-incision sling remains uncertain.[7]

For intrinsic sphincter deficiency, the Mini RISD multicenter trial randomized 112 women with urodynamic stress incontinence and ISD to a single-incision sling (Solyx; n = 54) or a retropubic sling (n = 58) between 2016 and 2022; 108 (96%) completed 12 months. Objective cure (negative cough stress test) and subjective cure did not differ at 12 months, and 74% versus 69% reported being very much or much better (relative risk 0.91, 95% CI 0.62 to 1.3). Five women in the single-incision arm had repeat continence surgery, compared with 2 repeat retropubic slings for recurrent SUI in the retropubic arm. The trial was not designed to show long-term equivalence.[11]

Counseling cautions​

IssueSIMS counseling point
Long-term dataThe Ajust/Altis SIMS trial reaches 3 years after randomization; most pooled trials have shorter follow-up.[5][1] EAU cites heterogeneous-device data in which repeat surgery after more than 3 years was 10.3% with SIMS versus 7.6% with transobturator MUS; withdrawn designs contribute to pooled estimates, so current-device durability remains uncertain.[7]
Dyspareunia11.7% (17/145) vs. 4.8% (7/145) at 3 years in the randomized direct-question sexual-function subgroup; baseline dyspareunia was also higher in the SIMS arm[5]
Mesh exposure3.3% (9/276) vs. 1.9% (5/261) over 3 years in the SIMS trial; the difference was not statistically significant[5]
Further surgery for SUI2.5% (7/276) vs. 1.1% (3/261) over 3 years in that trial[5]
Mesh permanenceColoplast states that the Altis implant is permanent; complete mesh removal may not always be possible or advisable, removal may not resolve pain, and SUI may recur or worsen after mesh-related revision.[13]
Voiding dysfunctionNew urgency or obstructive voiding can occur after sling placement; retention may require catheterization, and persistent obstruction may require sling loosening, incision, or removal.[13][7]
Device heterogeneityMini-sling products differ, limiting extrapolation across devices

Operative Pearls​

  • Use it in patients whose severity and goals match the evidence base.
  • This trial found less early pain and a shorter hospital stay, but not a statistically clear difference in return to normal activities within 28 days. Long-term comparative data remain less mature than for RMUS and TMUS.[5]
  • Persistent dyspareunia after SIMS should prompt evaluation for exposure, focal anchor tenderness, tape tension, and pelvic floor myalgia.

Videos​

Solyx Single-Incision Sling
AUGS (2020)

References​

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

2. 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

3. 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

4. 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;111(8):5518-5534. doi:10.1097/JS9.0000000000002584

5. 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

6. NICE. Urinary incontinence and pelvic organ prolapse in women: management. NG123. Published 2 April 2019, last updated 24 June 2019. Recommendation 1.5.11 (no single-incision sub-urethral short mesh sling except in a clinical trial). Surgical recommendations.

7. European Association of Urology. Non-neurogenic Female LUTS: Disease Management. Limited update March 2026, section 4.2.4.c.2.e (midurethral slings). Midurethral sling recommendations.

8. Bastawros DA, Kennelly MJ. Mini-slings: unique issues. In: Goldman HB, ed. Complications of Female Incontinence and Pelvic Reconstructive Surgery. 2nd ed. Springer (Humana Press); 2017:193-204. doi:10.1007/978-3-319-49855-3_18

9. Karram M, Abdelaziz A. Single-incision mini-slings. In: Cardozo L, Staskin D, eds. Textbook of Female Urology and Urogynecology. Vol 2: Surgical Perspectives. 5th ed. CRC Press; 2023:817-821. doi:10.1201/9781003144243-82

10. Sutherland SE. Single incision midurethral sling (SIS). In: Smith JA Jr, Dmochowski RR, Thomas JC, Preminger GM, eds. Hinman's Atlas of Urologic Surgery. 5th ed. Elsevier; 2025:784-788.

11. Ow LL, Alexander JW, Leitch A, et al. "Mini or Retropubic Sling in Women with Intrinsic Sphincter Deficiency at 12 Months—A Randomized Controlled Trial (Mini RISD)." Int Urogynecol J. 2026;37(5):1237-1246. doi:10.1007/s00192-025-06420-7

13. Coloplast. Altis Single Incision Sling System: Procedural Technique. PM-04640; May 2024. Includes Altis brief statement PM-03363; April 2024. PDF.

12. Matthews CA, Rardin CR, Sokol A, et al. "A randomized trial of retropubic vs single-incision sling among patients undergoing vaginal prolapse repair." Am J Obstet Gynecol. 2024;231(2):261.e1-261.e10. doi:10.1016/j.ajog.2024.04.036