Urinary Incontinence Surgery

A sling treats one kind of leaking. Leaking on the way to the toilet is a different disease, and nothing on this page touches it.

Two conditions share one symptom and get confused constantly. Urine escaping when you cough, lift or laugh comes from weak support under the urethra, and an operation fixes that, while urine escaping because the urge arrives faster than you can move comes from a bladder muscle squeezing when it should not, and no operation on the urethra changes it. Disappointment after incontinence surgery nearly always follows an operation aimed at the wrong one.

Two diseases, one symptom

Incontinence surgery has a reputation for unreliability that it only partly deserves. The operations themselves work, and the largest analysis ever assembled in this field pooled 175 randomized trials covering 21,598 women to prove it, and what goes wrong happens earlier, in the room where somebody decides what is causing the leak, because two entirely different mechanisms produce the same wet underwear and only one of them has anything to do with the urethra. Getting that wrong produces an operation performed correctly on a problem it cannot touch, and a patient who concludes, reasonably enough, that incontinence surgery does not work.

The question that sorts them

One question separates the two better than any test. At the moment the urine escapes, were you rushing to a toilet, or were you doing something else entirely. Rushing means urgency. Coughing, lifting, laughing or exercising means stress. Somebody who answers both has mixed incontinence and needs the proportions written down, which is what the bladder diary is for.

Stress incontinence

The urethra stays closed because it sits on a hammock of tissue that firms up the instant pressure rises above it. Childbirth stretches that hammock, age thins it, chronic coughing and heavy lifting wear it, and prostate surgery in men can damage the muscular part of the closure directly, so that once the support gives way, any rise in abdominal pressure pushes urine past a urethra that has nothing to press against. That is the whole mechanism, and it explains why every operation in this field does one of two things. It either puts a new support underneath the urethra or it lifts the tissue beside it back up where it used to sit.

What it looks like in real life

Small amounts, at predictable moments, with no warning and no urgency beforehand. A drop on sneezing. A tablespoon on a tennis court. Nothing at all overnight, because lying down removes the pressure, which is one of the more useful distinguishing features and one that patients rarely think to mention. Somebody who leaks in bed is telling you something different is going on.

Urgency incontinence

Here the bladder muscle contracts on its own, without permission, and generates enough pressure to overwhelm a perfectly normal urethra. The warning is the defining feature. An urge arrives, it builds fast, and the distance to the toilet becomes the only thing that matters. Familiar triggers include cold air, running water, arriving at the front door, and the first sip of coffee, all of which act on a nervous system that has learned the wrong reflex. Frequency and getting up at night come with it. Nothing done to the urethra fixes a muscle that squeezes behind it without permission. The treatments here are entirely separate and they are covered further down. Bladder retraining, fluid and caffeine adjustment, medication, injections of botulinum toxin into the bladder wall, and electrical stimulation of the nerve supplying the bladder, of which the last two have been compared head to head in a proper randomized trial, and the results are more interesting than the marketing around either of them.

When you have both

Mixed incontinence is the commonest pattern and the one most likely to end in disappointment, because an operation treats one half of the problem and the patient judges it on the whole. Somebody whose leaking is 80 percent stress and 20 percent urgency will be delighted by a sling. Somebody whose split runs the other way will tell everyone the operation failed, and from where they are standing they are right.

How the split gets measured

Three days of a bladder diary do the work no questionnaire can. Every drink, every visit to the toilet, every leak, and what you were doing at the moment of each leak. Three days rather than one, because behavior on a single day distorts. Filling it in honestly, including the bad day, tells a surgeon whether an operation addresses most of your problem or a fraction of it, and it costs nothing except attention, while a department that books an incontinence operation without one is guessing at the most important number in the consultation.

The tests that decide

Four things get done before anybody discusses an operation, and only one of them involves equipment.

Examination and the cough test

Pelvic examination with a comfortably full bladder, asking the patient to cough. Watching urine escape at the instant of the cough confirms stress incontinence in front of the surgeon and needs no machine. The same examination checks for prolapse, since a bulge pushing on the urethra changes both the diagnosis and the operation, and it assesses how well the pelvic floor contracts, which predicts whether training will work.

Why the timing of the leak matters so much

Leaking a second or two after the cough, rather than during it, suggests the cough triggered a bladder contraction. That is urgency wearing a stress costume, and it is the single commonest way the diagnosis goes wrong.

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What comes first

Every guideline in this field puts conservative treatment ahead of surgery and patients arriving at a private clinic have rarely had it properly.

Urine test, diary, weight, and the floor

Urine testing rules out infection, which mimics urgency exactly and gets missed constantly. The bladder diary establishes the pattern. Weight matters more than anybody wants to hear, since abdominal fat raises the pressure the urethra has to resist and weight loss in overweight women produces measurable improvement without any operation, alongside a supervised course of pelvic floor muscle training, meaning taught by somebody who checks that the right muscle is contracting, run for at least three months.

Supervised means checked

Handed a leaflet, a large proportion of women contract the wrong muscles, the abdominal wall or the buttocks above all, and squeeze harder in the belief that nothing is happening because they are not trying hard enough. One session with a physiotherapist who confirms the contraction changes the outcome of the next three months.

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What pelvic floor training achieves

The training figures deserve reading twice, because they sit in the part of a hospital website that contains a single dismissive sentence on exercises. A Cochrane review pooling 31 trials across fourteen countries found that women with stress incontinence doing supervised pelvic floor training were eight times more likely to report themselves cured than women given nothing, at 56 percent against 6 percent. The reviewers rated that particular finding high quality, which is the top grade available and one that most surgical evidence never reaches. Adverse events across the whole review were rare and minor. An operation with those figures would be advertised on billboards. Two honest qualifications belong beside them. Follow up in most of the trials ran under twelve months, so nobody can say from this evidence how many of those cures survive five years, and the women in these trials did supervised programs with a physiotherapist and never a printed sheet, which is the version almost nobody receives. Neither qualification makes surgery the sensible first step. Both explain why a proportion of properly treated women still come to an operation, and why the ones who do arrive with a stronger pelvic floor and a better result.

The operations for women

Four procedures account for nearly all surgery for stress incontinence in women, and they differ in what they put where.

1. Retropubic midurethral sling. A narrow tape of polypropylene mesh passed under the middle of the urethra and up behind the pubic bone, exiting through two small cuts above it. Known in most hospitals by the trade name of the original device.
2. Transobturator midurethral sling. The same tape under the urethra, passed sideways through the obturator openings in the pelvis and out through the groin creases. Designed to avoid the space behind the pubic bone where the bladder and blood vessels sit.
3. Single incision sling, also called a mini sling. A shorter tape anchored into tissue on either side through one vaginal cut, with no exit wounds at all.
4. Autologous fascial sling and open colposuspension. The two operations that use no mesh whatever. The first makes a sling from a strip of the patient own abdominal fascia, the second stitches the tissue beside the urethra up to a ligament behind the pubic bone.

What they all have in common

Every one of them supports the urethra so that a rise in abdominal pressure closes it instead of opening it. None of them touches the bladder muscle. That single sentence is the reason the first three sections of this page exist.

How they rank against each other

A network meta analysis published in the BMJ in 2019 pooled 175 randomized trials covering 21,598 women, which makes it the most complete comparison available and likely to stay that way. It ranked the procedures by the probability of achieving cure at twelve months, and the ordering surprises people who assume newer means better. The traditional autologous fascial sling came first at 89.4 percent. The retropubic mesh sling came second at 89.1 percent, close enough that the two are indistinguishable. Open colposuspension, an operation many units abandoned two decades ago, came third at 76.7 percent. The transobturator sling, which was introduced specifically to be safer and gentler than the retropubic version, came fourth at 64.1 percent, and compared directly against the retropubic sling the transobturator route gave an odds ratio for cure of 0.74, with a confidence interval that excludes chance. None of which makes the transobturator sling a bad operation, and the reason surgeons still use it is written into the same analysis. Complications split in opposite directions. The transobturator route produced more repeat surgery and more groin pain, while the retropubic route produced more pain above the pubic bone, more injuries to blood vessels, more perforations of the bladder or urethra during placement, and more difficulty emptying afterward. A surgeon choosing between them is choosing which set of risks fits the patient in front of him, and a department that only offers one of the two has made that choice for everybody in advance. The authors were careful to add that long term data remain limited and that the quality of evidence for most of these comparisons is low, which is the sort of sentence that never survives the journey to a clinic brochure.

The mesh question

Anybody researching this has met the mesh controversy and deserves a straight account of it. Polypropylene mesh served two different purposes in pelvic surgery. One use involved transvaginal mesh for prolapse, meaning large sheets placed to hold up a dropped bladder or bowel, and that use produced serious complications at rates high enough that regulators in several countries removed the products from the market. The other used the narrow midurethral tape for incontinence, a strip roughly a centimeter wide, and it is a different device placed in a different plane for a different problem. Conflating the two has frightened a great many women away from the operation with the strongest evidence base in the field. That said, the tape is not free of trouble, and pretending otherwise is how the prolapse mesh disaster happened in the first place. Mesh can erode through the vaginal wall, which in the five year Austrian randomized trial happened in 5.2 percent after the retropubic route and 4.5 percent after the transobturator route, and it can cause lasting pain. Removing it is difficult and incomplete removal is common, and several countries restricted its use while reviews were carried out, while some still require the operation to be done in specialist centers with mandatory registry entry. Anybody offering you a mesh sling should be able to say, without looking it up, what the erosion rate is in their own hands and what happens if you need it removed.

Mini slings and the evidence gap

Single incision slings were designed to remove the exit wounds and the blind passage of a needle through the pelvis, and a Cochrane review updated in 2023 pooled 62 studies covering 8,051 women to see whether they work. Against the transobturator sling the verdict comes out clear and reassuring. Cure or improvement at twelve months came out identical, with a risk ratio of 1.00 and a confidence interval so tight the reviewers graded it high certainty. Mesh exposure happened less. Postoperative difficulty emptying was less common. Pain at two years was substantially less common.

Where the picture gets complicated

Two findings in the same review point the other way and neither gets quoted in marketing. Quality of life at twelve months came out lower after single incision slings than after transobturator slings, which sits oddly beside identical cure rates and suggests something the cure measurement is missing, while the rate of needing repeat continence surgery or mesh revision ran higher, at a risk ratio of 1.42, with a confidence interval wide enough to include no difference at all. The reviewers graded both of those findings low certainty and wrote plainly that longer term data are needed to clarify safety and effectiveness. Comparison against the retropubic sling rests on two trials and 297 women, which is thin ground for choosing an operation you will live with for thirty years.

The operations without mesh

Two operations predate mesh entirely and both remain available, which matters enormously to women who have decided against a synthetic implant and are told, wrongly, that their only option is to live with it.

Fascial sling and colposuspension

An autologous fascial sling uses a strip of the patient own tough tissue, taken from the sheath of the abdominal muscles through a low cut, and passed under the urethra as a hammock. It ranked first for cure in the network meta analysis. It also requires a larger operation, a longer stay, a second wound that has its own pain, and a higher chance of difficulty emptying the bladder afterward, sometimes needing self catheterization for a period. Open colposuspension stitches the tissue beside the urethra upward to a ligament behind the pubic bone through an abdominal incision, ranked third for cure, and carries a recognized tendency to encourage prolapse of the back wall of the vagina years later. Both count as genuine options with real trade offs, and any surgeon who cannot describe them is offering a narrower service than he appears to, which is worth establishing at the first appointment instead of the second.

The day itself

Midurethral sling surgery takes half an hour, and the shortness misleads people into underestimating it.

One detail separates a good result from a difficult year, and it is the tension. Too loose and the leaking continues. Too tight and the patient cannot empty her bladder, develops urgency she did not have before, and may need the tape divided months later. There is no machine that measures this. It is judgment built on volume, which is the honest reason surgeon experience matters more here than the choice of device.

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Recovery

Recovery from a sling is short and the continence result is apparent almost immediately, which distinguishes this from most operations. Women who leaked on coughing stop leaking on coughing within days. What takes longer to settle is everything else. The stream often feels slower for a few weeks while swelling resolves. Urgency can flare temporarily, and distinguishing a temporary flare from a tape that is too tight takes a few weeks of observation plus a measurement of how much urine stays behind after voiding.

What can go wrong

Complications after a sling fall into four groups and each has a characteristic timing, which makes them easier to recognize than most surgical problems.

Pain that persists past the first weeks belongs in a separate category and deserves a surgeon who takes it seriously rather than one who waits for it to settle.

Leaking after prostate surgery

Men reach this page by a different route and their situation differs enough to deserve its own section, since stress incontinence in a man is nearly always the consequence of prostate surgery, where the muscular closure at the bladder neck was removed with the prostate and the remaining sphincter below it has to do the whole job alone. Most men recover over the first year and a minority do not, and the size of the leak determines which operation suits.

A Canadian economic model followed both options over ten years for severe leakage and produced a result that deserves quoting. The artificial sphincter cost less in total than the sling over that horizon and delivered more quality adjusted life years, 7.58 against 6.43, because the sling failed more often in severe cases and those failures generated their own costs, so for severe post prostatectomy incontinence the sphincter remains the reference standard, and a clinic offering only slings is offering a narrower answer than the problem needs.

Treating the urgency side

Somebody whose leaking is mostly urgency needs the other half of this field, and it works, which is the point of separating the two so carefully at the top of this page. Bladder retraining stretches the interval between visits deliberately and takes weeks. Caffeine, alcohol and fizzy drinks act as irritants in many people and removing them costs nothing. Medication comes in two families, one older and cheaper with dry mouth and constipation as its price, the other newer with fewer of those effects, and a medication review belongs in the same conversation, since diuretics taken late in the day, several blood pressure tablets and a few antidepressants all make urgency worse, and moving a dose by a few hours costs nothing and occasionally settles the whole problem. Where all of that fails, two further options exist and they have been compared properly.

The ROSETTA trial randomized 386 women with refractory urgency incontinence between injections of botulinum toxin into the bladder wall and an implanted sacral nerve stimulator. Both worked and neither worked better. Daily leaking episodes fell by 3.00 with the stimulator and 3.12 with the injections, a difference of nothing, and quality of life scores matched. The costs did not match. Over two years the stimulator cost 35,680 dollars against 7,460, and the gap persisted at five years. Injections need repeating every six to nine months and a small proportion of patients have to catheterize themselves temporarily afterward, which are real disadvantages, and those disadvantages do not justify an extra twenty eight thousand dollars, and a clinic that reaches for the implant first should be asked why.

Having this done in Istanbul

Sling surgery travels reasonably well, and the reason it sometimes travels badly has nothing to do with the surgery. A sling takes half an hour and recovery takes days. The work that determines whether it succeeds happens before anybody books a flight, in the diary, the examination and the decision on which half of the problem is being treated, and none of that can be done by correspondence.

1. A three day bladder diary, completed before you write to us, covering every drink, every toilet visit, every leak and what you were doing at the time.
2. Any urodynamic study report and any ultrasound of the bladder or kidneys you have had.
3. A note of previous pelvic or prostate operations, previous deliveries, and any prolapse already diagnosed.
4. What you have already tried, particularly whether pelvic floor training was supervised by a physiotherapist and for how long.
5. Your medications, since several in common use make leaking worse and a change costs nothing.

One of our surgeons reads all of it and replies in writing, at no charge, saying which kind of incontinence the picture fits and what that kind needs. Where the conclusion is a supervised course of pelvic floor training you can do at home for three months, the reply says so and offers no date. Where the diary suggests urgency rather than stress, the reply says that too, and a sling is not proposed.

Questions worth asking

Plan four to five nights for a sling, covering the consultation and examination on the first day, the operation on the second, the emptying check and wound review before discharge, and a final review with fitness to fly confirmed in writing by a doctor who has examined you that morning. A fascial sling or an artificial sphincter needs longer, six to seven nights, because both are larger operations with catheters that stay in. Several things that would otherwise need arranging separately come as part of the pathway here. We work in seven languages without booking an interpreter, those being English, Arabic, French, Russian, Serbian, Romanian and Spanish, and anything outside that list is arranged in advance. One coordinator takes your first message, stays with you to discharge, and keeps answering on WhatsApp after you return home, where a question about the stream or a wound gets a same day answer and a written follow up goes out at three months. A companion sleeps in the room on a bed the ward provides. Hotel nights and airport transfers are booked before you land. An invitation letter for a visa application leaves our office around ten days ahead of the flight. Meals come halal, vegetarian or adjusted for diabetes, and a prayer room sits on the ward floor. On cost we publish no figures, because the price turns on which operation, on whether a prolapse repair happens at the same time, and on how many nights the ward keeps you.

1. How many incontinence operations do you personally perform in a year, and how many of each type.
2. Do you offer the retropubic sling, the transobturator sling and a mesh free option.
3. What is your own rate of mesh exposure, and how many of your patients cannot empty the bladder afterward.
4. If this tape has to come out, who does that and where.
5. What did my bladder diary show, and what proportion of my leaking is urgency.

Questions we are asked, an incontinence surgery FAQ

References

1. 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.
2. Dumoulin C, Cacciari LP, Hay-Smith EJC. Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Cochrane Database Syst Rev. 2018;10(10):CD005654.
3. 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.
4. Tammaa A, Aigmüller T, Hanzal E, et al. Retropubic versus transobturator tension free vaginal tape, five year results of the Austrian randomized trial. Neurourol Urodyn. 2018;37(1):331-338.
5. Harvie HS, Amundsen CL, Neuwahl SJ, et al. Cost effectiveness of sacral neuromodulation versus onabotulinumtoxinA for refractory urgency urinary incontinence, results of the ROSETTA randomized trial. J Urol. 2020;203(5):969-977.
6. Shamout S, Nazha S, Dragomir A, Campeau L. A cost utility analysis of artificial urinary sphincter versus AdVance male sling in post prostatectomy stress urinary incontinence. Neurourol Urodyn. 2018;37(7):2195-2203.