Introduction

In 2006, the single-incision synthetic midurethral sling was introduced as a modification to traditional retropubic and transobturator midurethral slings (MUS). These slings were designed to require less dissection in the midurethral area without the need to make additional incisions suprapubically or in the groin. They are placed entirely through an incision in the vagina having no exit point. They were designed to minimize the risk of bladder perforation associated with traditional retropubic MUS and the risk of groin discomfort or other issues related to the inner thigh associated with passage of transobturator slings through the obturator membrane and adductor compartment. Single-incision minislings are anchored into the obturator internus muscle or connective tissue of the endopelvic fascia of the retropubic space behind the pubic bone, depending on the configuration of the sling chosen by the surgeon. A survey of urologists in the United States suggests that 10% of practicing urologists have already adopted this technology for regular use in patients with primary stress urinary incontinence (SUI). However, the U.S. Food and Drug Administration (FDA) has required the manufacturers of single-incision slings to pursue additional studies to document long-term efficacy and safety further. These studies, which will be ongoing over the next 2 years, will determine the future of these devices.

Indications and Patient Selection

Indications for the single-incision slings are similar to the indications for the more traditional MUS. Because these slings are less invasive than a retropubic or transobturator MUS, they may be desirous for some special patient populations. Because they avoid the retropubic space, the minisling may be considered specifically in patients who have undergone previous retropubic and abdominal procedures and may be at higher risk for significant pelvic adhesions. Because it does not entail complete passage of trocars to the skin level, it may be considered in patients with significant soft tissue mass or obesity in the areas of tradition MUS trocar site exit (i.e., truncal or intertrigonal obesity) that may surpass the length of the trocar. Because single-incision minisling procedures can be done under local anesthesia, they can also be considered in patients with significant comorbidities in whom general anesthesia is contraindicated. At the present time, the authors rarely use single-incision slings in patients with primary SUI because long-term data showing efficacy comparable to retropubic or transobturator MUS are lacking (see Outcomes section).

Description of Various Types of Single-Incision Slings

Five single-incision minislings are commercially available at the present time in the United States: TVT-Secur (Ethicon Women’s Health & Urology, Somerville, NJ), MiniArc Single-Incision Sling system (American Medical Systems, Minnetonka, MN), Solyx SIS system (Boston Scientific Corp, Natick, MA), AJUST Adjustable Single-Incision Sling (Bard, Covington, GA), and Minitape (MPathy Medical, Raynham, MA).

The TVT-Secur is a preassembled polypropylene (Prolene) woven mesh tape (8 cm × 1.1 cm) and metal inserter device. Sandwiching each end of the tape are polyglactin-910 (Vicryl) and polydioxanone (PDS) woven fleece patches that are designed to allow connective tissue ingrowth while undergoing concurrent absorption (within 90 to 180 days) encouraging the permanent fixation of the mesh sling. The sling and inserter device are inserted and the position of the sling is confirmed, after which the inserter device is disengaged and removed, leaving the mesh behind.

The MiniArc Single-Incision Sling (Figure 8-1) is a polypropylene mesh (8.5 cm × 1.1 cm) with permanent self-fixating tips that is deployed with a supplied metal 2.3-mm needle/trocar. The mesh is connected to the tip of the needle before insertion; the mesh and needle are inserted; and the needle is removed, leaving the mesh behind. Self-fixating tips are constructed of polypropylene and have two anchoring barbs that help resist up to 5.5 lb of pull-out force to remove the mesh. A redocking maneuver can be set up before insertion to allow retrieval and reinsertion of the mesh if necessary.

Figure 8-1 MiniArc Single-Incision Sling.

(Courtesy American Medical Systems, Minnetonka, MN.)

The Solyx SIS system (Boston Scientific Corp., Natick, MA; Figure 8-2) includes a polypropylene mesh tape (9 cm in length) with permanent barbed self-fixating tips and a metal and plastic delivery device or trocar. This system is designed similarly to the MiniArc Single-Incision Sling system, in that each tip of the sling is sequentially attached to the end of the delivery device for mesh placement, which is removed after insertion. The edges of the center 4 cm of the mesh (advertised as the suburethral portion) are bonded together to potentially reduce irritation and the possibility of mesh erosion or extrusion.

Figure 8-2 Solyx SIS.

(Courtesy Boston Scientific Corp, Natick, MA.)

The AJUST Adjustable Single-Incision Sling (Bard Medical, Covington, GA; Figure 8-3) is a new adjustable minisling that allows the surgeon to tighten or loosen the sling after it has been anchored into the obturator membrane.

Figure 8-3 AJUST Adjustable Single-Incision Sling.

(Bard Medical, Covington, GA.)

Surgical Techniques

Figure 8-4 illustrates how the authors prefer to tension various synthetic MUS.

Figure 8-4 Tensioning of synthetic midurethral slings. A, Synthetic retropubic slings are usually left very loose, easily allowing an instrument to be passed between the sling and the posterior urethra. B, Transobturator synthetic midurethral slings are usually tensioned slightly tighter than retropubic slings. C, Single-incision slings are tensioned so that they come in direct contact with the posterior urethra, making it very difficult to pass an instrument between the sling and the posterior urethra.

(From Baggish MS, Karram MM, eds. Atlas of Pelvic Anatomy and Gynecology Surgery, ed 3. St. Louis: Saunders; 2011.)

TVT-Secur

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