Midurethral sling: is there an optimal choice?

Midurethral slings (MUS) are the most common procedure performed for female stress urinary incontinence (SUI). Several variations have been introduced and evidence supporting the optimal approach for outcomes is necessary.

The bottom-up approach to the retropubic MUS may have higher subjective cure rates and lower rates of bladder puncture, voiding dysfunction, and vaginal extrusion compared to the top-bottom approach. Short-term and medium-term cure after retropubic and transobturator approaches are similar, whereas the retropubic approach may have better outcomes in the long term. The transobturator approach, however, appears to be associated with less bladder puncture, vascular injury, and postoperative voiding dysfunction, albeit at the expense of greater groin pain. De-novo storage symptoms and impact on sexual function are similar. The single incision mini sling (SIMS) may offer similar cure rates as the transobturator approach, with lower rates of early postoperative pain. SIMS offers inferior cure rates compared with the retropubic MUS.

The bottom-up retropubic MUS may currently be the 'optimal' MUS procedure; however, the transobturator MUS should also be considered. Long-term results are currently emerging and detailed informed consent is required regardless of the approach.