You are leaving Medscape Education
Cancel Continue
Log in to save activities Your saved activities will show here so that you can easily access them whenever you're ready. Log in here CME & Education Log in to keep track of your credits.

Table 1.  

Commercial Kits Available for Midurethral Sling Placement

Table 2.  

Clinical Outcomes in Patients Undergoing Midurethral Sling Placement


The Evolution of Midurethral Slings

  • Authors: David E Rapp, MD ; Kathleen C Kobashi, MD
Start Activity

Target Audience and Goal Statement

This activity is intended for primary care clinicians, gynecologists, urologists, geriatricians, and other specialists who care for women with stress urinary incontinence.

The goal of this activity is to review the etiology of female stress urinary incontinence (SUI) and the development of different types of and insertion techniques for midurethral slings for the treatment of SUI.

  1. Identify the principles of early urethral slings used to address female incontinence
  2. List the sources of material used for urethral slings
  3. Describe principles of maintenance of urinary continence in females
  4. Describe the cure rates associated with midurethral sling placement for stress urinary incontinence
  5. List the most common complications associated with midurethral slings


As an organization accredited by the ACCME, Medscape, LLC requires everyone who is in a position to control the content of an education activity to disclose all relevant financial relationships with any commercial interest. The ACCME defines "relevant financial relationships" as financial relationships in any amount, occurring within the past 12 months, including financial relationships of a spouse or life partner, that could create a conflict of interest.

Medscape, LLC encourages Authors to identify investigational products or off-label uses of products regulated by the US Food and Drug Administration, at first mention and where appropriate in the content.


  • David E Rapp, MD

    Fellow in Incontinence and Pelvic Floor Reconstruction, Virginia Mason Medical Center, Seattle, Washington


    Disclosure: David E. Rapp, MD, has disclosed no relevant financial relationships.

  • Kathleen C Kobashi, MD

    Head, Section of Urology, Virginia Mason Medical Center, Seattle, Washington


    Disclosure: Kathleen C. Kobashi, MD, has disclosed a consultant relationship to Coloplast. Dr. Kobashi has also disclosed that she is on the speakers’ bureau for Novartis and Astellas.

CME Author(s)

  • Désirée Lie, MD, MSEd

    Clinical Professor, Family Medicine, University of California, Orange; Director, Division of Faculty Development, UCI Medical Center, Orange, California


    Disclosure: Désirée Lie, MD, MSEd, has disclosed no relevant financial relationships.

Accreditation Statements

    For Physicians

  • This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of Medscape, LLC and Nature Publishing Group.

    Medscape, LLC is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

    Medscape, LLC designates this educational activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™ . Physicians should only claim credit commensurate with the extent of their participation in the activity.

    Contact This Provider

For questions regarding the content of this activity, contact the accredited provider for this CME/CE activity noted above. For technical assistance, contact [email protected]

Instructions for Participation and Credit

There are no fees for participating in or receiving credit for this online educational activity. For information on applicability and acceptance of continuing education credit for this activity, please consult your professional licensing board.

This activity is designed to be completed within the time designated on the title page; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity online during the valid credit period that is noted on the title page.

Follow these steps to earn CME/CE credit*:

  1. Read the target audience, learning objectives, and author disclosures.
  2. Study the educational content online or printed out.
  3. Online, choose the best answer to each test question. To receive a certificate, you must receive a passing score as designated at the top of the test. Medscape encourages you to complete the Activity Evaluation to provide feedback for future programming.

You may now view or print the certificate from your CME/CE Tracker. You may print the certificate but you cannot alter it. Credits will be tallied in your CME/CE Tracker and archived for 6 years; at any point within this time period you can print out the tally as well as the certificates by accessing "Edit Your Profile" at the top of your Medscape homepage.

*The credit that you receive is based on your user profile.


The Evolution of Midurethral Slings

Authors: David E Rapp, MD ; Kathleen C Kobashi, MDFaculty and Disclosures


Summary and Introduction


Use of urethral slings in the treatment of incontinence started in the early 20th century. An evolution in understanding the pathogenesis of urinary incontinence led to development of the midurethral sling, which was designed to replace the natural suburethral vectors of support, as described in the integral theory. Since the introduction of tension-free vaginal tape in 1995, multiple other commercially available types of midurethral sling have been introduced. In general, these sling types share the common characteristics of using a thin, type I synthetic mesh inserted at a midurethral level and applied without tension. The midurethral sling procedure has subsequently undergone multiple technical modifications, predominantly alterations to the technique and route used for sling insertion. Despite the variety in techniques, available evidence suggests that all sling types provide efficacious and durable outcomes. Several adverse effects have been reported that are specific to certain techniques, and include the risk of vascular, enteric or nerve injury, lower urinary tract injury, urinary retention or voiding dysfunction, and vaginal erosion. Nonetheless, the midurethral sling provides a safe surgical option overall, and represents a notable advance in the treatment of stress urinary incontinence.


At the beginning of the 20th century, VonGiordano described the first urethral sling, which used gracilis muscle.[1] Modifications to the technique were subsequently described that predominantly used other muscle bodies, such as a pyramidalis muscle flap and plication of the perivesical muscular structures.[2-4] Common to these techniques was the belief that muscle placed around the bladder neck would provide a sphincteric function.

As sling techniques evolved, a variety of materials came into use. Price[5] described the first fascia lata sling in 1933. The origin of the contemporary pubovaginal sling may be found in the classic technique described by Aldridge in 1942,[6] in which a strip of rectus fascia was secured beneath the urethra to provide increased resistance at times of heightened abdominal pressures. This technique was later modified to leave the external oblique aponeurosis attached to the pubic tubercle and suture the fascial ends beneath the proximal urethra.[7]

This era of sling development was also notable for the popularity of abdominal retropubic and transvaginal suspension procedures, characterized by techniques to suspend the bladder neck by fixation of surrounding tissues. Accordingly, in 1949, Marshall et al.[8] pioneered a technique for bladderneck suspension through the fixation of perivesical bladder-neck tissue to the pubic symphysis. Rare but severe bony complications were attributed to pubic symphyseal fixation, however, and consequently Burch[9] described a modified retropubic suspension in which the fixation point was positioned laterally along Cooper’s ligament.

Although satisfactory continence rates were achieved by retropubic procedures, the invasive nature of the abdominal approach and consequently long durations of hospital stay and postoperative convalescence rendered them less ideal than the vaginal approach. Additionally, perioperative morbidity was notable. Despite the reduced morbidity associated with the transvaginal needle suspensions, however, the effects of these procedures on stress urinary incontinence (SUI) were not durable.

In an effort to improve the efficacy of surgical treatment of SUI, McGuire and Lytton[10] revived, in 1978, the use of the pubovaginal sling. They described a combined abdominovaginal approach with complete detachment of the rectus fascia, which was repositioned suburethrally as a sling. The morbidity associated with autologous graft harvesting led, eventually, to exploration of the use of allografts and xenografts, for example, the use of cadaveric fascia lata anchored over the rectus fascia or via transvaginal bone anchors. Irrespective of allograft type or fixation method, however, early reports of isolated failure were attributed to weak tensile strength and suture pull-out.[11] Continued refinements in materials were sought to identify an ideal compound for use in transvaginal slings that would be inert, sterile, noncarcinogenic, and mechanically durable. In this Review we provide an overview of the pathogenesis of SUI and of the evolution of the midurethral sling, with a focus on the types of slings currently available and the outcomes of this therapy.