Sling procedure for urinary stress incontinence

Important things you need to know

Patient choice is an important part of your care. You have the right to change your mind at any time, even after you have given consent and the procedure has started (as long as it is safe and practical to do so). If you are having an anaesthetic you will have the opportunity to discuss this with the anaesthetist, unless the urgency of your treatment prevents this.

We will also only carry out the procedure on your consent form unless, in the opinion of the responsible health professional, a further procedure is needed in order to save your life or prevent serious harm to your health. However, there may be procedures you do not wish us to carry out and these can be recorded on the consent form. We are unable to guarantee that a particular person will perform the procedure. However the person undertaking the procedure will have the relevant experience.

All information we hold about you is stored according to the Data Protection Act (2018) (opens in a new tab).

About retropubic midurethral sling / transobturator midurethral sling for the surgical treatment of stress urinary incontinence

These operations involve inserting a strip of tape made of a synthetic material (polypropylene) to form a sling that supports the urethra (pipe that leads from the bladder to the outside). This helps to stop urine from leaking out.

These are performed under a general anaesthetic in the day surgery unit of the hospital, which is currently based in the Addenbrooke’s Treatment Centre (ATC).

Intended benefits

• The aim of this procedure is to cure or improve stress urinary incontinence. This will not improve symptoms of frequency and urgency.
• No operation is guaranteed to cure stress incontinence but these procedures offer a good chance of improving your symptoms. Studies show that 90% of women are cured or have significant improvement after these procedures.

Who will perform my procedure?

This procedure will be performed by a consultant urogynaecologist or a qualified doctor undergoing training under the direct supervision of the consultant.

Preparing for your operation

• You should maintain a sensible diet. Daily exercise in the run up to the operation will improve your recovery. A 30 minute brisk walk, three to four times a week should be sufficient. Swimming is a good alternative. Avoid alcohol and cigarettes in the month before the operation.
• Stopping smoking will benefit your health in all sorts of ways such as lessening the risk of chest problems after your anaesthetic. By not smoking – even if it is just while you are recovering – you will bring immediate benefits to your health. If you are unable to stop smoking before your operation, you may need to bring nicotine replacements for use during your hospital stay. You will not be able to smoke in hospital. If you would like information about a smoking cessation clinic ask any of the staff.
• Discuss the operation with your General Practitioner (GP) and get him/her to review your medications. Medications such as non-steroidal anti-inflammatories (such as Ibuprofen, Diclofenac [voltarol]) need to be stopped at least seven days before the operation. Blood thinning medications such as Warfarin need to be converted to an alternative drug before the operation. Hormone replacement therapy (HRT) or the contraceptive pill should be stopped four weeks before your surgery and not recommenced until six weeks after your operation. If you are on high blood pressure medication you should arrange to have your blood pressure checked by your GP.
• If you have any symptoms of a cold or ‘flu in the days leading up to the operation you must let your surgeon know as this may necessitate the cancellation of your operation. It may cause some problems to undergo surgery if you have any sort of infection.
• In the two days before the operation take plenty of fluids. It is important to avoid dehydration in the days before the operation.

Before your procedure?

Once the decision for the procedure has been made, patients having the procedure under a general anaesthetic will be asked to attend a pre-admission clinic, when you will meet a specialist nurse. For some women we may arrange a telephone consultation. At this clinic, we will ask for details of your medical history and carry out any necessary clinical examinations and investigations. Please ask us any questions about the procedure, and feel free to discuss any concerns you might have at any time.

We will ask if you take any tablets or use any other types of medication either prescribed by a doctor or bought over the counter in a pharmacy. Please bring all your medications and any packaging (if available) with you. Please tell the ward staff about all of the medicines you use. If you wish to take your medication yourself (self-medicate), please ask your nurse. Pharmacists visit the wards regularly and can help with any medicine queries.

This procedure involves the use of general anaesthesia. We explain about the different types of anaesthesia or sedation we may use at the end of this leaflet. You will see an anaesthetist before your procedure.

Most people who have this type of procedure will be able to go home the same day. However, it is wise to bring an overnight bag in case you have to stay overnight. Your doctor will discuss the length of stay with you.

You will need to starve for six hours before the operation and drink only clear fluids, water is best, for three hours before. The pre-admission staff will tell you what time to do this and also advise you of what time you are to come to the hospital.

Hair removal before an operation

For most operations, you do not need to have the hair around the site of the operation removed. However, sometimes the healthcare team need to see or reach your skin and if this is necessary they will use an electric hair clipper with a single-use disposable head, on the day of the surgery. Please do not shave the hair yourself or use a razor to remove hair, as this can increase the risk of infection. Your healthcare team will be happy to discuss this with you.

During the procedure

• Before your procedure, you will be given the necessary anaesthetic and/or sedation - see below for details of this and the role of the anaesthetist in your care.
• You will be given antibiotics whilst you are asleep; this is administered intravenously (into the vein) by the anaesthetist. This is given as a preventative measure against possible infection. It is therefore important that you tell a member of staff if you are allergic to any antibiotics.
• During a retropubic midurethral sling operation, a synthetic sling is inserted through a cut in the vagina, to support the bladder entrance (urethra). The surgeon makes small cuts just above the pubic area and passes the synthetic tape through them. The tape remains permanently in place (see picture on page 2).
• During a transobturator sling operation, a synthetic sling is inserted through a cut in the vagina to support the bladder entrance (urethra). The surgeon makes two small cuts on the inside of both thighs and passes the synthetic tape through them. The tape remains permanently in place. A cystoscopy (telescope looking into bladder) is performed to check your bladder has not been damaged during this process.

After the procedure

Once your surgery is completed you will usually be transferred to the recovery ward where you will be looked after by specially trained nurses, under the direction of your anaesthetist. The nurses will monitor you closely until the effects of any general anaesthetic have adequately worn off and you are conscious. They will monitor your heart rate, blood pressure, oxygen levels too and check for any vaginal bleeding. You may be given oxygen via a facemask, fluids via your drip and appropriate pain relief until you are comfortable enough to return to your ward.

If there is not a bed in the necessary unit on the day of your operation, your operation may be postponed as it is important that you have the correct level of care after major surgery.

Significant, unavoidable or frequently occurring risks of this procedure

If you have a pre-existing medical condition, are obese, have significant pathology or have had previous surgery the quoted risks for serious or frequent complications will be increased.

The table below is designed to help you understand the risks associated with this type of surgery (based on the RCOG Clinical Governance Advice, Presenting Information on Risk). This is further explained in the following patient information leaflet available from the RCOG (2015): Understanding how risk is discussed in healthcare: Information for you. (opens in a new tab)

Serious risks

• There is a 1 - 2 in 100 chance of mesh erosion into the vagina. This may require further surgery to resolve the problem (common / uncommon).
• There is a 4 in 100 risk of damage to the bladder or the urethra (common).
• Injury to other organs such as bowel and major blood vessels has been reported. These occur in less than 1 in 100 of women (uncommon).
• 1 - 15 in 100 women after their operation will develop the need to pass water very often, or get little warning of needing to go to the toilet or have trouble getting to the toilet in time. This may respond to drug treatment (common).
• Following transobturator tape about 1 in 10 women have pain in the inner thigh at the site of the tape insertion. This can be difficult to resolve (common).

Frequent risks

• There is a 4 in 100 risk of developing a clot due to bleeding in the area where the tape is placed. This will usually resolve in the few months following the procedure (common).
• 4 - 10 in 100 women will develop a urinary tract infection after the procedure (common).
• Immediately following surgery 5 - 15 in 100 women (common) may have problems with fully emptying the bladder, requiring catheterisation for a few days. It is very rare for this to be a long-term problem.

Alternative procedures that are available

• Other procedures include urethral bulking agents (injections), colposuspension and autologous fascial slings (operations).
• Many women who have undergone a period of supervised pelvic floor muscle exercise training will not require surgery.
• Absorbent products such as incontinence pants or pad may provide some patients additional ways of treating their urinary problems. Additionally, devices that are placed into your vagina may occasionally be useful for managing urine leakage, such as during physical exercise.
• The alternative to this surgery is to decide not to have surgery and the implications of deciding not to have surgery will be discussed with you.

When to seek help

As with any procedure, complications can occur.

You should seek medical advice from your GP, clinic 24, Daphne ward or the emergency department for:

• Abdominal pain, that is not relieved with the painkillers advised or that continues for more than three weeks
• Raised temperature (fever) and ‘flu-like symptoms. This may be due to infection
• Feeling faint, dizzy or unwell
• Burning and stinging when trying to pass urine-this may be due to urine infection

You should attend the emergency department immediately for:

• Pain, redness and swelling in legs-this may be a sign of DVT.
• Shortness of breath or chest pain or cough it could be due to clots that have
• travelled to your lungs called pulmonary embolism.

Further information

• International Urogynaecological Association (opens in a new tab)
• IUGA - Your pelvic floor (opens in a new tab)
• The Royal College of Obstetricians and Gynaecologists (opens in a new tab)
• Bladder and Bowel Community (opens in a new tab) (Telephone: 08453 450165)

Anaesthesia

Anaesthesia means ‘loss of sensation’. There are three types of anaesthesia: general, regional and local. The type of anaesthesia chosen by your anaesthetist depends on the nature of your surgery as well as your health and fitness. Sometimes different types of anaesthesia are used together.

Before your operation

Before your operation you will meet an anaesthetist who will discuss with you the most appropriate type of anaesthetic for your operation, and pain relief after your surgery. To inform this decision, he / she will need to know about:

• your general health, including previous and current health problems
• whether you or anyone in your family has had problems with anaesthetics
• any medicines or drugs you use
• whether you smoke
• whether you have had any abnormal reactions to any drugs or have any other allergies
• your teeth, whether you wear dentures, or have caps or crowns.

Your anaesthetist may need to listen to your heart and lungs, ask you to open your mouth and move your neck and will review your test results.

Pre-medication

You may be prescribed a ‘premed’ prior to your operation. This is a drug or combination of drugs which may be used to make you sleepy and relaxed before surgery, provide pain relief, reduce the risk of you being sick, or have effects specific for the procedure that you are going to have or for any medical conditions that you may have. Not all patients will be given a premed or will require one and the anaesthetist will often use drugs in the operating theatre to produce the same effects.

Moving to the operating room or theatre

You will usually change into a gown before your operation and we will take you to the operating suite. When you arrive in the theatre or anaesthetic room and before starting your anaesthesia, the medical team will perform a check of your name, personal details and confirm the operation you are expecting.

Once that is complete, monitoring devices may be attached to you, such as a blood pressure cuff, heart monitor (ECG) and a monitor to check your oxygen levels (a pulse oximeter). An intravenous line (drip) may be inserted. If a regional anaesthetic is going to be performed, this may be performed at this stage. If you are to have a general anaesthetic, you may be asked to breathe oxygen through a face mask.

General anaesthesia

During general anaesthesia you are put into a state of unconsciousness and you will be unaware of anything during the time of your operation. Your anaesthetist achieves this by giving you a combination of drugs. While you are unconscious and unaware your anaesthetist remains with you at all times. He or she monitors your condition and administers the right amount of anaesthetic drugs to maintain you at the correct level of unconsciousness for the period of the surgery.

Your anaesthetist will be monitoring such factors as heart rate, blood pressure, heart rhythm, body temperature and breathing. He or she will also constantly watch your need for fluid or blood replacement.

Regional anaesthesia

Regional anaesthesia includes epidurals, spinals, caudals or local anaesthetic blocks of the nerves to the limbs or other areas of the body. Local anaesthetic is injected near to nerves, numbing the relevant area and possibly making the affected part of the body difficult or impossible to move for a period of time. Regional anaesthesia may be performed as the sole anaesthetic for your operation, with or without sedation, or with a general anaesthetic. Regional anaesthesia may also be used to provide pain relief after your surgery for hours or even days. Your anaesthetist will discuss the procedure, benefits and risks with you and, if you are to have a general anaesthetic as well, whether the regional anaesthesia will be performed before you are given the general anaesthetic.

Local anaesthesia

In local anaesthesia the local anaesthetic drug is injected into the skin and tissues at the site of the operation. The area of numbness will be restricted. Some sensation of pressure may be present, but there should be no pain. Local anaesthesia is used for minor operations such as stitching a cut, but may also be injected around the surgical site to help with pain relief. Usually a local anaesthetic will be given by the doctor doing the operation.

Sedation

Sedation is the use of small amounts of anaesthetic or similar drugs to produce a ‘sleepylike’ state. Sedation may be used as well as a local or regional anaesthetic. The anaesthesia prevents you from feeling pain and the sedation makes you drowsy. Sedation also makes you physically and mentally relaxed during an investigation or procedure which may be unpleasant or painful (such as an endoscopy) but where your co-operation is needed. You may remember a little about what happened but often you will remember nothing. Sedation may be used by other professionals as well as anaesthetists.

What will I feel like afterwards?

How you will feel will depend on the type of anaesthetic and operation you have had, how much pain relieving medicine you need and your general health.

Most people will feel fine after their operation. Some people may feel dizzy, sick or have general aches and pains. Others may experience some blurred vision, drowsiness, a sore throat, headache or breathing difficulties.

You may have fewer of these effects after local or regional anaesthesia although when the effects of the anaesthesia wear off you may need pain relieving medicines.

What are the risks of anaesthesia?

In modern anaesthesia, serious problems are uncommon. Risks cannot be removed completely, but modern equipment, training and drugs have made it a much safer procedure in recent years. The risk to you as an individual will depend on whether you have any other illness, personal factors (such as smoking or being overweight) or surgery which is complicated, long or performed in an emergency.

Deaths caused by anaesthesia are very rare. There are probably about five deaths for every million anaesthetics in the UK.

For more information about anaesthesia, please visit the Royal College of Anaesthetists’ website (opens in a new tab).

Information about important questions on the consent form

Use of tissue

As a leading bio-medical research centre and teaching hospital, we may be able to use tissue not needed for your treatment or diagnosis to carry out research, for quality control or to train medical staff for the future. Any such research, or storage or disposal of tissue, will be carried out in accordance with ethical, legal and professional standards. In order to carry out such research we need your consent. Any research will only be carried out if it has received ethical approval from a Research Ethics Committee. You do not have to agree and if you prefer not to, this will not in any way affect the care and treatment we provide. The leaflet ‘Donating tissue or cells for research’ gives more detailed information. Please ask for a copy.

If you wish to withdraw your consent on the use of tissue (including blood) for research, please contact our Patient Advice and Liaison Service (PALS), on 01223 216756.

ReSPECT (Recommended Summary Plan for Emergency Care and Treatment)

It is Trust policy that before we commence any treatment plan we discuss your wishes in the unlikely event there is a complication / emergency resulting from the treatment. The ReSPECT process creates a personalised recommendation for your clinical care in emergency situations where you are not able to make decisions or express your wishes. This enables your health professional to make clinical decisions and to act in your best interests and for your benefit.

The conversation helps us to understand your priorities of care and use those to develop an agreed plan that records what types of care or treatment:

• You would want to be considered for in an emergency
• You would not want to receive
• Would not work or be of overall benefit to you.

Privacy and dignity

Same sex bays and bathrooms are offered in all wards except critical care and theatre recovery areas where the use of high-tech equipment and / or specialist one to one care is required.

Consent form

Below is a print version of the consent form for this procedure, please print and sign prior to attending the hospital. The postal address for the Urology department can be found on the urology service page.