Sling surgery vs pelvic ligament suspension in Korea

What a mid-urethral sling does

A narrow strip of synthetic mesh (TVT or TOT), often called a bladder sling, is placed under the middle of the urethra to give it a backstop when abdominal pressure rises. It has been performed for decades and is well studied. It treats the urethra's support directly and leaves a permanent implant in place.

ACOG calls the midurethral sling the most common operation for stress incontinence. It usually takes less than 30 minutes, and you can usually go home the same day. ACOG puts the risk that the mesh erodes through the vaginal tissue at less than 5 percent, and says erosion can cause long-lasting pain, infection and pain during intercourse.

What the guidelines say about slings

NICE says that for all the surgical procedures it recommends for stress incontinence, including mesh procedures, there is evidence of benefit but limited evidence on long-term adverse effects.

NICE also asks surgeons to advise women that a retropubic mid-urethral mesh sling is a permanent implant and that complete removal might not be possible. It lists colposuspension and an autologous sling, made from the patient's own tissue, among the choices women should be offered.

In the US, the AUA/SUFU guideline lists the midurethral sling (retropubic, transobturator or single-incision), the autologous fascia pubovaginal sling, Burch colposuspension and bulking agents as options to discuss. Before a clinician selects a synthetic midurethral sling, the guideline requires a discussion of the specific risks and benefits of mesh and of the alternatives to a mesh sling.

In April 2019 the FDA ordered manufacturers to stop selling mesh for transvaginal repair of prolapse. Mesh slings for stress incontinence were not part of that order.

What pelvic ligament suspension does

Pelvic ligament suspension is the other operation in this comparison. The technique restores pelvic support by re-anchoring the patient's own lax pelvic ligaments. It is used for stress urinary incontinence, cystocele, rectocele and uterine prolapse. Pelvic ligament suspension surgery was developed by Dr. Mo Hyung-jin, the clinic's medical director. A patent application for the technique has been filed with the Korean Intellectual Property Office.

How much evidence each has

Mid-urethral slings have far more published long-term data than pelvic ligament suspension. That is a real difference, and it belongs in your decision.

A newer operation has fewer years of published follow-up. Ask any surgeon you consult which outcomes they record and how long they follow patients.

Bladder lift surgery and native-tissue repair

Patients often search for bladder lift surgery. The phrase has no single medical meaning. It can describe a colposuspension such as the Burch procedure, in which stitches on either side of the urethra hold the bladder neck in place, an autologous sling made from the patient's own tissue, or a ligament-based repair. Operations that use the patient's own tissue instead of mesh are called native-tissue repairs.

NICE advises that women whose non-surgical treatment has failed be offered colposuspension (open or laparoscopic) or an autologous rectus fascial sling, with a retropubic mid-urethral mesh sling included in the same choice. ACOG adds that a traditional sling made of the patient's own tissue needs more recovery time than a midurethral sling and usually means a hospital stay of a few days.

Materials

Sling: synthetic mesh tape. Ligament suspension: the patient's own ligaments and sutures, without synthetic mesh.

Mesh-free incontinence surgery and alternatives to bladder sling surgery

Non-surgical choices come first. The AUA/SUFU guideline lists pelvic floor muscle exercises with or without biofeedback, a continence pessary and vaginal inserts. ACOG lists pelvic muscle exercises, physical therapy and biofeedback, a pessary and lifestyle changes such as drinking less fluid and limiting caffeine.

If surgery is the next step, the alternatives to bladder sling surgery are colposuspension, an autologous sling made from your own tissue, urethral bulking injections and, at Podo, pelvic ligament suspension. ACOG says an autologous sling is often used after problems with a prior synthetic sling or in women with known reactions to mesh. NICE reserves bulking agents for women in whom other operations are unsuitable or unacceptable, and says repeat injections may be needed.

If you already have a sling or mesh

Patients who have a sling or mesh from another clinic can be treated; if the existing mesh is well positioned, it is left in place and pelvic ligament suspension is performed. A sling or mesh that is poorly positioned can be removed at the clinic.

Options at the clinic

The clinic performs both operations for stress urinary incontinence: pelvic ligament suspension, which uses the patient's own ligaments without synthetic mesh, and the mid-urethral synthetic mesh sling. Which one suits you is decided after examination and measurement. Urethral bulking injections are offered at the clinic; Burch colposuspension is not performed. NICE describes bulking agents as an option when other operations are not suitable, and notes that repeat injections may be needed.

Recovery steps

Both are day or overnight procedures with return to light activity within days. After pelvic ligament suspension at Podo, avoid lifting more than 10 kg (about 22 pounds) for 8 weeks; intercourse can usually resume about 8 weeks after surgery, once a check confirms healing. Specific timelines are on each procedure page.

Pelvic ligament suspension for incontinence alone is performed under IV sedation, with same-day discharge. Plan for 5 to 10 days in Seoul after incontinence or prolapse surgery. A final check is done 5 to 10 days after surgery, before you fly home.

Follow-up

Sling patients are followed for mesh-related problems and voiding difficulty; ligament suspension patients for recurrence of laxity. Both need honest long-term follow-up.

NICE advises a follow-up appointment within 6 months for every woman who has had surgery for stress urinary incontinence. After a retropubic mid-urethral mesh sling, that visit should include a vaginal examination to check for exposure or extrusion of the mesh.

Questions to ask any surgeon

How many of these operations do you perform each year? Which outcomes do you record, and for how long do you follow patients? What happens if the operation does not work, or if the problem returns? If a sling is proposed, will I get written details of the implant? NICE asks providers to give them, including the implant's name, manufacturer, date of insertion and the surgeon's contact details. When a first incontinence operation has failed, NICE advises seeking advice from a regional multidisciplinary team.

Deciding

Previous surgery, whether prolapse is present, your views on implanted material, and measurement of your supports all matter. We explain what we recommend for you and why, and we will say if a sling is the more appropriate choice.

Sources

1. NICE guideline NG123: Urinary incontinence and pelvic organ prolapse in women, recommendations
2. FDA: Urogynecologic surgical mesh implants
3. American Urological Association / SUFU: Surgical Treatment of Female Stress Urinary Incontinence guideline
4. ACOG patient FAQ: Surgery for Stress Urinary Incontinence
5. FDA: Urogynecologic surgical mesh, FDA's activities
6. ACOG Committee Opinion 795: Elective Female Genital Cosmetic Surgery