Know before you go: Bladder sling surgery
“I thought it would bounce back,” Robin Barnhart says of her body, specifically her bladder and its trouble with urinary incontinence. After delivering two babies in just over a year, Barnhart, a 42-year-old preschool teacher, experienced leakage from her bladder that progressively got worse over a period of 10 years. “I would leak all the time,” Barnhart says, “God forbid I got a cold or went to a comedy show.”
Barnhart found herself avoiding activities she used to enjoy, like dance classes or jumping up and down with her students in her classroom. “I was purposely saying, ‘I can’t do that,’” she says, and she became increasingly unhappy with the lack of results from her other efforts.
Over the years, besides doing Kegels, she’d also been to several doctors. She’d tried physical therapy and pelvic floor therapy, and even saw one doctor who recommended a hysterectomy, which she didn’t go through with because her insurance changed.
On the recommendation of another friend, Barnhart ultimately went to a urogynecologist, a doctor trained in the diagnoses and treatment of women with pelvic floor problems. The doctor had her squat over a pad and cough, and when a puddle resulted, the two scheduled a mesh mid-urethral bladder sling surgery for the soonest date possible.
An average of 145,000 U.S. women have the surgery each year, and like many of them, Barnhart saw the surgery as a last resort. And for good reason: there’s a lot of confusion and myths about bladder sling surgery—and, recently, many high-profile cases against it.
“It’s disconcerting how vague people can be when they talk about mesh,” says Dr. Brett Vassallo, a specialist in female pelvic medicine and reconstructive pelvic surgery outside of Chicago, IL. “And doctors are guilty of this. We’re often not specific enough when we talk.”
So let’s be specific. In a nutshell, sling surgery is a solution for stress urinary incontinence (SUI), which allows leaks to happen due to weakened pelvic floor muscles around the urethra and opening of the bladder. The mesh sling is inserted into the body and supports the urethra, essentially doing the job that the pelvic floor muscles no longer can.
Prior to mesh slings, there were two main surgeries performed for female SUI, and several doctors still perform them. The most common is the Burch procedure, which involves four sutures, two on either side of the bladder neck, which are then sewn into the back of the pubic bone. The other surgery is with bladder neck slings made from fascial tissue obtained from the patient herself or from a cadaveric source. Both the Burch and the traditional bladder neck fascial sling have higher complication rates than the modern mid-urethral sling.
Today, three main types of mesh mid-urethral sling procedures exist: retropubic (TVT), transobturator (TOT), and single-incision. The sling itself is made of a small piece of polypropylene mesh. Over time, the body’s tissues grow into the mesh and fix it in place. Both the TVT and TOT surgeries make small incisions in the vagina to guide the sling in place, though some versions of the surgery begin laparoscopically in the abdomen and exit through the vagina. The TVT technique weaves the mesh under the urethra in a U shape with each end of the mesh brought up behind the pubic bone. The TOT approach passes the mesh under the urethra and then through the spaces on each side between the labia and creases in the thighs. Once the mesh is inserted, the doctor tests for any bladder issues and makes sure the sling is in place.
It’s important to know which procedures a doctor performs and how he or she was trained, as not all doctors will have been trained in all procedures. Different types of surgeries are better for different types of bodies, too.
Post-surgery recovery is two to four weeks, with recommendations to stay away from heavy lifting for up to 12 weeks. According to Dr. Vassallo and other sources, overall complication rates from mid-urethral slings are low, and mesh complications such as mesh exposure, pain, and excessive tension in the sling, which causes difficulty voiding, occur in the 1-2 percent range. The TVT procedure is more likely to result in a bladder puncture (cystotomy), and the TOT is more likely (than the TVT) to cause chronic groin pain and/or pain during intercourse due to the mesh puncturing the wall of the vagina.
A few cases of sling erosion have also been reported. One example is from Tracy Goodman, a 50-year-old mom in central Oregon. After losing significant weight, Goodman found that “I was able to hold my urine, but I was having accidents.” Indeed, her sling had “collapsed and needed to be shored up” due to the internal changes in her body. She ended up having a second surgery to resituate the sling, and though the complication was a hardship, she says she would do it again. Dr. Vassallo, too, has corrected similar complications, but finds that “dealing with those complications is an easy thing.” Overall, existing studies show an 88 to 95 percent success rate in correcting SUI with the sling procedure.
Still, those reported complications and the fact that in 2008 the FDA issued a public health warning about mesh materials has frightened some people away from bladder sling surgery.
But according to Harvard Medical School, “The largest problem involved a specific brand of polypropylene mesh called OB Tape, and that brand is no longer on the market.” In addition, many of the notorious mesh complications have had to do with transvaginal mesh (TVM), which is used for prolapse repair, not incontinence treatment. With that different kind of mesh surgery, way more mesh is placed inside the body with far more opportunities for puncture and complications.
Nonetheless, 48,000 women have recently sued mesh manufacturers Boston Scientific after experiencing injuries from mesh used in UI treatment, and a recent report revealed that the origins of the plastic used for the device are dubious and of inferior quality (although Boston Scientific denies the claims).
For women considering the surgery, though, it’s vital to choose a doctor who’s a specialist in women’s pelvic medicine for any type of mesh treatment—whether for prolapse or SUI. A recent New York Times article cautioned about marketers and hack lawyers who try to persuade women to have their mesh, no matter the type, removed with lures of class-action lawsuit windfalls. Dr. Vassallo knows that “doctors have made livings taking mesh out unnecessarily because it’s a revenue stream.” A reliable and specialized doctor will know how to test for SUI and how to weigh the risks of surgery. Goodman, who had more than one condition in need of repair, maintains that “anything is better than the complete loss of control and having things not be where they should be,” but she also she told me about another friend whose surgery was botched and the woman is still suffering with severe health issues.
For Barnhart, however, the benefits have outweighed the risks. Before the sling, she never had the urge to urinate and now she knows when to go. She’s more confident and willing to try new things, like rock climbing, an activity she could not have imagined while she was still experiencing UI. “I didn’t realize how much I was missing out on. I’m even interested in my partner again,” she says with a laugh.
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