What is a Midurethral Sling surgery?
Sometimes called a bladder sling, TVT, or sub-urethral sling, it is a surgery to place a narrow ribbon of polypropylene mesh underneath the urethra. The urethra is the tube that allows urine to pass out of the body. The ribbon of mesh acts as a layer of support so that the urethra is closed off when there is downward pressure, like when you sneeze. This helps to hold in the
urine. During this surgery, the mesh is put in through an incision in the vaginal wall, then passed behind the pubic bone and brought out through two very small (1/2 inch) incisions in the pubic hair skin. Once in place, it has a ‘U’ shape, like a sling or hammock. The ends of the mesh are trimmed so they are below the skin.
When is this surgery used?
It is used to treat stress urinary incontinence, which is leaking of urine that happens when you cough, sneeze, laugh, lift something heavy, or exercise.
What is polypropylene mesh?
Polypropylene mesh is a surgical suture material that has been woven into a fabric. It is a permanent mesh that will not dissolve over time. It has been used for many years in various surgeries, including hernia repairs. The warnings about “vaginal mesh” that you may have heard about are for mesh placed through the vagina to support prolapse. The risk of mesh-related problems from the narrow ribbon of mesh used in the TVT procedure is much lower. If you have more questions about mesh, please talk with your surgeon. There are options for surgery without mesh that you can discuss. Please visit the U.S. Food and Drug Information webpage below for more information about mesh use in Urogynecology surgery.
How do I prepare for surgery?
- You may return for a visit 1-3 weeks before your surgery. At this visit, you will review procedure, get blood drawn for pre-op testing, and you may get an electrocardiogram (EKG) done to look for signs of heart disease. You will also receive more detailed education, including whether you need to stop any of your medicines before your surgery.
- You may also get preoperative evaluation from your primary care doctor or cardiologist, especially if you have heart disease, lung disease, or diabetes. This is done to make sure you are as healthy as possible before surgery.
- Quit smoking. Smokers may have difficulty breathing during the surgery and tend to heal more slowly after surgery. If you are a smoker, it is best to quit at least 6-8 weeks before surgery.
- Be active. If you can, walk every day or do other activities you enjoy.
When will I go home after surgery?
Most women spend one night in the hospital. If you are in good health and do not live far away, you may be able to go home the same day the surgery is done. Discuss this with your doctor. However, depending on your overall health and your condition at the end of surgery, you may still need to stay overnight. You should plan for someone to be at the hospital at 10 a.m. on the day you are discharged so they can help you get ready to go and then drive you home.
Do I need someone to stay with me after surgery?
If you live alone, we recommend you ask a friend or relative to stay with you at least until noon the day after you get home. It is good to have someone who plans to check on you in person or by phone every day for the first week you are home. You should stock your home with food before you leave for the hospital, but you may still need someone to shop for you or drive you to the store during your first week home.
What can I expect during the surgery?
- In the operating room, you will receive general anesthesia (medicine to produce deep sleep, loss of feeling and muscle relaxation).
- A tube (catheter) will be placed in your bladder to drain urine and monitor the amount of urine coming out during surgery. The catheter will usually be removed before you go home.
- Compression stockings will be placed on your legs to prevent blood clots in your legs during surgery. Depending on your medical history, you may get a shot, with a small needle placed under your skin, of a blood-thinning medication.
- At the end of surgery, some gauze may be put in your vagina, somewhat like a large tampon. This helps prevent bleeding immediately after surgery. You may feel a sensation of pressure in your vagina from this. It will be removed before you leave the hospital.
What happens after the surgery?
You will go to the recovery room where you will be monitored until you are ready to go to a hospital room. While you are in the hospital you will:
- Start eating a regular (solid) diet. This may happen later on the day of your surgery or on the day after surgery. If you have special dietary needs, please tell us.
- Take medications for pain and nausea if needed.
- Re-start your routine medications.
- Start walking as soon as possible to help healing and recovery.
- Have compression stockings on your legs to prevent blood clots. The stockings will stay on your legs until you are up and walking.
- Be checked to see if your bladder empties normally. It is common to temporarily have trouble completely emptying your bladder after this surgery. If you cannot empty your bladder normally, then either:
- You will have the catheter put back in for a few more days and then come to the Urogynecology office for a second check, or
- You will be taught how to catheterize yourself with a short, straight, narrow tube. You will do this after each time you urinate (or after 4 hours if you cannot go) until you can empty your bladder normally. For most women, this takes a few days, but for some it may take weeks.
- We know no one wants to go home with a catheter, but it is important to protect your bladder.
- Use fiber supplements and Miralax to keep your stool soft like toothpaste. You should not strain or have discomfort with bowel movements. You will get a prescription for this to use at home as well. It is normal to go home before your first bowel movement.
What are possible risks from this surgery?
We work very hard to make sure your surgery is as safe as possible, but problems can occur, even when things go as planned. It is important that you are aware of these possible problems, how often they happen, and what will be done to correct them. Possible risks during surgery include:
- Bleeding: If there is excessive bleeding, you will receive a blood transfusion. If you have personal or religious reasons for not wanting a transfusion, you must discuss this with your doctor before the surgery.The risk of having a blood transfusion is less than 1 in a 100.
- Damage to the bladder, ureters (the tubes that pass urine from the kidneys to the bladder), or bowel: The risk of damage is less than 1 in 100. If damage occurs, it will be repaired while you are in surgery if possible.
- Adding a surgery requiring an abdominal incision: The location and size of the incision will depend on what kind of additional surgery you need. If you have an abdominal incision, you may need to stay in the hospital for two or three nights.
- Nerve damage: We are very careful to position you in the operating room so that there is no harmful pressure on your nerves during surgery, but there is a small risk that this will happen. Your nerves can also be damaged by the surgery itself. The overall risk of nerve damage is 2 to 10 in 100. Nerves often recover, but it can take many months.
- Death: All surgeries have a risk of death. Some surgeries have a higher risk than others. The chance of dying from this kind of surgery is less than 1 in 10,000.
Possible risks that can occur days to weeks after surgery:
- Blood clot in the legs or lungs: A blood clot in a vein blocks blood flow and can cause leg swelling and pain. It can travel to the lungs and cause shortness of breath, chest pain and death. The risk of getting a blood clot after surgery is about 2 in 1,000.
- Bowel obstruction: A blockage in the bowel that causes abdominal pain, bloating, nausea and vomiting. The risk of bowel obstruction is less than 5 in 1,000.
- Discomfort during sexual activity: If this occurs, we can help you reduce it. The risk of new discomfort following surgery is less than 5 in 100.
- Exposed mesh: The permanent mesh used for the TVT can erode through the vaginal tissue or, rarely, into the bladder or urethra. This can cause pain or infection and you may need surgery to remove the exposed mesh. The risk of mesh complications is about 2 in 100.
- Infection: This includes urinary tract infection and also infection where the surgery was done. Infections are treated with antibiotics. The risk of getting a urinary tract infection is about 40 in a 100. The risk of other surgery-related infections is about 7 in 100.
- Prolapse symptoms: The risk of prolapse happening again after a prolapse repair surgery is up to 20 in a 100 and usually happens many years after the surgery.
- Scar tissue: Tissue thicker than normal skin forms where surgery was done. There may be pain at the scar tissue. Scar tissue rarely requires treatment.
- Urinary symptoms:
- Temporarily unable to empty your bladder normally when you urinate. Within the first 2 weeks after surgery, the risk of incomplete bladder emptying is up to 50 in 100. If needed, you will be taught how to use a catheter.
- Continued leaking with laughing, coughing, sneezing or exercise. The risk of this is 10 to 15 in 100.
- Urine stream is slower than before surgery or stops and then restarts. It will improve with time. Do not try to push your urine out; pushing will stop urine flow, just like when you sneeze.
- New or worse bothersome urinary urgency or leaking because of urgency. These symptoms often gradually go away by around 6 months after the surgery. The risk of this is not the same for everyone. Talk to your doctor if you have questions about this.
Disclaimer: This document contains information for the typical patient with your condition. It may include links to online content that was not created by Dr. Stewart and he assumes no responsibility for their content. It does not replace medical advice from your health care provider because your experience may differ from that of the typical patient. Talk to your health care provider if you have any questions about this document, your condition or your treatment plan.
The information above is an adaptation of patient education originally created by Michigan Medicine and is licensed under a Creative Commons AttributionNonCommercial-ShareAlike 4.0 International Public License. Author: Diana Stetson PA-C Reviewer: Megan Schimpf MD Revised: 01/17/2021 by Ryan Stewart, DO.