Adjustable Slings: A Handy Apparatus in the Stress Incontinence Tool Kit

INTRODUCTION: Midurethral slings are the most commonly performed surgical treatment for stress urinary incontinence. These can be placed via retropubic or transoburator approaches, and both techniques have demonstrated high cure rates and patient satisfaction. While highly efficacious and safe, conventional slings have the disadvantage of not being able to be objectively tensioned. The adjustable sling can be a favorable option particularly for patients with recurrent or refractory stress urinary incontinence or intrinsic sphincter deficiency due to the advantage of postoperative tension adjustment to optimize outcomes. OBJECTIVE: To describe the mechanism of a commercially available adjustable sling, review its indications and advantages, and demonstrate the procedure to perform long-term adjustments. METHODS: Our patient is a 49-year-old G3P2012 with a history of Ehler’s Danlos syndrome who had urinary retention after midurethral sling placement. After sling incision, she had return of her stress incontinence which was refractory to a second retropubic sling and two rounds of periurethral bulking. She underwent placement of an adjustable retropubic sling with complete resolution of her stress incontinence. Five years later, she had mild recurrence of her stress incontinence, and she underwent a sling tension adjustment with an excellent surgical outcome. RESULTS: The adjustable sling consists of a polypropylene mesh with Prolene suspension suture threads and a varitensor regulation device. The varitensor rests tension free upon the rectus fascia and holds the suspension suture of the sling. Long-term readjustment of the sling is a short outpatient procedure that can be performed under sedation. The skin is incised, and the varitensor is exposed. The manipulator is secured to the varitensor and the subcutaneous tissue and skin are closed. In the PACU, the patient’s bladder is backfilled, and they are asked to perform a cough/Valsalva stress test. The manipulator is used to tighten the sling in small increments until there is no leakage. The manipulator is then removed. CONCLUSIONS: Adjustable midurethral slings provide a valuable adjunct in the surgical management of complex stress urinary incontinence, offering the advantage of postoperative and long-term tension adjustment.