Mini Sling for Stress Urinary Incontinence Treatment
The mini sling is a essentially a miniature sling delivered through a single incision site via the vagina. Most other slings require either two or three incisions. Both the TVT and TOT slings requires three incision sites, an incision in the vagina and two smaller exit incisions in the pubic area or the groins bilaterally. The mini sling was produced in an attempt to maintain cure rates yet minimize pain, blood loss, and voiding dysfunction post operatively.
There are two main types of mini slings are in circulation today:
- Secure made by Gynecare whose cure rates average in the 60-70% range
- MiniARC - made by American Medical System (AMS) whose cure rates are 90%.
Single Incision Mini-Sling: The next step in Minimally Invasive Treatment For SUI
Dr. Moore was the first surgeons in the United States to place the Mini-Arc mini-sling (click here to view press release).
The mini-sling procedure utilizes the same concepts of the tension-free tape mid-urethral slings, however only one incision is needed and the procedure can be completed in as little as 5-10 minutes under local anesthesia!! The procedure was initially released in September of 2006 by Gynecare with a procedure called the TVT-Secure and Dr. Miklos and Moore were some of the first surgeons to evaluate and study the procedure. They liked the concept of a single incision sling, however were not enthused by the engineering and design of the Secure sling. In early 2007, with development input from Dr. Moore and Miklos, American Medical Systems made several improvements to the procedure and in April, Dr Moore was the first surgeon in the United States to place the Mini-Arc mini-sling (click here to view press release). Dr. Moore’s and Miklos’ center in Atlanta, because of their reputation of being world leader’s in treatment for SUI, was chosen as the lead center in the USA to evaluate and study the Mini-Arc procedure. Dr. Moore was chosen as principal investigator, leading 5 centers in the USA and the world, to study and present the initial results in the USA, which have been excellent and very exciting! Since 2007, the results have continued to be impressive and it has become a mainstay in treatment in female SUI. Once again, Dr. Moore and Miklos were in the lead of bringing new technology to the field of female urology that has now become a procedure that has been adopted world-wide.
Dr. Moore, along with Dr. Miklos, in 2009, were the first in the world to publish longer term follow-up on patients that underwent the Mini-arc sling in the Journal of Surgical Technology (click here to view paper). They found a cure rate of over 90% at one year, which is consistent with other slings such as the TVT and the TOT sling and minimal risks of any complications. Dr. Moore is also co-author of the largest multi-center trial completed to date in the world on the mini-arc mini sling which was just published in the Journal of Urology in August of 2010. Consistent with their first paper, the multicenter trial (centers from all over the world were involved in this trial, along with Dr. Moore and Miklos’ Center) showed an objective cure rate of over 90% with very low risk of voiding dysfunction (i.e. obstruction), pain, infection or other complications. Average hospital stay was less than 3 hours and return to normal activity was very rapid. Dr. Ty Erikson presented a study at the American College of Ob/Gyn that showed that almost 70% of women did not take ANY pain medication after having the procedure completed... another indication of how minimally invasive the procedure is.
As stated by the American Urologic Association consensus statement in 2001, there are only 2 procedures that are proven to have effective long-term cure rates for the treatment of stress urinary incontinence (SUI). These procedures are the abdominal Burch Colposuspension (or MMK) and the sling procedure that is completed vaginally. However, in the past, the sling procedure was far from standardized. There have been multiple different descriptions using different materials for the sling (fascia from the patient, cadaveric fascia or dermis from humans or animals, synthetics, etc), different anchoring points, and different methods to adjust the tension of the sling. In many cases patients had to undergo general anesthesia, were in the hospital for several days, required a catheter to drain the bladder coming out of the abdomen (because it took so long to void on their own) and many patients suffered high rates of voiding dysfunction following these slings.
However the introduction of the tension-free vaginal tape procedures to the United States in the late 90’s revolutionized the treatment of SUI. It introduced a standardized sling procedure that could be completed safely in 20 minutes under local anesthesia, utilizing 3 very small incisions with minimal dissection, a cough test for individual tension patient adjustment and excellent cure rates. Over 1 million of these procedures have been completed worldwide. This procedure was called the TVT sling and since several other types of similar slings have been developed to try to improve on its safety.
Single Incision Mini- Sling- New, Safer Approach
Despite its relative safety, the original tension free vaginal tape procedures require the blind passage of needles through 2 small incisions in the abdomen just above the pubic bone. The retropubic space that the needle has to pass through to get to these abdominal incisions is also a very vascular space with venous plexuses and the potential for injury to large blood vessels in the pelvis. Secondary to this and the areas that the needle has to pass to place the mesh tape, there is potential for complications such as injury to the bladder, intestines, or nerves in the pelvis and/or abdomen. All of these injuries have been reported in the literature. Secondary to this, physicians in Europe began investigating to find a safer approach to place the mesh tape sling.