Advice for women considering vaginal slings and our position on concerns about TVT mesh implants

Mr Mohammed Belal

By Mohammed Belal, consultant urologist specialising in bladder conditions, BPC

The use of vaginal slings is a long-established approach for treating stress incontinence in women. The principle is simple: the sling is fitted like a ‘hammock’ under the urethra to provide support. When there is pressure, such as during a cough, sneeze or exercise, the sling supports the urethra to stay closed and prevent leaking of urine.

Although the principle is long-established, there is widespread variation in where the sling is fitted, how it is fitted and the type of material used for the sling. One method which was widely adopted is using TVT (tension free vaginal tape) to create the sling. This method offered two advantages: the TVT, or mesh, is an artificial product, rather than constituted from the patient’s own body tissue, thus there was no need for the demands of removing the patient’s own tissue to create the sling. Also, the mesh was designed to embed into the patient’s body, holding the sling in place, making the procedure for TVT simpler and less invasive than previous methods.

However, during the last decade, there has been a wave of concerns about the safety of mesh implants. Many thousands of women in the UK and the US experienced severe pain, bleeding and infection when the mesh became loose and perforated the bladder and vaginal area.

Each month, I see three or four women with complications from failed mesh procedures. For these patients, I remove the mesh and undertake any necessary repairs to the urethra. I regularly see many patients who come to BPC because we offer the pubovaginal sling using autograft. This is a more complex operation – both in terms of where the sling is located and the fact that we need to remove and use the patient’s own tissue (usually from the stomach) to create the sling. But we know this is a more durable procedure with fewer complications.

I am also seeing an increase in women who are enduring the debilitating symptoms of incontinence for too long because urologists are becoming more cautious about surgical options. Many urologists do not have experience of undertaking the pubovaginal sling with autograft, so some women can be left with no effective solution if further surgical options are not available in the team treating them.

Our approach at BPC is bespoke and individualised. I would counsel anyone under the age of 50 towards the pubovaginal sling with autograft and this would be the best approach for many women in their fifties and sixties. In older women and those less able to tolerate a more invasive procedure, there could be a rationale for considering TVT, providing the patient is fully informed about risks and benefits. The current position of the Medicines and Healthcare Products Regulatory Agency for the UK (MHRA) is that vaginal mesh implants are under enhanced scrutiny and should only be considered with full counselling of the risks and benefits. Read document here: MHRA summary of the evidence on the benefits and risks of vaginal mesh

We remain mindful, as specialists in incontinence, that one impact of this very concerning chapter is that more women will be left with no treatment, or with treatment that is too conservative for the condition they have. Patients should be cautious and informed about the risks of TVT, but there are other surgical solutions; unfortunately, they are not available in every service and we regularly see women who have travelled from hundreds of miles to BPC because we can offer a wider range of options.