title: The fate of synthetic mid-urethral slings in 2013: A turning point.
abstract: BACKGROUND
  Since the introduction of the first retropubic tension-free synthetic sling to treat stress urinary incontinence (SUI), newer approaches, different techniques and new devices have been created. Transobturator and single-incision sling (SIS) techniquespara-were developed with the goal of diminishing the rate of complications andspeeding the recovery phase.
  
  
  METHODS
  For this review we searched Medline for relevant papers, with an emphasis on meta-analysis and randomised controlled trials (RCTs). Specially selected reports were identified to address both 'index patients' (defined as those with genuine SUI and no previous anti-incontinence procedure or other genitourinary sign or symptom that might affect her SUI) and, briefly, non-index patients. Two authors independently reviewed papers for eligibility.
  
  
  RESULTS
  Level 1 evidence from a Cochrane review and two meta-analyses indicated that subjective outcomes with the mid-urethral sling (MUS) were similar to those from colposuspension. However, the MUS was better than colposuspension when assessing objective outcomes (Level 1). MUS are equally effective as autologous pubovaginal slings (Level1). Two meta-analyses suggest that retropubic MUS (RMUS) might be better than transobturator MUS when assessing objective outcomes. Five more recent RCTs with longer term outcomes showed high success rates and only one reported a significant advantage for the RMUS in women with intrinsic sphincteric deficiency. One meta-analysis addressing the SIS showed inferior outcomes to the MUS (Level 1). New and improved SIS techniques have been used, but long-term outcomes are limited and results are still controversial when compared to the MUS.
  
  
  CONCLUSIONS
  MUS are still the standard to treat the index patient as previously stated by the American and European Associations of Urology. Currently data are lacking to define which sling and what approach works best. Complications are significantly different between sling types and are dependent on technique.
authors.affiliation: Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.
authors.forename: Paholo G
authors.initials: PG
authors.lastname: Barboglio
authors.affiliation: Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.
authors.forename: E
authors.initials: E
authors.lastname: Ann Gormley
keywords: DUPS, distal urethral polypropylene sling; FDA, United States food and drug administration; ISD, intrinsic sphincteric deficiency; MUS, Mid-urethral sling; Mid-urethral; OR, odds ratio; POP, pelvic organ prolapse; PVS, pubovaginal sling; RCT, randomised controlled trial; RMUS, retropubic mid-urethral sling; RR, relative risk; Retropubic; SIS, single-incision sling; SUI, stress urinary incontinence; Sling; Stress urinary incontinence; Synthetic; TFS, tissue-fixation mini-sling; TMUS, transobturator mid-urethral sling; TOT, transobturator tape; TVT, tension-free vaginal tape; TVT-O, TVT-obturator; TVT-S, TVT-Secur; Transobturator tape; UITN, urinary incontinence treatment network; VLPP, Valsalva leak-point pressure