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Are slings now the gold standard treatment for the management of female urinary stress incontinence and if so which technique?

Purpose of review Sling surgery for the treatment of female stress urinary incontinence has become so popular as a consequence of excellent results that possibly the time has come to consider this type of surgery as the new gold standard. Prior to reaching this conclusion careful consideration of the developments that have led to this perception are necessary. These reflections should include (patho)physiology, historical background, and alternative techniques and materials. Recent findings Pathophysiological concepts and theories on clinical staging have changed in recent years. The importance of pressure transmission and hammock-like support has been complemented by the so-called ‘integral’ theory. Analysis of the available literature shows that the new sling procedures provide a new reference point in time because they not only show good medium-term results, but they are also minimally invasive with quick post-operative recovery. Summary Loosely applied mid-urethral slings are the new gold standard therapy for female stress urinary incontinence. Whether these slings should be made of synthetic material (polypropylene) or bio-material (allografts or xenografts) can only be determined after comparative randomized controlled trials. Bio-materials have the advantage of versatility that makes them useful as a loose sling in patients with a ‘good’ urethra or as a tight sling in patients with a ‘bad’ urethra. Furthermore, synthetic materials carry with them the risk of complications associated with any nonabsorbable material such as erosion. The field of stress incontinence treatment is evolving continuously and no doubt current techniques will be surpassed by newer, better concepts in the future.