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The MONARC Transobturator Sling

monarc

- Patient Information Leaflet

Prepared by:
Prof. Ajay Rane, Consultant Urogynaecologist, MBBS MD MRCOG FRCS FRANZCOG CU
Audrey Corstiaans CNC , Urogynaecology

Updated August 2008


What is a MONARC Transobturator Sling?
The MONARC Transobturator sling is a new minimally invasive operation performed to correct stress urinary incontinence (SUI). It utilises the concept of providing support for the urethra, as seen with the popular tension-free vaginal tape (TVT) operation, which has been shown to cure SUI in 80 to 90% cases at 6 years follow up. However, in contrast to the TVT operation, the MONARC sling is performed with a different approach that is thought to reduce the risk of bladder injury during surgery. The sling used in this operation is made up of polypropylene, the same material used in TVT operations, which have been shown to be very, well tolerated by the body.This procedure is to treat stress urinary incontinence.  The MONARC is not a cure for urgency although it may help with this symptom.

This procedure is to treat stress urinary incontinence. The MONARC is not a cure for urgency although it may help with this symptom.

What is involved?
The procedure is mainly performed under a short general anaesthetic, and takes about 15 minutes. Local or Spinal anaesthesia may be used if required. During the procedure, 2 small incisions will be made at the vulval area and another small incision will be made inside the vagina just under the urethra. The sling will be tunnelled between these incisions inside the body. The incisions are then either closed with dissolvable sutures or surgical glue.

Complications

There can be a small risk of bleeding (which is rarely severe enough to require blood transfusion), wound infection and injury to surrounding organs (eg. bladder). There is also a very small risk of sling rejection or infection, which may require sling removal.
A small number of women may develop difficulty-passing urine following surgery, and this may require the use of a catheter temporarily. Some women can develop bladder overactivity, but this can be treated with pelvic muscle exercises and medication.  Anaesthesia itself is never without risks and the risks are greater for women, who smoke and are overweight.

Results
Initial studies have shown it to cure SUI in 92.9-94.1% of cases in short term (follow up of up to 12 months). Weight loss if overweight, reducing or quitting smoking, improving pelvic muscle tone by doing pelvic muscle exercises and continuing to do them after surgery will ensure that the operation is a success.

Recovery
When you go home you must not lift heavy objects (more than 9lbs or 4kgs) or do strenuous work for about 6 weeks. Avoid intercourse for the same period. You can return to work usually in ten to fourteen days.

Afterwards
You will be seen in either the clinic or at urodynamics 8 to 12 weeks after the operation. If everything is well the success of your operation should be permanent. 5 days of antibiotics have to be taken to prevent infection of the mesh.  We strongly recommend taking anti-inflammatory medication (Nurofen) for 1 week, twice a day with food post operatively, unless you have a medical reason for not doing so or are already on anti-inflammatory medication. 

Post Operative Instructions:

You will have some vaginal discharge for 4 to 6 weeks.  This should be light bleeding or spotting only, and this may vary during that period of time as healing occurs and your stitches dissolve.
 We recommend you are not to self examine or self assess your operative site till you have been examined by the doctor post operatively.

Pain should be relieved with Panadol or Panadeine (remember if you take Panadeine, this increases the risk of constipation so ensure you have an adequate intake of fibre and fluids in your diet). 

Do not use tampons, pads are better.
Do not drive an automatic car for 1 week*
Do not drive a manual car for 2 weeks*
Do not make a bed for 2 weeks
Do not hang out washing for 4 weeks
Do not use your Vaginal Oestrogen for 4 weeks
Do not stretch upward for 6 weeks
Do not mop or vacuum for 6 weeks
Do not lift anything over 4kg for 6 weeks
Do not have sexual intercourse for 6 weeks


The first week is the most important, where one must rest.

*It is important to check with your insurance company, re driving your car as each company has different policies on driving and surgery.

 Remember to rest, if you are tired and uncomfortable you have been doing too much and need to slow down

Discharge instructions
You may experience for up to 72 hours:
  • Urinary frequency
  • Dysuria (burning and stinging sensation when you pass urine)
  • Haematuria (blood stained urine)

Remember when emptying your bladder, sit on the toilet, feet flat and lean forwards. Drink 6 - 8 glasses of fluid per day; limit your caffeinated drinks to 3 per day, and take Ural (for the frequency and dysuria) if required.

Contact your G.P or your local hospital if you experience any of the following:
  • You cannot pass urine
  • You have severe pain or bleeding
  • You develop a fever
  • You have unusual vaginal discharge or odour
  • You have heavy vaginal bleeding or clotting
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