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Long-term Risk of Reoperation After Synthetic Mesh Midurethral Sling Surgery for Stress Urinary Incontinence

Berger, Alexander A. MD, MPH; Tan-Kim, Jasmine MD; Menefee, Shawn A. MD

doi: 10.1097/AOG.0000000000003526
Contents: Urogynecology: Original Research
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OBJECTIVE: To measure the long-term reoperation risk after synthetic mesh midurethral sling surgery.

METHODS: This retrospective cohort study evaluated all patients who underwent a midurethral sling surgery for stress urinary incontinence (SUI) (2005–2016) within a large managed care organization of 4.5 million members. We queried the system-wide medical record for Current Procedural Terminology and International Classification of Diseases, 9th or 10th Revision codes for patient data, and implant registry coding to assess the sling type. The primary outcome was the overall reoperation rate after midurethral sling, with secondary outcomes being reoperation for mesh revision, or removal and recurrent SUI. We used cumulative incidence to calculate reoperation risk as a function of time at least 1 year, least 5 years, and at least 9 years. We compared demographics, characteristics, and reoperation of patients using χ2 and Wilcoxon rank sum, and we used a Cox proportional hazards model to calculate adjusted hazard ratios.

RESULTS: In this cohort of 17,030 patients treated with primary midurethral slings, the overall reoperation rate was 2.1% (95% CI 1.9–2.4%) at 1 year, 4.5% (95% CI 4.1–4.8%) at 5 years, and 6.0% (95% CI 5.5–6.5%) at 9 years. Risk of reoperation was affected by race (P=.04), with Asian or Pacific Islander patients having a lower reoperation rate when compared with white patients. Reoperation rate for mesh revision or removal was 0.7% (95% CI 0.6–0.8%) at 1 year, 1.0% (95% CI 0.8–1.1%) at 5 years, and 1.1% (95% CI 0.9–1.3%) at 9 years. Reoperation for recurrent SUI was 1.6% (95% CI 1.4–1.8%) at 1 year, 3.9% (95% CI 3.5–4.2%) at 5 years, and 5.2% (95% CI 4.7–5.7%) at 9 years. Risk of reoperation for recurrent SUI was affected by the type of sling, with reoperation more common after single-incision compared with retropubic sling (adjusted hazard ratio 1.5 [95% CI 1.06–2.11] P=.03).

CONCLUSION: Midurethral slings have a low long-term risk of reoperation for mesh revision or removal, and recurrent SUI, adding to the evidence of their safety and efficacy for the treatment of women with SUI.

Midurethral slings have a low long-term risk of reoperation for mesh revision or removal and recurrent stress urinary incontinence.

Division of Female Pelvic Medicine and Reconstructive Surgery, Department of OB/GYN, Kaiser Permanente, and the Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics, Gynecology and Reproductive Science, University of California, San Diego, California.

Corresponding author: Alexander A. Berger, MD, MPH, Ob/Gyn Department, Kaiser Permanente, San Diego, CA; email:

The research is supported by a grant from the Regional Research Committee of Kaiser Permanente Southern California, Grant No. KP-RRC-20171101.

Financial Disclosure Shawn A. Menefee disclosed that he received royalties from UptoDate and the American Urogynecologic Society Board Member for travel for board meetings. The other authors did not report any potential conflicts of interest.

Presented at the American Urogynecologic Society/International Urogynecologic Society joint annual meeting, September 24–28, 2019, Nashville, Tennessee.

The authors thank Stephanie Tovar for her coordination of support and resources at the regional research committee; Zoe Li for their assistance with data management; and Liz Walton-Paxton and her team for assistance with mesh implant registry applications.

Each author has confirmed compliance with the journal's requirements for authorship.

Peer reviews are available at

© 2019 by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.