Share this article on:

Repeat Midurethral Sling Compared With Urethral Bulking for Recurrent Stress Urinary Incontinence

Gaddi, Anthony MD; Guaderrama, Noelani MD; Bassiouni, Nora MD; Bebchuk, Judith ScD; Whitcomb, Emily L. MD, MAS

doi: 10.1097/AOG.0000000000000282
Contents: Original Research

OBJECTIVE: To compare the effectiveness and safety of repeat midurethral sling with urethral bulking after failed midurethral sling.

METHODS: This is a retrospective cohort study of patients within Kaiser Permanente Southern California Medical Group who underwent a midurethral sling for stress urinary incontinence (SUI) from 2008 to 2011 and subsequently had either a midurethral sling or urethral bulking for recurrent SUI. Current Procedural Terminology codes were used to identify patients and electronic medical records were queried for individual patient information. Our primary outcome was either subjective failure defined by SUI or objective failure defined as a positive cough stress test, urodynamic stress incontinence, or retreatment for SUI. Secondary outcomes included perioperative complications and adverse events.

RESULTS: Of 6,914 midurethral slings performed, 165 patients underwent a repeat procedure for recurrent SUI, including 98 midurethral slings and 67 urethral bulking. Of the 165 patients who underwent repeat procedures, there were 11 failures (11.2%) in the midurethral sling group and 26 failures (38.8%) in the urethral bulking group (P=.004). There were no differences in perioperative complications or adverse events between the groups. In multivariable logistic regression, risk of failure was significantly higher in those undergoing urethral bulking compared with those undergoing midurethral sling (odds ratio 3.49, 95% confidence interval 1.34–9.09, P=.01).

CONCLUSIONS: In a managed care population, urethral bulking was associated with higher risk of failure than repeat midurethral sling after primary midurethral sling failure with no differences in perioperative complications or adverse events.


The repeat midurethral sling is associated with lower risk of failure than urethral bulking for recurrent stress urinary incontinence after failed midurethral sling.

Departments of Obstetrics and Gynecology and Research and Evaluation, Southern California Permanente Medical Group, Irvine Medical Center, Irvine, California.

Corresponding author: Emily L. Whitcomb, MD, MAS, Kaiser Permanente Irvine Medical Center, 6650 Alton Parkway, Irvine, CA 92618; e-mail:

Supported by a grant from the Regional Research Committee, Southern California Permanente Medical Group.

Financial Disclosure The authors did not report any potential conflicts of interest.

© 2014 by The American College of Obstetricians and Gynecologists.