There are several surgical approaches to manage female stress urinary incontinence (SUI).  The aim of this study was to compare long-term surgical reintervention rates (up to 20 years) following the use of different types of surgery for SUI.  This information will aid patients and providers in making informed decisions around surgical SUI care.

This was a population-based administrative cohort study which included all individuals undergoing first surgery for SUI performed by either synthetic mid-urethral sling (MUS), fascial sling (FS), retropubic urethropexy procedures (RUP) or synthetic pubovaginal sling (SPS). Demographics data including age, year of surgery, comorbidities, previous or concomitant hysterectomy or pelvic organ prolapse repair, and material resources were collected. The primary outcome was a composite outcome of surgical procedure for further SUI treatment, mesh excision or peri-urethral revision, abdominal wall hernia or pelvic organ prolapse repair. Competing-risk regression using multivariate Fine-Grey models was used to estimate sub-distribution hazard ratios (sHRs). Secondary outcomes included examining reintervention for stress urinary incontinence and other reintervention surgery separately.

103,058 cases of primary surgery for SUI were identified between fiscal year 2002 and 2023. There were 80,137 cases of MUS, 1,913 cases of FS, 14,607 cases of RUP, and 6,401 cases of SPS. The median age of the cohort was 54 years (interquartile range (IQR) 45-63, and was similar between exposure groups when compared to MUS (standardized mean difference, SMD <0.1). The median length of follow up was 13 years (IQR 9-17) which varied between groups with the shortest follow up being with MUS and SPS at 13 (IQR 8-16) and 13 (IQR 9-17, SDM 0.11) years respectively.  Follow up for FS was 16 years (IQR 10-20, SMD 0.43) and 17 years (IQR 12-20, SMD 0.66) for RUP. Cumulative incidence curves indicate that the 20-year cumulative incidence of the composite outcome was 21.8%, 20.1%, 18% and 15.4%, and surgical reintervention for SUI was 8.4%, 8.5%, 6.2% and 5.4% for the FS, RUP, SPS and MUS groups respectively, with close to half of all reinterventions occurring within 4 years of the original surgery (Figure 1B). The sHR for the composite outcome relative to MUS was 1.38 (95%CI 1.24-1.54) for FS, 1.21 (95%CI 1.16-1.28) for RUP and 1.17 (95%CI 1.09-1.25) for SPS. The sHR for reintervention relative to MUS for further treatment for SUI was 1.43 (95%CI 1.21-1.70) for FS, 1.47 (95%CI 1.35-1.59) for RUP and 1.15 (95%CI 1.02-1.29) for SPS. Comparing native tissue procedures, FS against RUP, sHR for the composite outcome was 1.14 (95%CI 1.02-1.27) and for further SUI treatment was 0.97 (95%CI  0.82- 1.16)

Over 20 years of follow‑up, MUS was associated with a lower probability of reintervention when compared to FS, RUP, and SPS, with differences confirmed in competing‑risks analyses. Among native tissue procedures (FS and RUP), the cumulative incidence of surgical reintervention for SUI did not differ over long‑term follow‑up.

To our knowledge this study represents the largest cohort with follow up on this time scale demonstrating that options for surgical management of SUI have good durability and safety over 20 years with MUS performing better than alternative procedures. Extended term follow up of randomized trials would help to further elucidate risks and benefits of these options to aid patients and providers in making well-informed decisions around surgical SUI care.

Continence 19S (2026) 102682
DOI: 10.1016/j.cont.2026.102682