Stress urinary incontinence (SUI) is a major public health concern. The success rate of synthetic mid-urethral sling (MUS) procedures generally remains high. However, safety concerns persist. This study aimed to evaluate MUS removal rates removal rates between transobturator (TOT) and retropubic (TVT), with secondary outcomes focusing on complication incidence and the occurrence of new MUS placement after TVT and transobturator TOT procedures.

Data were extracted from the French national hospital database for all hospitalizations related to MUS procedures performed between 2016 and 2024. Only patients treated with MUS from 2016 to 2019 were included to ensure a 5-year follow-up. Complications were recorded during the initial hospitalization and any subsequent rehospitalizations within 60 months postoperatively. MUS associated with pelvic organ prolapse mesh placement were excluded using the CCAM codes

Between 2016 and 2019, 69,879 TOT and 19,001 TVT procedures were included. The TVT group exhibited higher rates of sling removal (HR 0.50, CI95% = [0.47–9.53], p < 0.001) and urinary tract infections (0.7% vs. 0.5%, p < 0.01). In contrast, the TOT group had a 19% higher reintervention rate for SUI (HR = 1.19, CI95% = [1.10–1.29], p < 0.001).

This study provides real-world data from the French national PMSI database. In our study, complications were rare, and MUS removal was uncommon within 5 years of placement. Several important limitations should be recognized : clinical details, including patient history (particularly prior urinary incontinence surgeries), surgical specifics, and surgeon experience (e.g., annual case volume, specialty) were unavailable. We did not analyze acute or long-term chronic pain outcomes because CCAM codes do not reliably distinguish pain related to MUS from other etiologies, nor do they provide details on pain location or severity.

Although TVT is associated with a slightly higher rate of perioperative complications, it has become more efficient over time compared to TOT. However, the available evidence does not support preferential use of TOT given its higher risk of repeat surgery for SUI. Further large-scale studies are needed to more accurately assess comparative complication profiles.