Risk of Reoperation after Midurethral Sling for SUI from an Integrated Health System

Objectives: To assess the short and long-term reoperation rates after synthetic mesh midurethral sling surgery and compare risk for reoperation of MUS with and without concomitant prolapse procedure.

Methods: We conducted a cohort study including 32,793 adult female patients undergoing a MUS for SUI from 2009 to 2021 at a large managed care organization with data extracted from integrated electronic health records (EHR). Patients were grouped into those who underwent MUS alone or with non-prolapse surgery (N=7,706) and those who underwent MUS sling with concomitant prolapse surgery (N=25,087). Implant information, CPT, and ICD-9/10 codes were utilized to group index procedure information and indication for reoperation. The primary outcome was reoperation for persistent or recurrent stress urinary incontinence by MUS group. An important secondary outcome was reoperation for sling-related adverse events (pain, bleeding, infection, urinary retention, and mesh exposure) and all cause or overall reoperation rates by MUS group. Reoperation risk was calculated as a function of time while accounting for membership termination and death at ≤1yr, 1-5yrs, and >5yrs. Multivariable cause-specific Cox proportional hazards models were used to calculate hazard ratios. Adjusted cumulative incidence plots were calculated by outcome.

Results: The overall reoperation rate was 3.3% (N=1,073) with a mean follow-up time of 5.7yrs (±3.4yrs); and was 1.7%, 1.2%, and 0.5% at ≤1yr, 1-5yrs, and >5yrs, respectively. Reoperations for recurrent incontinence [(3.1% vs. 3.4%), N=947] and adverse events [(0.30% vs 0.41%), N=126] were not significantly different between the two groups. However, patients who underwent prolapse procedures at the time of MUS had a 49% increased risk of reoperation for recurrent incontinence between years 1-5 (Hazard Ratio (HR)=1.49, 95% Confidence Interval (CI)=1.03-2.18). There were no differences in reoperation risk for recurrent stress urinary incontinence between groups at ≤1yr and >5yrs. There were also no differences in risk of reoperation for sling-related adverse events between groups at ≤1yr or >1yr (HR=0.90, 95% CI=0.65-2.29) and (HR=1.29, 95% CI=0.87-2.09).

Conclusions: In a cohort of more than 32,000 women we found that MUS have a low long-term risk of reoperation for recurrent stress urinary incontinence, adverse events, and overall or all cause. Patients undergoing concomitant prolapse procedures had a higher risk of reoperation for recurrent incontinence in the first five years after sling insertion but no difference in reoperations rates for safety. This information continues to reaffirm the safety and efficiency of MUS for SUI, which can used to inform patients, providers, and other stakeholders.