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. 2018 Oct 23;320(16):1659-1669.
doi: 10.1001/jama.2018.14997.

Long-term Rate of Mesh Sling Removal Following Midurethral Mesh Sling Insertion Among Women With Stress Urinary Incontinence

Ipek Gurol-Urganci  1   2 , Rebecca S Geary  1   2 , Jil B Mamza  1   2 , Jonathan Duckett  3 , Dina El-Hamamsy  4 , Lucia Dolan  5 , Douglas G Tincello  6 , Jan van der Meulen  1   2
Affiliations

Long-term Rate of Mesh Sling Removal Following Midurethral Mesh Sling Insertion Among Women With Stress Urinary Incontinence

Ipek Gurol-Urganci et al. JAMA. .

Abstract

Importance: There is concern about outcomes of midurethral mesh sling insertion for women with stress urinary incontinence. However, there is little evidence on long-term outcomes.

Objective: To examine long-term mesh removal and reoperation rates in women who had a midurethral mesh sling insertion for stress urinary incontinence.

Design, setting, and participants: This population-based retrospective cohort study included 95 057 women aged 18 years or older who had a first-ever midurethral mesh sling insertion for stress urinary incontinence in the National Health Service hospitals in England between April 1, 2006, and December 31, 2015. Women were followed up until April 1, 2016.

Exposures: Patient and hospital factors and retropubic or transobturator mesh sling insertions.

Main outcomes and measures: The primary outcome was the risk of midurethral mesh sling removal (partial or total) and secondary outcomes were reoperation for stress urinary incontinence and any reoperation including mesh removal, calculated with death as competing risk. A multivariable Fine-Gray model was used to calculate subdistribution hazard ratios as estimates of relative risk.

Results: The study population consisted of 95 057 women (median age, 51 years; interquartile range, 44-61 years) with first midurethral mesh sling insertion, including 60 194 with retropubic insertion and 34 863 with transobturator insertion. The median follow-up time was 5.5 years (interquartile range, 3.2-7.5 years). The rate of midurethral mesh sling removal was 1.4% (95% CI, 1.3%-1.4%) at 1 year, 2.7% (95% CI, 2.6%-2.8%) at 5 years, and 3.3% (95% CI, 3.2%-3.4%) at 9 years. Risk of removal declined with age. The 9-year removal risk after transobturator insertion (2.7% [95% CI, 2.4%-2.9%]) was lower than the risk after retropubic insertion (3.6% [95% CI, 3.5%-3.8%]; subdistribution hazard ratio, 0.72 [95% CI, 0.62-0.84]). The rate of reoperation for stress urinary incontinence was 1.3% (95% CI, 1.3%-1.4%) at 1 year, 3.5% (95% CI, 3.4%-3.6%) at 5 years, and 4.5% (95% CI, 4.3%-4.7%) at 9 years. The rate of any reoperation, including mesh removal, was 2.6% (95% CI, 2.5%-2.7%) at 1 year, 5.5% (95% CI, 5.4%-5.7%) at 5 years, and 6.9% (95% CI, 6.7%-7.1%) at 9 years.

Conclusions and relevance: Among women undergoing midurethral mesh sling insertion, the rate of mesh sling removal at 9 years was estimated as 3.3%. These findings may guide women and their surgeons when making decisions about surgical treatment of stress urinary incontinence.

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Conflict of interest statement

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Drs Gurol-Urganci and van der Meulen reported receiving grants from the National Institute for Health Research (NIHR). Dr Duckett reported being chair of the British Society of Urogynaecology. Dr Tincello reported receiving a research grant from the NIHR’s Health Services and Delivery Research fund and providing consultancy services to Cambridge Medical Robotics, Femeda, and Astellas. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Study Cohort Selection Process of Women Aged 18 Years and Older Who Had a First-Ever Mesh Sling Insertion in the English National Health Service
ICD-10 indicates International Statistical Classification of Diseases and Related Health Problems, Tenth Revision. aA total of 1023 episodes failed on multiple criteria. bA total of 1820 patients in the retropubic group and 755 in the transobturator group had at least 1 removal operation.
Figure 2.
Figure 2.. Mesh Sling Removal, Reoperation for Stress Urinary Incontinence, and Any Reoperation According to Time After Initial Mesh Insertion in 95 057 Women
Any reoperation included mesh removal and/or reoperation for stress urinary incontinence. Death from any cause was included as a competing risk. The median time of follow-up was 5.5 years (interquartile range, 3.2-7.5 years) in women who were alive at the end of follow-up. The cumulative incidence of “Reoperation for stress urinary incontinence” and “Removal” do not sum to the cumulative incidence of “Any reoperation” because some patients had the first 2 concurrently or at different times.
Figure 3.
Figure 3.. Mesh Sling Removal and Reoperation for Stress Urinary Incontinence (SUI) According to Time After Initial Insertion in 95 057 Women by Route of Insertion
Death from any cause was included as a competing risk. The median time of follow-up was 5.4 years (interquartile range, 3.1-7.6 years) in women who had a retropubic insertion and 5.6 years (interquartile range, 3.4-7.5 years) in those who had a transobturator insertion.
Figure 4.
Figure 4.. Total Sling Removal With No Subsequent Midurethral Sling Insertion According to Time After Initial Insertion in 60 194 Women Who Had Mesh Sling Inserted via Retropubic Route
Death from any cause was included as a competing risk.
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