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Objective: To compare the reoperation rates for recurrent stress urinary incontinence (SUI) after retropubic and transobturator sling procedures., Methods: We conducted a retrospective cohort study of all women who underwent midurethral sling procedures at a single institution for primary SUI between 2002 and 2012. To minimize bias, women in the two groups were matched on age, body mass index, isolated compared with combined procedure, and preoperative diagnosis. The primary outcome was defined as reoperation for recurrent SUI. Secondary outcomes included intraoperative complications and mesh-related complications requiring reoperation after the index sling procedure., Results: We identified 1,881 women who underwent a sling procedure for primary SUI-1,551 retropubic and 330 transobturator. There was no difference between groups in any of the evaluated baseline variables in the covariate-matched cohort of 570 with retropubic slings and 317 with transobturator slings; results herein are based on the covariate-matched cohort. Women undergoing a transobturator sling procedure had an increased risk of reoperation for recurrent SUI compared with women undergoing a retropubic sling procedure (hazard ratio 2.42, 95% CI 1.37-4.29). The cumulative incidence of reoperation for recurrent SUI by 8 years was 5.2% (95% CI 3.0-7.4%) in the retropubic group and 11.2% (95% CI 6.4-15.8%) in the transobturator group. Women in the retropubic group had a significantly higher rate of intraoperative complications compared with women in the transobturator group (13.7% [78/570] vs 4.7% [15/317]; difference=9.0%, 95% CI for difference 5.3-12.6%); the majority of this difference was due to bladder perforation (7.0% [40/570] vs 0.6% [2/317]; difference=6.4%, 95% CI for difference 4.1-8.7%). The cumulative incidence of sling revision for urinary retention plateaued at 3.2% and 0.4% by 5 years in the two groups., Conclusion: Women with primary SUI treated with a retropubic sling procedure have significantly lower cumulative incidence of reoperation for recurrent SUI compared with women who were treated with a transobturator sling procedure. Retropubic slings were associated with a higher risk of sling revision for urinary retention.

Objectives: To compare the long-term risk of repeat stress urinary incontinence (SUI) surgery after different types of initial SUI surgery and to identify predictors of time to repeat SUI surgery in a large, population-based cohort., Methods: We used de-identified, adjudicated health care claims data from approximately 100 employer-based plans across the United States from 2000 to 2009. We identified the index SUI surgery in women aged 18 to 64 years. Kaplan-Meier survival curves were used to estimate cumulative incidence of repeat surgery through 9 years. Cox proportional hazards models were used to estimate the adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) for factors associated with recurrent SUI surgery., Results: Over 10 years, we identified 155,458 eligible women who underwent one or more SUI surgeries, with a total of 294,855 person-years of follow-up. Of these index surgeries, 127,848 (82.2%) were slings. The 9-year cumulative incidence of repeat surgery after any SUI surgery was 14.5% (95% CI 13.4-15.5). As expected, bulking agents had the highest cumulative incidence of repeat surgery (61.2%, 95% CI 56.3-66.0) followed by needle suspension (22.2%, 95% CI 16.5-27.9); the lowest 9-year incidences were for Burch (10.8%, 95% CI 9.3-12.3) and sling (13.0%, 95% CI 11.7-14.3). In a Cox proportional hazards model that adjusted for age, year of index surgery, and region of the United States, the rate of repeat surgery was 28% higher for slings compared with Burch (adjusted HR 1.28, 95% CI 1.19-1.37)., Conclusion: In this population-based analysis of women aged 18 to 64 years, Burch procedures had the lowest 9-year cumulative incidence of repeat SUI surgery.

Objectives: To estimate the rates of stress urinary incontinence (SUI) surgery from 2000 to 2009 by type of procedure, year, age, and region of the country., Methods: We used data between 2000 and 2009 from a database containing health care claims data from employer-based plans in the United States. We analyzed data for all women age 18-64 years, identifying all SUI procedures in this population. Rates per 100,000 person-years and 95% confidence intervals (CI) were calculated each year by procedure type, age, and region., Results: The study population included 32.9 million women age 18-64 years observed for 74,007,937 person-years between 2000 and 2009. During that time, there were 182,110 SUI procedures for a rate of 246.1 per 100,000 person-years (95% CI 239.7-252.6). The most common SUI surgery was sling (198.3 per 100,000 person-years, 95% CI 192.8-203.9) followed by Burch (25.9 per 100,000 person-years, 95% CI 24.8-27.2). There was a dramatic increase in slings, with a corresponding decrease in Burch procedures from 2000 to 2009. Other SUI surgeries had lower rates. Although this trend was evident across all regions, the Northeast had the lowest rate of SUI surgery, whereas rates in the West, Midwest, and South were 1.44-times, 1.76-times, and 2.09-times higher, respectively., Conclusion: In a dramatic shift over the past decade, slings have become the dominant procedure for SUI among women age 18-64 years. Although this trend was seen across the United States, considerable variability exists in the SUI surgery rates by region., Level of Evidence: III.

Objective: To compare efficacy and safety of trocar-guided tension-free vaginal mesh insertion with conventional vaginal prolapse repair in patients with recurrent pelvic organ prolapse., Methods: Patients with recurrent pelvic organ prolapse stage II or higher were randomly assigned to either conventional vaginal prolapse surgery or polypropylene mesh insertion. Primary outcome was anatomic failure (pelvic organ prolapse stage II or higher) in the treated vaginal compartments. Secondary outcomes were subjective improvement, effects on bother, quality of life, and adverse events. Questionnaires such as the Incontinence Impact Questionnaire and Urogenital Distress Inventory were administered at baseline, 6 months, and 12 months. Anatomic outcomes were assessed by an unblinded surgeon. Power calculation with α=0.05 and β=0.80 indicated that 194 patients were needed., Results: Ninety-seven women underwent conventional repair and 93 mesh repair. The follow-up rate after 12 months was 186 of 190 patients (98%). Twelve months postsurgery, anatomic failure in the treated compartment was observed in 38 of 84 patients (45.2%) in the conventional group and in eight of 83 patients (9.6%) in the mesh group (P<.001; odds ratio, 7.7; 95% confidence interval, 3.3-18). Patients in either group reported less bulge and overactive bladder symptoms. Subjective improvement was reported by 64 of 80 patients (80%) in the conventional group compared with 63 of 78 patients (81%) in the mesh group. Mesh exposure was detected in 14 of 83 patients (16.9%)., Conclusion: At 12 months, the number of anatomic failures observed after tension-free vaginal mesh insertion was less than after conventional vaginal prolapse repair. Symptom decrease and improvement of quality of life were equal in both groups., Clinical Trial Registration: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00372190., Level of Evidence: I.