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Original Investigation
October 23/30, 2018

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

Author Affiliations
  • 1Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom
  • 2Lindsay Stewart Centre for Audit and Clinical Informatics, Royal College of Obstetricians and Gynaecologists, London, United Kingdom
  • 3Medway Hospital, Gillingham, Kent, United Kingdom
  • 4Leicester General Hospital, Department of Obstetrics and Gynaecology, University Hospitals of Leicester, Leicester, United Kingdom
  • 5Belfast City Hospital, Department of Gynaecology, Lisburn Road, Belfast, Northern Ireland, United Kingdom
  • 6University of Leicester, Department of Health Sciences, College of Life Sciences, Leicester, United Kingdom
JAMA. 2018;320(16):1659-1669. doi:10.1001/jama.2018.14997
Key Points

Question  What are the long-term mesh removal rates following midurethral mesh sling insertion among women with stress urinary incontinence?

Findings  In this retrospective cohort study that included 95 057 women who underwent midurethral mesh sling insertion for stress urinary incontinence, the rate of sling removal was 3.3% at 9 years.

Meaning  These findings may inform decision making when choosing treatment for stress urinary incontinence.


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.