Introduction
Stress urinary incontinence (SUI), the involuntary loss of urine on effort or physical exertion (e.g., sporting activities) on sneezing or coughing is a critical public health issue.1 According to the European Menopause and Andropause Society (EMAS) clinical guide, the prevalence of urinary incontinence and of other lower urinary tract symptoms increases after menopause and affects between 38% and 55% of women aged over 60 years.2 A global review of epidemiological research on SUI that included studies published between January 1980 and October 2002 reported a median prevalence of female UI of 27.6%, most commonly caused by stress (50%).3 Age plays an important part in SUI diagnosis, as the prevalence increases with age, with one large study in the United States reporting SUI in 28% of women aged between 30 and 39 years and 55% of women aged between 80 and 90 years.4, 5 SUI impacts enormously on the patient’s lifestyle and quality of life, at considerable financial cost for both patients and the health care system.6-10
International guidance recommends conservative therapies as the first-line management of women with SUI, such as lifestyle changes and behavioral therapies, weight loss, and supervised pelvic floor muscle training.11, 12 For patients who do not experience improvement in physical symptoms and quality of life with nonsurgical management or pharmacotherapy, surgery is the next step.11, 12 The current gold standard for SUI surgery is the midurethral sling, with over 90% of surgeons worldwide using the midurethral sling for SUI between 2008 and 2018.13, 14 The midurethral retropubic sling in particular has proven highly effective for the treatment of SUI, with high subjective and objective cure rates of between 80% and 90% after more than 11 years of follow-up.15 The midurethral sling has replaced Burch culposuspension for the surgical correction of SUI,16 because of the important advantages of being minimally invasive, shorter operative and recovery times, high continence rates and low complication rates.17-19 Use of the midurethral sling in the surgical management of female SUI is supported by a joint position statement released by the American Urogynecologic Society (AUGS) and the Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction (SUFU),20 as well as a position statement by the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG),21 and the midurethral sling has become the surgical procedure of choice for female SUI in Australasia, Europe and the USA.21
Nonetheless, mesh-related adverse events are associated with the midurethral sling.22, 23 In response to surgical complications involving the use of transvaginal mesh for pelvic organ prolapse, the United States Food and Drug Administration (US FDA) issued a safety communication in 201124 and, since April 16, 2019, has banned the production and sale of transvaginal mesh for pelvic organ prolapse.25 By early 2015, over 70,000 women in the US had filed lawsuits alleging complications associated with transvaginal mesh used for both SUI and pelvic organ prolapse surgical procedures.26 Litigation suits relating to financial costs and safety concerns surrounding these procedures have increased general awareness amongst the public and medical community of all synthetic mesh use in pelvic floor disorders, including SUI.26 However, it is important to note that the US FDA publications did not refer to traditional midurethral slings as the subject of their safety communication; their 2019 advice stated that full-length midurethral slings are supported by 1-year follow-up safety and efficacy data from clinical trials and that longer-term follow-up data are also available, but are from a smaller pool of evidence.11 Nevertheless, the decision to use the midurethral sling for surgical treatment has become a challenging one for clinicians, surgeons and patients. With this in mind, we sought to determine the risk factors for 5-year complications after midurethral sling surgery, to improve the clinical decision-making process.