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.