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

Educational Objective
To understand some of the consequences of a surgical procedure for stress urinary incontinence.
1 Credit CME
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.

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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Article Information

Corresponding Author: Ipek Gurol-Urganci, PhD, Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Pl, London WC1H 9SH, United Kingdom (ipek.gurol@lshtm.ac.uk).

Accepted for Publication: September 20, 2018.

Author Contributions: Dr Gurol-Urganci had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Drs Gurol-Urganci and Geary are joint first authors and made equal contributions to this study and manuscript. Drs Tincello and van der Meulen are joint senior authors and made equal contributions to this study and manuscript.

Concept and design: Gurol-Urganci, Geary, Mamza, Duckett, Tincello, van der Meulen.

Acquisition, analysis, or interpretation of data: Gurol-Urganci, Mamza, Duckett, El-Hamamsy, Dolan, Tincello, van der Meulen.

Drafting of the manuscript: All authors.

Critical revision of the manuscript for important intellectual content: Gurol-Urganci, Geary, Duckett, El-Hamamsy, Dolan, Tincello, van der Meulen.

Statistical analysis: Gurol-Urganci, Mamza, van der Meulen.

Obtained funding: Gurol-Urganci, Duckett, Tincello, van der Meulen.

Administrative, technical, or material support: Geary, Tincello.

Supervision: Gurol-Urganci, Tincello, van der Meulen.

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.

Funding/Support: This study was supported by a grant from the NIHR Health Services and Delivery Research Programme (14/70/162). Independent scientific review of the proposal has been undertaken by the NIHR. Dr van der Meulen was partly supported by the National Health Service’s NIHR Collaboration for Leadership in Applied Health Research and Care North Thames at Bart’s Health NHS Trust. Hospital Episode Statistics data were made available by NHS Digital and reused with the permission of NHS Digital.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The authors are solely responsible for any errors or omissions. The opinions expressed in this article are those of the authors and do not necessarily reflect the position of their affiliations.

Additional Contributions: We thank Lynn Copley, MSc, and Natalie Eugene, MSc (for data extraction), and David Cromwell, PhD (for methodological advice on competing risk models), of the Clinical Effectiveness Unit of the Royal College of Surgeons of England and London School of Hygiene and Tropical Medicine. They did not receive any compensation for this work.

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