Comparison of Morbidity and Retreatment After Urethral Bulking or Midurethral Sling at the Time of Pelvic Organ Prolapse Repair

OBJECTIVE: To compare postprocedure retreatment rates for stress incontinence in patients who underwent either midurethral sling or urethral bulking at the time of concomitant repair of pelvic organ prolapse (POP).METHODS: This was a retrospective cohort study using data from the Premier Healthcare Database. Using Current Procedural Terminology codes, we identified patients who were undergoing POP repair and concomitant urethral bulking or midurethral sling between the years 2001 and 2018. Patients who underwent concomitant nongynecologic surgery, Burch urethropexy, or oncologic surgery, and those who did not undergo concomitant POP and anti-incontinence surgery, were excluded. Additional data collected included patient demographics, hospital characteristics, surgeon volume, and comorbidities. The primary outcome was a repeat anti-incontinence procedure at 2 years, and the secondary outcome was the composite complication rate.RESULTS: Over the study period, 540 (0.59%) patients underwent urethral bulking, and 91,005 (99.41%) patients underwent midurethral sling. The rate of a second procedure within 2 years was higher for urethral bulking, compared with midurethral sling (9.07% vs 1.11%, P<.001); in the urethral bulking group, 4.81% underwent repeat urethral bulking and 4.81% underwent midurethral sling. In the midurethral sling group, 0.77% underwent repeat midurethral sling and 0.36% underwent urethral bulking. After adjusting for confounders, midurethral sling was associated with a decreased odds of a repeat anti-incontinence procedure at 2 years (adjusted odds ratio 0.11, 95% CI 0.08-0.16). The probability of any complication at 2 years was higher with urethral bulking (23.0% vs 15.0%, P<.001).CONCLUSION: Urethral bulking at the time of POP repair is associated with a higher rate of repeat procedure and postoperative morbidity up to 2 years after surgery.