Despite being safe and less invasive than traditional surgery for stress urinary incontinence (SUI), proportion of mid-urethral sling surgeries performed in older women has decreased [1]. SUI prevalence increases with age and incurs a high cost for the individual and society [2]. However, evidence of the efficacy of mid-urethral sling surgery in older women and women with a significant disease burden is limited. This study in women, grouped according to the American Society of Anesthesiologists Physical Status (ASA) class, examined the influence of chronological age and disease burden on satisfaction, improvement, cure, and adverse events at a 1-year follow-up following mid-urethral sling surgery.

This cohort study was based on the Swedish National Quality Register of Gynecological surgery (GynOp) [3]. 5200 women aged 55-94 years had surgery (2010-2017) and were divided into three age cohorts: 55-64, 65-74, and 75-94 years of age. The preoperative questionnaire included height, weight, parity, prior abdominal and gynecological surgery, comorbidity, and physical performance. An anesthesiologist performed an ASA classification at the time of the intervention. Women in ASA class 1-2 (healthy or mild systemic disease) were categorized as healthy, and those with ASA class 3-4 (severe systemic disease with/ without a constant threat to life) were classified as having a significant disease burden. One year postoperatively, women were asked to complete a questionnaire about cure (defined here as SUI never or 1-4 times per month), change in urinary frequency, satisfaction, impact, and adverse events after surgery. Given the size of the study cohorts, an alpha level of 0.05, and a power value of 80%, the minimum significant difference in prevalence of outcomes was 5% in pairwise comparisons between groups using Fisher’s exact test for the analysis.

In Sweden 2007-2017, the proportion of mid-urethral sling surgeries performed in women ≥75 years more than halved (Trend P<0.0001). The response rate to the 1-year postoperative questionnaire was similar among age groups (>86%), resulting in a study population of 4581 women. The overall estimated probability of cure, improvement of SUI, and satisfaction with the procedure was similar and decreased by OR10yr 0.48 for cure to OR10yr 0.54 for satisfaction (all P<0.0001). Women with a significant disease burden had lower rates of cure and satisfaction compared with healthy women (65.5% vs. 83.7% and 65.7% vs. 80.6%, both P<0.0001). Women with prior incontinence surgery had a lower cure rate than first-time surgery (73.5% versus 84.3%, P<0.0001) (Figure 1). A low preoperative rate of leakage was associated with being unchanged or worse at follow-up (P<0.0001). Cure and satisfaction were also lower in women with diabetes (P<0.0001). Younger (55-74 years) and older women (≥75 years) were equally satisfied if they experienced a decrease of at least one step in the frequency of leakage. Older age was more likely to be associated with de novo urgency (P=0.0022) and nocturia ≥2 (P<0.0001), and women with a significant health burden experienced greater de novo urgency (P=0.0018). Body mass index ≥30 (kg/m2) was associated with a higher rate of de novo urgency and nocturia ≥2/night (P<0.0214 and P<0.015) (Figure 2). Adverse events, readmission, and 30-day mortality rates were low.

Older age, prior incontinence surgery, and a significant disease burden were associated with a less satisfactory outcome, whereas adverse events were few and similar across ages. Disease burden seemed more important than chronological age for all outcomes. Older women and those with a significant disease burden were satisfied with the procedure if they experienced a reduction of leakage episodes.

Despite mid-urethral sling surgery in older women and those with significant disease burden being associated with a lower cure rate and less satisfactory outcome, a majority of the women were satisfied provided they experienced a reduction in incontinence episodes.

Gibson W, Wagg A. Are older women more likely to receive surgical treatment for stress urinary incontinence since the introduction of the mid-urethral sling? An examination of Hospital Episode Statistics data. BJOG 2016;123:1386–1392.
Milsom I, Altman D, Cartwright R, et al. Epidemiology of urinary incontinence (UI) and other lower urinary tract symptoms (LUTS), pelvic organ prolapse (POP), and anal (AI) incontinence. In: Abrams P, Cardozo L, Wagg A, Wein A, editors. Incontinence 6th ed. Paris: Health Publications Ltd; 2016: pp 17–24.
Gynaecological Surgery. The Swedish National Quality Register of Gynaecological Surgery (GynOp). Available at: https://skr.se/en/kvalitetsregister/hittaregister/registerarkiv/gynekologiskaoperationer.44199.html. Accessed January 1, 2022.

Continence 2S2 (2022) 100280
DOI: 10.1016/j.cont.2022.100280