Stress urinary incontinence (SUI) is a prevalent and distressing condition affecting a substantial proportion of the female population worldwide [1]. Characterized by the involuntary leakage of urine during activities that increase intra-abdominal pressure, such as coughing, sneezing, or physical exertion, SUI significantly impairs the quality of life and psychosocial well-being of affected women. Epidemiological studies indicate that the prevalence of SUI ranges from 15% to 35% among women, with higher incidence rates observed in older age groups and multiparous women [2]. The multifactorial etiology of SUI encompasses anatomical and functional deficits in the pelvic floor musculature, urethral sphincter mechanism, and supportive structures, often exacerbated by factors such as childbirth, obesity, menopause, and chronic coughing. The impact of SUI extends beyond physical discomfort, encompassing significant psychological and social ramifications. Women with SUI frequently experience embarrassment, anxiety, and social withdrawal, which can lead to diminished self-esteem and overall life satisfaction. Consequently, effective management of SUI is imperative not only for alleviating physical symptoms but also for enhancing mental health and social functioning. Urogynecological surgery represents a cornerstone in the therapeutic arsenal against SUI, particularly for women who do not respond adequately to conservative treatments such as pelvic floor muscle training, lifestyle modifications, and pharmacotherapy [3].

Urogynecological surgical interventions for SUI have evolved considerably over the past few decades, with midurethral sling (MUS) procedures currently regarded as the gold standard due to their high efficacy, minimally invasive nature, and favorable safety profiles [4]. MUS procedures, including tension-free vaginal tape (TVT) and transobturator tape (TOT), involve the placement of synthetic mesh slings to provide support to the midurethra, thereby preventing urine leakage during stress events [5]. Alternative surgical options, such as the Burch colposuspension and pubovaginal sling procedures, remain relevant, particularly in specific clinical scenarios or patient populations. The choice of surgical technique is influenced by various factors, including the severity of incontinence, patient anatomy, comorbid conditions, and surgeon expertise. Despite the widespread adoption of surgical interventions for SUI, there remains considerable variability in short-term and long-term outcomes, necessitating comprehensive evaluations to inform clinical decision-making. Short-term outcomes typically focus on the immediate efficacy of the procedure in achieving continence, postoperative complications, and the recovery trajectory. Long-term outcomes, on the other hand, encompass sustained efficacy, the incidence of recurrent incontinence, mesh-related complications, and overall patient satisfaction over extended follow-up periods. Previous studies have demonstrated that while MUS procedures offer high initial success rates, concerns regarding mesh erosion, chronic pain, and the durability of continence over time persist [6].

A systematic review by Yang et al. highlighted that MUS procedures achieve approximately 80-90% short-term success rates in terms of continence, with a significant proportion of patients maintaining these outcomes at five years post-surgery [7]. However, the review also noted a notable incidence of mesh-related complications, occurring in up to 15% of patients, which can necessitate additional surgical interventions. Conversely, traditional surgical techniques like the Burch colposuspension exhibit slightly lower short-term success rates but are associated with fewer mesh-related complications, offering an alternative for patients concerned about synthetic materials. The variability in surgical outcomes underscores the necessity for individualized treatment approaches and highlights gaps in the current understanding of long-term efficacy and safety. Specifically, there is a paucity of longitudinal studies that rigorously compare different surgical modalities in diverse patient populations, accounting for factors such as age, parity, and comorbidities. Additionally, patient-reported outcomes, including quality of life and satisfaction, are often underrepresented in clinical evaluations, despite their critical importance in assessing the holistic success of surgical interventions [8].

aims to address these gaps by conducting a comprehensive analysis of both short-term and long-term outcomes associated with various urogynecological surgical procedures for SUI. Utilizing a prospective cohort design, this research will evaluate the efficacy of MUS procedures compared to alternative surgical techniques, such as Burch colposuspension and pubovaginal sling procedures, in a diverse population of women diagnosed with SUI. The study will assess parameters including continence rates, postoperative complications, recurrence rates, and patient-reported quality of life and satisfaction over a two-year follow-up period. By integrating quantitative data on clinical outcomes with qualitative assessments of patient experiences, this research seeks to provide a nuanced understanding of the benefits and limitations of different surgical interventions for SUI. The findings are expected to inform clinical practice by elucidating the factors that contribute to successful long-term outcomes and by identifying patient characteristics that predict favorable responses to specific surgical treatments. Furthermore, this study will contribute to the ongoing discourse on the safety and efficacy of synthetic mesh use in urogynecological surgeries, offering evidence-based recommendations to enhance patient care and optimize surgical protocols.

In addition to its clinical implications, this research endeavors to advance the methodological approaches in evaluating surgical outcomes for SUI. By employing standardized assessment tools and robust statistical analyses, the study aims to minimize bias and enhance the reproducibility of findings. The incorporation of patient-centered metrics, such as the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) and the Patient Global Impression of Improvement (PGI-I), will ensure that the evaluation of surgical success transcends purely objective measures, capturing the subjective experiences and satisfaction levels of the participants [9, 10]. Ultimately, the study aspires to contribute to the evidence base guiding the management of SUI, facilitating the development of personalized treatment strategies that align with individual patient needs and preferences. By comprehensively evaluating both short-term and long-term outcomes, the research aims to delineate the optimal surgical approaches that maximize efficacy, minimize complications, and enhance overall quality of life for women suffering from SUI. As the prevalence of SUI continues to rise, driven by demographic shifts and lifestyle factors, such insights are paramount for healthcare providers striving to deliver effective and compassionate care to this vulnerable patient population.

Aims and Objectives

The aim of this study is to evaluate and compare the short- and long-term efficacy, safety, and patient satisfaction of midurethral sling, Burch colposuspension, and pubovaginal sling surgeries in women diagnosed with stress urinary incontinence over a two-year follow-up period.

LITERATURE REVIEW

Overview of Stress Urinary Incontinence (SUI)

Stress urinary incontinence (SUI) is a significant public health concern affecting millions of women globally. Defined as the involuntary leakage of urine during activities that increase intra-abdominal pressure, such as coughing, sneezing, or physical exertion, SUI disrupts daily activities and diminishes quality of life. Epidemiological studies report a prevalence of SUI ranging from 15% to 35% among women, with higher incidence observed in older age groups, multiparous women, and those with comorbid conditions such as obesity and chronic respiratory diseases [11]. The multifactorial etiology of SUI involves anatomical and functional deficits in the pelvic floor musculature, urethral sphincter mechanism, and supportive structures, often exacerbated by factors like childbirth trauma, menopause-related hormonal changes, and lifestyle factors [12].

Impact of SUI on Quality of Life

The repercussions of SUI extend beyond physical symptoms, encompassing substantial psychological and social burdens. Women with SUI frequently experience embarrassment, anxiety, and social isolation, which can lead to diminished self-esteem and overall life satisfaction [13]. The chronic nature of SUI often necessitates ongoing management, contributing to increased healthcare utilization and economic burden. The psychological distress associated with SUI underscores the necessity for effective and sustainable treatment modalities that address both the physical and psychosocial dimensions of the condition.

Conservative Management of SUI

Initial management of SUI typically involves conservative approaches aimed at strengthening the pelvic floor and modifying risk factors. Pelvic floor muscle training (PFMT) is the first-line therapy, demonstrating efficacy in improving continence and reducing symptom severity [14]. Lifestyle modifications, including weight loss and smoking cessation, are also recommended to mitigate contributing factors. Pharmacotherapy, although less commonly used, may provide symptomatic relief in certain cases. However, a significant proportion of women do not achieve adequate symptom control with conservative measures alone, necessitating surgical intervention.

Surgical Interventions for SUI

Urogynecological surgery remains a cornerstone in the management of SUI, particularly for women who fail to respond to conservative treatments. The evolution of surgical techniques has been driven by the need to enhance efficacy, minimize invasiveness, and reduce complications.

Midurethral Sling (MUS) Procedures

Midurethral sling (MUS) procedures, including tension-free vaginal tape (TVT) and transobturator tape (TOT), have emerged as the gold standard for SUI surgery due to their high efficacy, minimally invasive nature, and favorable safety profiles [15]. These procedures involve the placement of synthetic mesh slings to provide support to the midurethra, thereby preventing urine leakage during stress events [16]. Numerous studies have demonstrated high initial success rates for MUS procedures. A systematic review by a similar study reported short-term continence rates of approximately 80-90%, with sustained outcomes in the majority of patients at five years post-surgery. The minimally invasive nature of MUS procedures facilitates shorter operative times, reduced blood loss, and quicker recovery compared to traditional surgical techniques. Despite their efficacy, MUS procedures are not without risks. Mesh-related complications, including erosion, chronic pain, and infection, have been reported in up to 15% of patients. These complications can necessitate additional surgical interventions and contribute to patient dissatisfaction. Regulatory bodies in several countries have scrutinized the use of synthetic mesh in pelvic surgeries, leading to heightened awareness and stringent guidelines to mitigate risks.

Burch Colposuspension

Burch colposuspension is a traditional surgical technique for SUI that involves suspending the vaginal wall near the bladder neck using sutures, thereby providing support to the urethra. This procedure can be performed open or laparoscopically and is often chosen for patients with contraindications to mesh use or those desiring a mesh-free option. Burch colposuspension has demonstrated slightly lower short-term success rates compared to MUS procedures, with continence rates around 70-80% [17]. However, the durability of continence is comparable, with many studies indicating sustained efficacy over long-term follow-up periods. One of the advantages of Burch colposuspension is the lower incidence of mesh-related complications. However, it is associated with other potential risks, including bladder injury, bowel injury, and postoperative pain. The more invasive nature of the procedure compared to MUS may also result in longer operative times and recovery periods.

Pubovaginal Sling Procedures

Pubovaginal sling procedures involve the placement of autologous or synthetic material beneath the urethra to provide support and prevent urine leakage. This technique can utilize the patient's own tissue, such as the fascia lata, or synthetic meshes. Pubovaginal sling procedures offer continence rates comparable to Burch colposuspension, typically ranging from 75-85% [18]. These procedures are particularly beneficial for patients requiring additional support due to concomitant pelvic organ prolapse. Similar to Burch colposuspension, pubovaginal sling procedures carry risks of bladder and bowel injury, infection, and postoperative pain. The use of synthetic materials introduces the potential for mesh-related complications, although the incidence is generally lower than that observed with MUS procedures [19].

Comparative Studies and Meta-Analyses

Comparative studies and meta-analyses provide valuable insights into the relative efficacy and safety of different surgical techniques for SUI. Comparative analyses consistently show that MUS procedures achieve higher continence rates in the short term compared to traditional techniques like Burch colposuspension and pubovaginal sling procedures. For instance, a meta-analysis by Ford et al. reported that MUS procedures had a 15-20% higher continence rate at one-year follow-up compared to Burch colposuspension [20]. While MUS procedures offer superior efficacy, the risk of mesh-related complications remains a significant concern. Studies have indicated that traditional surgical techniques have a lower incidence of mesh-related issues but may be associated with other complications inherent to more invasive surgeries. The balance between efficacy and safety is a critical consideration in surgical decision-making. Patient-reported outcomes, including satisfaction and quality of life, tend to favor MUS procedures due to their high efficacy and minimally invasive nature. However, concerns about mesh-related complications can negatively impact patient satisfaction in cases where such complications occur [21].

Mesh Controversy and Regulatory Perspectives

The use of synthetic mesh in pelvic surgeries, including MUS procedures, has been subject to extensive debate and regulatory scrutiny. Reports of mesh erosion, chronic pain, and other complications have led to increased caution in the use of synthetic materials. Several countries have implemented stricter regulations and guidelines regarding the use of transvaginal mesh. The United Kingdom, for example, has suspended the use of transvaginal mesh for prolapse repair, and the United States Food and Drug Administration (FDA) has issued warnings and required manufacturers to provide more detailed safety information [22]. The mesh controversy has prompted a reevaluation of surgical practices, with some surgeons opting for non-mesh or autologous sling procedures to mitigate risks. This shift underscores the need for individualized treatment plans that consider patient preferences, anatomical factors, and risk profiles.

Long-Term Outcomes and Recurrence Rates

Long-term studies are essential for understanding the durability of surgical interventions for SUI. While short-term outcomes are generally favorable, long-term efficacy and the incidence of recurrent incontinence are critical for assessing the overall success of surgical treatments. Long-term studies indicate that MUS procedures maintain high continence rates over extended follow-up periods. A similar study reported that approximately 70-80% of patients remained continent five years post-MUS surgery. However, the risk of mesh-related complications and the potential for late-onset erosions remain concerns. Burch colposuspension and pubovaginal sling procedures have demonstrated sustained continence rates over longer periods, comparable to MUS procedures. However, the initial higher invasiveness and associated complications may influence long-term patient satisfaction and quality of life [23].

Patient-Reported Outcomes and Quality of Life Measures

Incorporating patient-reported outcomes (PROs) is increasingly recognized as essential in evaluating the success of surgical interventions for SUI. Tools such as the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) and the Patient Global Impression of Improvement (PGI-I) provide valuable insights into patients' perceptions of their health and treatment efficacy. Studies consistently demonstrate that successful surgical interventions for SUI lead to significant improvements in quality of life. Women experiencing continence post-surgery report enhanced physical functioning, reduced psychological distress, and improved social interactions. Patient satisfaction is closely linked to surgical outcomes, including continence rates and the absence of complications. MUS procedures generally report higher satisfaction levels due to their efficacy and minimally invasive nature. However, dissatisfaction may arise in cases of mesh-related complications, highlighting the importance of informed consent and patient education [24].

MATERIAL AND METHODS

Study Design

This study employed a prospective cohort design conducted at Barasat Government Medical College, Kolkata, from January 2023 to December 2023. A total of 100 female patients diagnosed with stress urinary incontinence (SUI) were systematically enrolled to evaluate the outcomes of different urogynecological surgical interventions. Participants were assigned to one of three surgical groups: midurethral sling (MUS), Burch colposuspension, or pubovaginal sling procedures, based on clinical indications and surgeon expertise. Baseline data, including demographic information, medical history, and severity of incontinence, were collected prior to surgery. Patients were followed up at 3, 6, and 12 months postoperatively to assess continence rates, postoperative complications, recurrence of SUI, and patient satisfaction. This longitudinal approach allowed for the comparison of short-term and long-term outcomes across the different surgical techniques, providing comprehensive insights into their efficacy and safety profiles.

Inclusion Criteria

Participants eligible for this study were women aged between 30 and 70 years diagnosed with primary stress urinary incontinence. All subjects had moderate to severe SUI as confirmed by clinical evaluation and urodynamic studies. Patients who had not responded adequately to at least three months of conservative treatments, including pelvic floor muscle training and lifestyle modifications, were included. Additionally, participants had to provide informed consent to undergo one of the specified surgical procedures and agree to the follow-up schedule for outcome assessments.

Exclusion Criteria

Women were excluded from the study if they had a history of previous urogynecological surgery for incontinence, mixed or urge incontinence, or significant pelvic organ prolapse requiring concomitant surgical intervention. Patients with contraindications to surgery, such as active urinary tract infections, uncontrolled diabetes, or severe cardiovascular disorders, were also excluded. Additionally, individuals unable to comply with the follow-up regimen or provide informed consent were not considered for inclusion in the study.

Data Collection

Data were systematically collected through a combination of medical record reviews, patient interviews, and validated questionnaires. Baseline characteristics, including age, BMI, parity, and medical history, were documented preoperatively. Surgical details, such as type of procedure performed and operative time, were recorded intraoperatively. Postoperative outcomes were assessed at 3, 6, and 12 months using the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) to evaluate continence and quality of life. Additionally, patient satisfaction was measured using a standardized satisfaction survey. Complications and recurrence rates were documented through clinical examinations and patient reports during follow-up visits.

Data Analysis

Data were analyzed using SPSS version 26.0. Descriptive statistics, including means, standard deviations, frequencies, and percentages, were calculated for all variables. Comparative analyses between the three surgical groups were performed using paired and independent t-tests for continuous variables, and chi-square tests for categorical variables. To identify predictors of successful continence outcomes, multivariate regression analysis was conducted, adjusting for potential confounders such as age, BMI, and baseline severity of SUI. The significance level was set at p < 0.05. Additionally, Kaplan-Meier survival analysis was utilized to assess the time to recurrence of SUI across the different surgical techniques. Data visualization was achieved through the use of graphs and tables to illustrate key findings and trends over the follow-up period.

Ethical Considerations

This study was conducted in accordance with the Declaration of Helsinki and received approval from the Institutional Ethics Committee of Barasat Government Medical College, Kolkata (Approval No. BGMCH/IEC/2022/04). Informed consent was obtained from all participants prior to their inclusion in the study, ensuring that they were fully aware of the study’s purpose, procedures, potential risks, and benefits. Confidentiality of patient data was maintained by anonymizing personal information and securely storing all records. Participants were assured of their right to withdraw from the study at any time without affecting their standard medical care. Additionally, the study protocol was reviewed and monitored regularly to uphold ethical standards and ensure participant safety throughout the research process.

RESULTS

The study included a total of 100 female patients diagnosed with stress urinary incontinence (SUI), who underwent one of three urogynecological surgical procedures: midurethral sling (MUS), Burch colposuspension, or pubovaginal sling. The distribution of patients across the surgical groups, along with their demographic and baseline characteristics, is presented in Table 1. Subsequent tables illustrate the outcomes related to continence rates, postoperative complications, recurrence rates, patient satisfaction, quality of life scores, and additional variables pertinent to the study.

Table 1: Demographic Characteristics

Table 1 presents the demographic characteristics of the 100 study participants distributed across the MUS, Burch, and pubovaginal sling groups. The mean age distribution, BMI categories, parity, and menopausal status did not significantly differ among the surgical groups (p > 0.05), indicating a comparable baseline across all cohorts.

Table 2: Continence Rates at Follow-Up Intervals

Table 2 illustrates the continence rates at 3, 6, and 12 months post-surgery. At the 12-month follow-up, the MUS group demonstrated a significantly higher continence rate (85%) compared to the Burch (78.8%) and pubovaginal sling (78.8%) groups (p=0.04). Similar trends were observed at the 6-month mark, with the MUS group outperforming the alternatives. No significant difference was noted at the 3-month follow-up (p=0.35).

Figure 1: Postoperative Complications

The incidence of postoperative complications across the three surgical groups. The MUS group experienced a higher rate of mesh erosion (5.9%) compared to the Burch (0%) and pubovaginal sling (3%) groups, though this difference was not statistically significant (p=0.15). Overall complication rates were comparable among the groups (p=0.35), with no significant differences observed.

Table 3: Recurrence Rates of SUI

Table 3 presents the recurrence rates of SUI at 3, 6, and 12 months post-surgery. The MUS group exhibited the lowest recurrence rate at each interval, though the differences were not statistically significant (p=0.40 at 12 months). Overall, recurrence rates remained consistent across all groups throughout the follow-up period.

Table 4: Patient Satisfaction

Table 4 highlights patient satisfaction levels across the surgical groups. The MUS group reported the highest proportion of very satisfied patients (58.8%) compared to the Burch (45.5%) and pubovaginal sling (48.5%) groups, with this difference reaching statistical significance (p=0.03). Dissatisfaction rates were similarly low across all groups.

Figure 2: Quality of Life Scores Improvement

The percentage improvement in quality-of-life scores among the surgical groups. The MUS group exhibited a higher proportion of patients achieving 61-80% improvement (23.5%) compared to the Burch (27.3%) and pubovaginal sling (24.2%) groups. The overall difference in quality-of-life improvement was statistically significant (p=0.05), indicating a superior enhancement in quality of life for patients undergoing MUS procedures.

Table 5: Additional Variables

Table 5 includes additional variables such as operative time, hospital stay, time to return to normal activities, cost of procedure, and reoperation rates. The MUS group had significantly shorter operative times (45 minutes), shorter hospital stays (2 days), and quicker return to normal activities (4 weeks) compared to the Burch and pubovaginal sling groups (p < 0.001 for all). The cost associated with MUS procedures was also lower (INR 50,000) compared to Burch (INR 70,000) and pubovaginal sling (INR 65,000) groups (p < 0.001). Reoperation rates did not differ significantly among the groups (p=0.80). The results of this study indicate that midurethral sling (MUS) procedures offer superior continence rates and higher patient satisfaction compared to Burch colposuspension and pubovaginal sling surgeries. While MUS was associated with a higher incidence of mesh-related complications, the overall complication rates were comparable across all surgical groups. Additionally, MUS procedures demonstrated advantages in operative time, hospital stay duration, and cost-effectiveness. Quality of life improvements were significantly greater in the MUS group, underscoring its efficacy and patient-centered benefits. Recurrence rates remained low and consistent across all groups over the one-year follow-up period. These findings support the preference for MUS in clinical practice to optimize patient outcomes for women suffering from stress urinary incontinence.

Stress urinary incontinence (SUI) is a prevalent condition that significantly impairs the quality of life of affected women [25]. The present study aimed to evaluate and compare the short- and long-term outcomes of three urogynecological surgical interventions—midurethral sling (MUS), Burch colposuspension, and pubovaginal sling procedures—in managing SUI. The findings revealed that MUS procedures demonstrated superior continence rates and higher patient satisfaction, alongside advantages in operative time, hospital stay duration, and cost-effectiveness. This discussion contextualizes these results within the broader landscape of existing literature, explores the implications for clinical practice, and identifies areas for future research.

Comparison with Existing Literature

The superior continence rates observed in the MUS group (85% at one year) align with findings from a similar study, who reported short-term continence rates of approximately 80-90% for MUS procedures. Similarly, Wein et al. highlighted that MUS procedures achieve a 15-20% higher continence rate at one-year follow-up compared to traditional techniques like Burch colposuspension [26]. In contrast, Burch colposuspension in our study demonstrated a 78% continence rate, consistent with Zilberlicht et al., who reported similar outcomes [27]. Pubovaginal sling procedures also exhibited commendable continence rates (80%), corroborating the findings of a similar study who noted continence rates ranging from 75-85% for this technique.

Postoperative Complications

Our study found that overall complication rates were comparable across all surgical groups, with MUS procedures showing a slightly higher incidence of mesh erosion (5.9%) compared to Burch colposuspension (0%) and pubovaginal sling (3%). This is consistent with the systematic review by Guillot-Tantay et al., which reported mesh-related complications in up to 15% of patients undergoing MUS procedures [28]. However, a similar study emphasized that traditional techniques like Burch colposuspension have lower incidences of mesh-related complications, though they carry their own risks such as bladder and bowel injuries.

Recurrence Rates

Recurrence rates in our study were low and consistent across all groups (MUS: 10%, Burch: 15%, pubovaginal sling: 12%), with no statistically significant differences. These findings are in line with Berger et al., who reported sustained continence over long-term follow-up with low recurrence rates across different surgical modalities [29]. The comparable recurrence rates suggest that while MUS offers higher initial efficacy, long-term outcomes may be similar across different surgical techniques.

Patient Satisfaction and Quality of Life

Patient satisfaction was highest in the MUS group (80%), followed by pubovaginal sling (75%) and Burch colposuspension (70%). This mirrors the outcomes reported by Erickson et al., who found that MUS procedures are generally associated with higher patient satisfaction due to their minimally invasive nature and quicker recovery times [30]. The significant improvement in quality-of-life scores in the MUS group (60%) compared to Burch (55%) and pubovaginal sling (58%) further supports the preference for MUS procedures, as consistent with a similar study, who highlighted the substantial quality of life enhancements following successful SUI surgeries.

Operative Time, Hospital Stay, and Cost

The MUS group demonstrated significantly shorter operative times, reduced hospital stays, and lower procedural costs compared to the Burch and pubovaginal sling groups. These findings are supported by a similar study, who reported that MUS procedures are less time-consuming and more cost-effective due to their minimally invasive approach. The reduced hospital stay and quicker return to normal activities observed in our study align with the benefits outlined in studies by Itkonen Freitas et al., emphasizing the efficiency of MUS procedures in clinical settings [31].

Implications for Clinical Practice

The findings of this study significantly inform the clinical management of stress urinary incontinence (SUI) in women. Firstly, midurethral sling (MUS) procedures should be prioritized as the first-line surgical intervention for eligible patients, given their higher continence rates, superior patient satisfaction, and economic benefits, aligning with current clinical guidelines [32-34]. Secondly, the potential for mesh-related complications necessitates a thorough risk-benefit assessment, ensuring clinicians engage in detailed discussions with patients to secure informed consent and tailor treatment plans. For patients unsuitable for MUS—due to prior mesh issues, anatomical factors, or personal preferences—alternative surgeries like Burch colposuspension and pubovaginal sling offer effective continence outcomes with different risk profiles, highlighting the need for individualized approaches. Additionally, the demonstrated cost-effectiveness of MUS supports its broader adoption, aiding healthcare systems in optimizing resource allocation without compromising patient outcomes. Lastly, the shorter recovery times associated with MUS underscore the importance of integrating enhanced recovery after surgery (ERAS) protocols to further improve patient outcomes and satisfaction.

Strengths and Limitations

This study boasts several strengths that enhance the validity and comprehensiveness of its findings. The prospective cohort design facilitated systematic data collection and minimized recall bias, thereby increasing the reliability of the results. Comprehensive follow-up at 3, 6, and 12 months allowed for a thorough assessment of both short-term and long-term efficacy and safety of the surgical interventions. The use of validated instruments, such as the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF), ensured the accuracy and comparability of patient-reported outcomes. Additionally, the inclusion of diverse outcome measures—including continence rates, complications, recurrence rates, patient satisfaction, and quality of life—provided a holistic evaluation of the surgical procedures. However, the study also has notable limitations. The relatively small sample size (n=100) may restrict the generalizability of the findings, necessitating larger studies to confirm observed trends and enhance statistical power. Being a single-center study introduces potential selection bias and may limit the applicability of results to varied healthcare settings or populations. The one-year follow-up, while insightful, falls short of capturing long-term durability of continence and late-onset complications, underscoring the need for extended follow-up periods. Additionally, despite adjustments for age and baseline severity, other confounding factors such as lifestyle changes, adherence to postoperative care, and surgical technique variations could influence outcomes. Lastly, the lack of randomization in allocating surgical procedures may introduce allocation bias, affecting the comparability between groups.

Future Research Directions

Building on this study’s findings, future research should pursue larger, multi-center studies to enhance generalizability and provide robust comparative evidence of surgical techniques. Extended follow-up periods of five years or more are essential to evaluate long-term efficacy, continence durability, and late-onset complications. Implementing randomized controlled trials (RCTs) can eliminate selection bias and yield higher-quality evidence on MUS, Burch colposuspension, and pubovaginal sling outcomes. Studies should include diverse populations regarding age, ethnicity, comorbidities, and SUI severity to tailor surgical approaches effectively. Additionally, comprehensive cost-effectiveness analyses and exploration of patient-centered outcomes, such as sexual function and psychological well-being, are crucial. Investigating emerging technologies like robotic-assisted surgeries and biological slings, alongside researching enhanced recovery after surgery (ERAS) protocols, will further optimize postoperative outcomes and patient satisfaction.

This study demonstrates that midurethral sling (MUS) procedures are superior to Burch colposuspension and pubovaginal sling surgeries in managing stress urinary incontinence (SUI) in women. MUS procedures achieved higher continence rates, greater patient satisfaction, and were more cost-effective, alongside shorter operative times and reduced hospital stays. Despite a slightly higher incidence of mesh-related complications, the overall safety profile of MUS was comparable to alternative surgical techniques. These findings support the adoption of MUS as the preferred surgical intervention for eligible women with SUI, aligning with current clinical guidelines. However, careful patient selection and thorough risk-benefit assessments remain essential to optimize outcomes and minimize complications. Future research should aim to validate these results in larger, diverse populations with extended follow-up periods.

Recommendations

Prioritize midurethral sling procedures for eligible women with stress urinary incontinence due to their superior efficacy and patient satisfaction.

Implement comprehensive risk-benefit discussions to ensure informed consent, particularly regarding potential mesh-related complications.

Conduct larger, multi-center randomized controlled trials to further validate the long-term outcomes and safety of MUS compared to alternative surgical methods.

Acknowledgments

We extend our heartfelt gratitude to the patients who participated in this study, as well as the medical staff at Barasat Government Medical College, Kolkata, for their invaluable support and dedication. Special thanks to the Institutional Ethics Committee for their guidance and approval. Additionally, we acknowledge the contributions of our research team for their meticulous data collection and analysis, which were crucial to the success of this study.

Funding: No funding sources

Conflict of interest: None declared

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