Symbolic image representing freedom from urinary incontinence after surgical treatment.

Stress Urinary Incontinence: Is Surgery Still the Best Solution?

Beau Callahan in Health & Wellness November 2025 • 4 min read.

"Exploring the latest advancements and controversies in surgical management for stress urinary incontinence (SUI)."

For nearly two decades, mid-urethral sling (MUS) procedures have been a go-to surgical option for gynecologists and urologists treating stress urinary incontinence (SUI) worldwide. Since their introduction in the late 1990s, these procedures have offered a seemingly straightforward solution to a common and often debilitating condition affecting women's quality of life.

But like any medical advancement, the story of MUS is complex. While long-term effectiveness is generally good and comparable to older techniques like Burch colposuspension and pubovaginal slings, the rise of MUS has not been without controversy. Bulking agents are emerging as minimally invasive alternatives, while the transobturator tape (TOT) method maintains popularity despite some questions about long-term efficacy.

This brings us to a critical question: Where does surgical management of SUI stand today? As the field evolves, it's essential to understand the various options, weigh their benefits and risks, and consider how factors like patient history, surgeon experience, and individual needs influence treatment decisions.

Understanding Mid-Urethral Sling (MUS) Procedures: How Effective Are They?

Symbolic image representing freedom from urinary incontinence after surgical treatment.

MUS procedures distinguished themselves from earlier methods through the use of small incisions and trocar needles, positioning the tape at the mid-urethra rather than under the bladder neck. This minimally invasive approach led to reduced post-operative complications, less pain, and shorter hospital stays, contributing to the rapid adoption of MUS from 1998 onwards. Data from 2012 across 15 OECD countries indicated that MUS accounted for a staggering 82% of all SUI operations.

However, the dominance of synthetic MUS has faced increasing challenges in recent years. It's important to note that the core issue isn't necessarily the scientific data on efficiency or safety, but rather medicolegal concerns arising from class actions and significant payouts, particularly in the United States. This has been amplified by negative publicity in the media, where the use of synthetic mesh in SUI surgery is sometimes conflated with its use in vaginal prolapse repair.

Reduced Availability: Several companies have stopped producing MUS devices.
Stricter Regulations: Government regulations surrounding synthetic slings have become more stringent.
Limited Research: Opportunities for ongoing research and development have been curtailed.

These factors have created a shifting landscape where the number of SUI operations and the types of procedures performed are subject to change. While the introduction of minimally invasive MUS led to a surge in SUI surgeries in the late 1990s, the past decade has seen a decline in MUS procedures in some regions. This decline highlights the need for clinicians to be well-versed in alternative options, including non-synthetic mesh procedures, colposuspension, pubourethral slings, and urethral bulking agents.

The Path Forward: Balancing Innovation, Safety, and Patient Needs

The management of stress urinary incontinence continues to evolve. While MUS procedures have revolutionized surgical options, it's critical to acknowledge the growing awareness of long-term outcomes, potential complications, and the importance of tailoring treatment to individual patient needs. Staying informed about the latest research, mastering a variety of surgical techniques, and engaging in open communication with patients are essential for providing the best possible care in this dynamic field. As research continues and new technologies emerge, the goal remains clear: to improve the lives of women affected by SUI through safe, effective, and personalized treatment strategies.

About this Article -

This article was crafted using a human-AI hybrid and collaborative approach. AI assisted our team with initial drafting, research insights, identifying key questions, and image generation. Our human editors guided topic selection, defined the angle, structured the content, ensured factual accuracy and relevance, refined the tone, and conducted thorough editing to deliver helpful, high-quality information.See our About page for more information.

This article is based on research published under:

DOI-LINK: 10.1016/j.bpobgyn.2018.10.003, Alternate LINK

Title: Surgical Management Of Urinary Stress Incontinence – Where Are We Now?

Subject: Obstetrics and Gynecology

Journal: Best Practice & Research Clinical Obstetrics & Gynaecology

Publisher: Elsevier BV

Authors: Peter L. Dwyer, Debjyoti Karmakar

Published: 2019-01-01

Everything You Need To Know

What are mid-urethral sling (MUS) procedures, and why did they become so popular for treating stress urinary incontinence (SUI)?

Mid-urethral sling (MUS) procedures are surgical interventions for stress urinary incontinence (SUI) that involve placing a synthetic tape at the mid-urethra to provide support. They gained popularity because they are minimally invasive, using small incisions and trocar needles, which led to reduced post-operative complications, less pain, and shorter hospital stays compared to older techniques like Burch colposuspension and pubovaginal slings. MUS accounted for 82% of all SUI operations across 15 OECD countries in 2012.

Besides mid-urethral slings (MUS), what other surgical options are available for stress urinary incontinence (SUI), and when might they be considered?

Besides mid-urethral slings (MUS), surgical options for stress urinary incontinence (SUI) include Burch colposuspension, pubovaginal slings, non-synthetic mesh procedures, and urethral bulking agents. These alternatives are considered when there are concerns about the use of synthetic mesh due to medicolegal issues, stricter regulations, or when a patient is not a suitable candidate for MUS. Surgeon experience, patient history, and individual needs are key factors in determining the most appropriate treatment approach.

Why is the use of synthetic mid-urethral slings (MUS) in stress urinary incontinence (SUI) surgery facing increasing challenges despite their effectiveness?

The use of synthetic mid-urethral slings (MUS) is facing challenges primarily due to medicolegal concerns stemming from class actions and significant payouts, especially in the United States. Negative publicity in the media, which sometimes conflates their use with vaginal prolapse repair, has also contributed. This has led to reduced availability of MUS devices, stricter government regulations, and limited opportunities for ongoing research and development. The scientific data regarding the efficiency and safety of MUS is not necessarily the core issue.

How do bulking agents compare to mid-urethral slings (MUS) in treating stress urinary incontinence (SUI), and what makes them a potentially attractive option?

Bulking agents are minimally invasive alternatives to mid-urethral slings (MUS) for treating stress urinary incontinence (SUI). They involve injecting a substance into the urethral wall to improve its ability to close and prevent leakage. Unlike MUS, bulking agents do not involve the placement of a synthetic mesh, which may be appealing to patients and clinicians concerned about mesh-related complications and medicolegal issues. However, the long-term efficacy of bulking agents may not be as durable as MUS, potentially requiring repeat injections.

Considering the controversies and evolving landscape of stress urinary incontinence (SUI) treatment, what is the most important factor in determining the best course of action for a patient?

The most important factor in determining the best course of action for a patient with stress urinary incontinence (SUI) is tailoring treatment to individual patient needs. This involves a comprehensive evaluation of the patient's medical history, severity of symptoms, and personal preferences, as well as a thorough discussion of the benefits and risks of all available treatment options, including mid-urethral slings (MUS), Burch colposuspension, pubovaginal slings, non-synthetic mesh procedures, and urethral bulking agents. Open communication between the clinician and patient is essential to ensure informed decision-making and the best possible outcome. Also surgeon experience and mastery of a variety of surgical techniques are required.