Now Online in the International Urogynecology Journal: Our Case Series of 252 Women With Midurethral Sling Complications

Our newest paper is online today in the International Urogynecology Journal, the official journal of the International Urogynecological Association. It is a different kind of paper from the meta-analyses my team usually publishes: a case series, built from an unusual dataset, that asks a narrow question and answers it carefully.

Complications of Midurethral Sling Stratified by Surgical Route: A Litigation-Derived Case Series of 252 Women

Azadi A, Marchand GJ, Ostergard DR. Int Urogynecol J. Published online November 3, 2026. DOI 10.1007/s00192-026-06920-0.

Where to read it

The article on link.springer.com (subscription access; the abstract is free) · DOI 10.1007/s00192-026-06920-0. PubMed: PMID 42975585.

Why this paper matters to me

I am a minimally invasive gynecologic surgeon, not a urogynecologist, but I see the downstream of sling complications all the time: women who leak again, women in pain, women who have already had one revision and want to know whether the next operation will be the last. Dr. Ali Azadi, the lead author, is a urogynecologist who has been my co-author on dozens of papers. Dr. Donald Ostergard is a founder of what is now the American Urogynecologic Society, started the first fellowship in the field, and wrote the textbook that carries his name. The dataset came from his years of work as an expert in sling litigation, and he stripped every identifier from it himself before either of us saw a single record.

So this was a chance to put a very unusual dataset in front of the field, and to do it with the limits stated plainly, starting with the title.

What the dataset is, and what it is not

These are 252 women who had a midurethral sling placed between September 2000 and February 2016, developed complications, and went on to civil litigation. Their records were abstracted through November 2019. Dr. Ostergard assembled the dataset while providing expert medical opinions in civil product-liability proceedings, and before sharing it he personally removed every direct and indirect identifier under the HIPAA Safe Harbor method. Our Institute’s IRB reviewed the protocol in March 2026 and found it exempt as a secondary analysis of fully de-identified data with no patient contact.

That makes it a cohort selected on complications and on litigation. It cannot tell you how often slings fail, because every woman in it had a sling that failed her in some way. It cannot tell you whether the retropubic, transobturator or single-incision route is safer, because we had no baseline or surgeon characteristics and we did not test or adjust a single between-route comparison. We put the word litigation in the title so that nobody could miss it.

What we did

We stratified the series by route: 97 retropubic, 124 transobturator and 31 single-incision, the last group too small for anything but description. Follow-up totaled 1,732 person-years. Onset dates existed only for revision operations, so every other complication is reported as a crude proportion and as a follow-up-adjusted frequency per 100 person-years with exact Poisson confidence intervals, not as an incidence rate that pretends to know when things happened. Time-to-event analysis was reserved for revisions, where we had the dates.

What we found

Recurrent stress incontinence was the most frequently documented endpoint in every route group, at 48% to 60%.
Every between-route confidence interval overlapped. We tested nothing and adjusted nothing, and we say in the conclusions that differences between routes cannot be attributed to route.
Among women who reached a first revision, the five-year cumulative incidence of a second was 51% after retropubic and 47% after transobturator placement. Roughly one in two.
Among women who reached a second revision, the exploratory five-year cumulative incidence of a third reached 70% in the transobturator group. That estimate comes from 36 women at risk and 14 third-revision events across both groups combined, which is why we call it exploratory and hypothesis generating, and nothing more.

What it means

If you are a woman with a sling that has already been revised: the next operation may not be the last one, and you deserve to hear that before you consent to it, from a surgeon who does a lot of sling revisions. If you are a surgeon: counsel accordingly, and do not cite this paper as evidence about sling safety in general or about which route to choose, because it is neither. If you are a researcher: the field needs prospective registries with dated onset for every complication, baseline and surgeon characteristics, and follow-up long enough to count third and fourth operations. Those registries would answer the questions a litigation series cannot.

Thanks

Thanks to Dr. Ali Azadi for leading this one, and to Dr. Donald Ostergard for the dataset and for a career the rest of us are still catching up to. Dr. Ostergard has provided expert medical opinions in civil product-liability proceedings involving midurethral sling devices, from which the dataset was assembled; Dr. Azadi and I have no expert-witness involvement in mesh litigation and no other relevant conflicts.

Greg J. Marchand, MD, FACS, FACOG, FICS