FOR IMMEDIATE RELEASE
MESA, Ariz. – November 3, 2026
The Marchand Institute for Minimally Invasive Surgery is pleased to announce the publication of a 252-woman case series on complications of the midurethral sling in the International Urogynecology Journal, the official journal of the International Urogynecological Association (IUGA). The study was led by urogynecologist Ali Azadi, MD, with Greg J. Marchand, MD, Director of the Marchand Institute, and Donald R. Ostergard, MD, a founder of what is now the American Urogynecologic Society, as co-authors.
The paper, “Complications of Midurethral Sling Stratified by Surgical Route: A Litigation-Derived Case Series of 252 Women,” was published online as an Original Article on November 3, 2026 (DOI 10.1007/s00192-026-06920-0).
Read the Study
Publisher page: link.springer.com (subscription access; the abstract is free)
DOI: 10.1007/s00192-026-06920-0
PubMed: PMID 42975585
Authors: Ali Azadi, MD (Department of Obstetrics and Gynecology, University of Arizona College of Medicine Phoenix; Star Urogynecology, Advanced Pelvic Health Institute for Women, Peoria, Arizona; Creighton University School of Medicine Phoenix); Greg J. Marchand, MD (Marchand Institute for Minimally Invasive Surgery, Mesa, Arizona); and Donald R. Ostergard, MD (Department of Obstetrics and Gynecology, University of California Irvine School of Medicine; Long Beach Memorial Medical Center, Long Beach, California).
Why Midurethral Slings Matter
Stress urinary incontinence, the loss of urine with coughing, sneezing, laughing or exercise, is one of the most common conditions in women’s health, and the midurethral sling is its standard surgical treatment. Since the retropubic sling was introduced in 1996, a narrow strip of synthetic mesh placed beneath the urethra through a small vaginal incision has become the most widely used operation for stress incontinence in the world. It is usually day surgery, and for most women it works. Two further routes followed: the transobturator sling, which passes the mesh out through the groin, and the single-incision mini-sling, which is anchored through the vaginal incision alone.
A minority of women develop complications: recurrent leakage, pain, mesh exposure, or difficulty emptying the bladder. Some of them need a revision operation, and some of those go on to litigation. The question this paper set out to answer is narrow and practical: among women whose sling has already caused trouble, what happens after that first revision?
A Dataset Unlike Any Other
The 252 women in this series underwent sling placement between September 2000 and February 2016 and later pursued civil litigation; their records were abstracted through November 2019. The dataset was assembled and maintained by Dr. Ostergard while providing expert medical opinions in civil product-liability proceedings involving midurethral sling devices. Before it was shared with his co-investigators, he personally de-identified it by removing every direct and indirect identifier under the HIPAA Safe Harbor method, so that no investigator had access to identifiable information at any stage. The Marchand Institute’s Institutional Review Board reviewed the protocol in March 2026 and determined the study to be exempt as a secondary analysis of a pre-existing, fully de-identified dataset with no patient contact. The study was conducted in accordance with the Declaration of Helsinki.
That origin is both the value of the series and its limit, and the authors say so in the title. A cohort selected on complications and litigation cannot estimate how often slings fail in the general population, and it cannot support a causal comparison between surgical routes. What it can do is describe, in unusual detail, the course that women with serious sling complications actually followed.
Study Design and Methodology
The study is a retrospective case series stratified by surgical route: 97 women received a retropubic sling, 124 a transobturator sling, and 31 a single-incision sling, the last group reported descriptively because of its size. Follow-up totaled 1,732 person-years. Because onset dates were not available for endpoints other than revision, complications are reported as crude proportions and as follow-up-adjusted frequencies per 100 person-years with exact Poisson 95% confidence intervals, rather than as dated-event incidence rates. Time-to-event methods were applied only to revision surgery, where the dates were known. No between-route comparison was tested or adjusted, because baseline and surgeon characteristics were not available for a litigation-selected cohort.
Key Findings
- Recurrent stress incontinence led every group. It was the most frequently documented endpoint after retropubic, transobturator and single-incision placement alike, in 48% to 60% of women.
- Routes could not be separated. Crude proportions and follow-up-adjusted frequencies are reported by route, and every between-route confidence interval overlapped. None was tested or adjusted, and the authors are explicit that differences between routes cannot be attributed to route.
- After a first revision, a second was common. Among women who reached a first revision, the five-year cumulative incidence of a second was 51% after retropubic placement and 47% after transobturator placement.
- After a second revision, a third was likely. Among women who reached a second revision, the exploratory five-year cumulative incidence of a third reached 70% in the transobturator group. That estimate rests on 36 women at risk and 14 third-revision events across the retropubic and transobturator groups combined, and the paper labels it exploratory and hypothesis generating.
Clinical Takeaways
For women, the message is about counseling. A sling that has needed one revision is a sling that may need another, and the decision to revise should be made with that expectation on the table, by a surgeon who revises slings regularly. For surgeons, the paper is a reminder of what a litigation-derived series can and cannot say: it describes the course of complications in women who had them, and it says nothing about the overall safety of the sling or about which route to choose. For researchers, the authors set out what would be needed to answer the questions this series cannot: prospective registries with dated onset of every complication, baseline and surgeon characteristics, and follow-up long enough to count third and fourth operations.
“Once a sling has been revised, the odds of needing another operation are not small,” said Greg J. Marchand, MD, FACS, FACOG, FICS, co-author and Director of the Marchand Institute for Minimally Invasive Surgery. “About half of the women who reached a first revision reached a second within five years. That is a number every woman should hear before her first revision, not after.”
“This is a litigation-selected series, and we say so in the title,” Dr. Marchand added. “It cannot tell you how often slings fail or which route is safer, and anyone who uses it to argue either point is misreading it. What it can tell you is what the road looks like for the women who do have complications, and that road includes more surgery than many of them are told to expect.”
Acknowledgements
The Institute congratulates lead author Ali Azadi, MD, of the University of Arizona College of Medicine Phoenix, Creighton University School of Medicine Phoenix and Star Urogynecology, a long-standing collaborator on the Institute’s research, and thanks Donald R. Ostergard, MD, of the University of California Irvine School of Medicine and Long Beach Memorial Medical Center, for assembling and de-identifying the dataset that made the study possible. Dr. Ostergard has provided expert medical opinions in civil product-liability proceedings involving midurethral sling devices, from which the analyzed dataset was assembled; the remaining authors have no expert-witness involvement in mesh-related litigation and no other relevant conflicts.
About the Marchand Institute
The Marchand Institute for Minimally Invasive Surgery is a 501(c)(3) tax-exempt non-profit research and educational institution based in Mesa, Arizona (EIN 42-2857240). The Institute produces peer-reviewed systematic reviews and meta-analyses in minimally invasive gynecologic surgery and women’s health, conducts FDA clinical trials, and trains surgeons through an SLS-accredited fellowship. All reviews are prospectively registered with PROSPERO and reported to PRISMA standards. The Institute accepts no pharmaceutical or medical device industry funding and declares no conflicts of interest. It is directed by Greg J. Marchand, MD, FACS, FACOG, FICS, a dual board-certified minimally invasive gynecologic surgeon, the first Master Surgeon in minimally invasive gynecology accredited by the Surgical Review Corporation in the United States, a member of the U.S. Department of State’s Fulbright Specialist Roster, and the holder of a Guinness World Record and two World Record Academy records for minimally invasive procedures.
For more information on our surgical fellowships or to view our library of research, please visit MarchandInstitute.org.
Media Contact
Maria A. Sainz, Director of Communications and Media Relations
Marchand Institute for Minimally Invasive Surgery
maria@marchandobgyn.com | (480) 999-0905
10238 E. Hampton Ave., Suite 212, Mesa, AZ 85209
###