We would like to extend our gratitude to Rotem and O'Sullivan [1] for their positive and thoughtful comments on our long-term follow-up study on mid urethral sling (MUS) surgery. We appreciate their recognition of the importance of performing such long-term follow-up studies, especially in surgical methods involving synthetic meshes.

We fully agree on the importance of differentiating between various types of mesh and their distinct risk profiles. We also agree on the important point of careful patient selection and counselling that might increase success rates and minimise complication risks. One excellent example is the association between higher BMI and lower subjective cure rates found in our study and also later confirmed in a recent study from Sweden, where obese women had higher rates of incontinence and lower satisfaction than normal-weight women 10 years after surgery [2].

Adding to the safety aspect of MUS surgery, we would also highlight the results from a recently published paper from our study population showing that negative impact of urinary incontinence on sexual life decreased after MUS surgery [3]. Persistent pain after MUS in this population was infrequent (3%–4%) with no difference between sexually active and inactive women.

Additionally, we would emphasise the importance of having national quality registries with good coverage and data quality when it comes to surgeries that involve implants, whether they are synthetic, autologous or xenografts. Good registries are particularly useful when new techniques are implemented as they can discover serious adverse events early. Events may occur infrequently at the individual hospital or for the individual surgeon but show a systematic pattern when results from all reporting hospitals are continuously monitored and analysed. Our study demonstrates the value of such a high coverage quality register. In the Norwegian Female Incontinence Registry, preoperative and surgical data as well as results from a mandatory 6–12 months follow-up are continuously reported. This registry prepares several annual reports to reporting hospitals on results and complications in which results from each hospital department are compared to a national average [4]. We suggest that countries where polypropylene MUS have been banned might benefit from having quality registries in place before reintroducing MUS. Another important factor adding to safety is that everyone who performs MUS surgery in Norway has received training from an experienced surgeon in a one-to-one setting for at least 10 surgeries before performing them on their own, which is considered good clinical practice.

Summing up, we are pleased that our study contributes to the robust evidence supporting the safety and efficacy of MUS surgery. We share the commitment to precise risk assessment and patient-specific evaluations, and we think standardised preoperative assessment and quality registries are important to enable women and surgeons to make safe, evidence-based and informed decisions.

Thank you again for your valuable comment and for highlighting the significance of our findings.

Sincerely,

Dr. Berit Rein Solhaug, Dr. Rune Svenningsen, Dr. Maria Øyasæter Nyhus and Dr. Ingrid Volløyhaug

我们要感谢 Rotem 和 O'Sullivan [1] 对我们尿道中段悬吊术 （MUS） 手术的长期随访研究的积极和深思熟虑的评论。我们感谢他们认识到进行此类长期随访研究的重要性，尤其是在涉及合成网片的手术方法中。

我们完全同意区分各种类型的网状结构及其不同的风险状况的重要性。我们还同意谨慎选择患者和咨询的重要性，这可能会提高成功率并将并发症风险降至最低。一个很好的例子是在我们的研究中发现的较高 BMI 和较低主观治愈率之间的关联，后来在瑞典最近的一项研究中也证实了这一点，其中肥胖女性在手术后 10 年内的失禁发生率高于正常体重女性，满意度较低 [2]。

除了 MUS 手术的安全性外，我们还将强调我们研究人群最近发表的一篇论文的结果，该论文显示 MUS 手术后尿失禁对性生活的负面影响减少 [3]。该人群 MUS 后持续疼痛很少见 （3%-4%），性活跃和不活跃的女性之间没有差异。

此外，我们将强调在涉及植入物的手术（无论是合成、自体还是异种移植物）时，拥有具有良好覆盖范围和数据质量的国家质量登记册的重要性。当实施新技术时，良好的登记特别有用，因为它们可以及早发现严重的不良事件。事件可能很少发生在个别医院或个体外科医生身上，但当所有报告医院的结果都得到持续监测和分析时，就会显示出系统性的模式。我们的研究证明了这种高覆盖率质量寄存器的价值。在挪威女性失禁登记处，不断报告术前和手术数据以及强制性 6-12 个月随访的结果。该登记处会准备几份关于结果和并发症的年度报告，向报告医院报告，其中将每个医院科室的结果与全国平均水平进行比较 [4]。我们建议，在重新引入 MUS 之前，建立质量登记制度可能会对这些国家/地区有所帮助。另一个增加安全性的重要因素是，在挪威进行 MUS 手术的每个人都在自己进行手术之前接受了经验丰富的外科医生的一对一培训，至少进行了 10 次手术，这被认为是良好的临床实践。

总而言之，我们很高兴我们的研究有助于支持 MUS 手术的安全性和有效性的有力证据。我们共同致力于精确的风险评估和针对患者的评估，我们认为标准化的术前评估和质量登记对于使女性和外科医生能够做出安全、循证和明智的决定非常重要。

再次感谢您的宝贵意见并强调我们调查结果的重要性。

 真诚地

Berit Rein Solhaug 博士、Rune Svenningsen 博士、Maria Øyasæter Nyhus 博士和 Ingrid Volløyhaug 博士