In a controlled clinical trial, Itkonen Freitas and co-workers (2020) examined if polyacrylamide hydrogel is non-inferior to tension-free vaginal tape in the treatment of women with primary SUI. Subjects were randomized to tension-free vaginal tape or polyacrylamide hydrogel treatment. The primary outcome was patient satisfaction and secondary outcomes were effectiveness in reducing urinary leakage and complications at 1-year follow-up. For statistical power, significance was considered at 5 %, power was set at 80 % and the non-inferiority limit was 20 % with a 10 % expected drop-out rate. A total of 224 women with primary SUI entered the study between September 28, 2015 and March 1, 2017. Of the women 111 were randomized to tension-free vaginal tape and 113 were randomized to polyacrylamide hydrogel. At 1 year a satisfaction score of 80 or greater on a VAS of 0 to 100 was reached in 95.0 % and 59.8 % of patients treated with tension-free vaginal tape and polyacrylamide hydrogel, respectively. Therefore, polyacrylamide hydrogel did not meet the non-inferiority criteria set in this study. As secondary outcomes, the cough stress test was negative in 95.0 % of tension-free vaginal tape cases versus 66.4 % of polyacrylamide hydrogel cases (difference 28.6 %, 95 % CI: 18.4 to 38.5). However, most peri-operative complications, including those in 19 tension-free vaginal tape cases versus 3 polyacrylamide hydrogel cases (difference 16.0 %, 95 % CI: 7.8 to 24.9), and all 6 re-operations due to complications (difference 5.9 %, 95 % CI: 1.2 to 12.4) were associated with tension-free vaginal tape. The authors concluded that mid-urethral tension-free vaginal tape slings were associated with better satisfaction and cure rates than polyacrylamide hydrogel in women with primary SUI. However, complications were mainly associated with tension-free vaginal tape. Therefore, tension-free vaginal tape should be offered as 1st-line treatment in women who expect to be completely cured by the initial treatment and are willing to accept the complication risks. Since polyacrylamide hydrogel treatment also provides high satisfaction and cure rates, women with primary SUI can be offered polyacrylamide hydrogel as an alternative treatment.