Introduction and Hypothesis <p>Since 2018 we have offered polyacrylamide hydrogel (PAHG) injection as an alternative to tension-free vaginal tape (TVT) for primary stress urinary incontinence (SUI). Our study aim was to investigate patient choice, demographics, re-treatments, and complications for these procedures.</p> Methods <p>Patient demographics were collected from the Hospital Registry for women with primary SUI treated with TVT or PAHG, including patient age, body mass index, smoking status, obstetric history, and prior pelvic surgeries. Re-treatments and complications were collected at 2-year follow-up after each primary procedure.</p> Results <p>Among 391 primary procedures, 55% (<i>n</i> = 217) of women chose the TVT and 45% (<i>n</i> = 174) the PAHG treatment, with similar patient demographics. Within 2 years, the re-treatment rates were 0.9% (<i>n</i> = 2) for TVT and 27.0% (<i>n</i> = 47) for PAHG (<i>p</i> &lt; 0.001). Among patients undergoing re-treatment after primary PAHG, 57.4% (<i>n</i> = 27) opted for re-injection and 42.6% (<i>n</i> = 20) chose a mid-urethral sling. Three patients received TVT after two PAHG injection treatments. Complications occurred in 14.3% and 9.2% after TVT and PAHG respectively (<i>p</i> = 0.124). Complications after TVT ranged from Clavien–Dindo grades I–IIIb, with 4.1% of patients requiring reoperations, whereas PAHG complications were grades I–II with no reoperations. Including re-treatments, complication rates were 14.3% (TVT) and 10.9% (PAHG; <i>p</i> = 0.322).</p> Conclusions <p>Similar clinical profiles in both TVT and PAHG groups suggest no specific demographic factors predict decision making. After a 2-year follow-up, the overall complication rates were similar, with PAHG associated with a higher likelihood of requiring re-treatment, whereas TVT carried a greater risk of severe complications. The re-treatment rates were lower than previously reported, indicating that actual patients are fairly satisfied with their primary choice.</p>