Objectives. To analyze the safety and efficacy of tension-free vaginal tape (TVT) surgery in elderly versus younger women with stress urinary incontinence (SUI). Methods. A total of 157 consecutive elderly women, aged 70 years and older, and 303 younger women (mean age, 74.8 and 57.2 years, respectively) who underwent TVT for urodynamically-confirmed SUI were prospectively enrolled. Concomitant genitourinary prolapse repair was performed in 84% of the elderly and 67% of the younger women. The main outcome measures were perioperative morbidity, postoperative SUI, persistent or de novo urge incontinence, and voiding dysfunction. Results. The incidence of TVT-related morbidity was similar in both groups, except for significantly fewer cases of bladder perforation among elderly women (1.3% versus 4.9%, P <0.05). However, some age-related morbidity was noted among the elderly women: 2 cases of pulmonary embolism, 2 cases of cardiac arrhythmia, 1 case of severe pneumonia, and 1 case of deep vein thrombosis. The outcome analysis was restricted to 123 elderly and 208 younger women with follow-up of at least 12 months (mean, 30 ± 12 months; range, 12 to 67 months). The incidence of persistent postoperative SUI and persistent urge incontinence was similar in both age groups. However, de novo urge incontinence was significantly more common among elderly women (18% versus 4%, P <0.05). Two elderly and three younger women had postoperative pressure-flow studies suggestive of bladder outlet obstruction. Conclusions. Tension-free vaginal tape surgery in elderly women is associated with good outcome results; however, the risk of postoperative de novo urge incontinence, as well as age-related morbidity, is increased.