This study aimed to evaluate the benefit but also the extrusions, dislocations, and failures of a titanium incus prosthesis along with the long-term audiological outcomes. We prospectively collected data from 139 patients undergoing ossiculoplasty using the Fisch titanium incus prosthesis between 2001 and 2016. Overall, 126 patients with at least 6 months of follow-up (mean 4.5 years, range 6-155 months) were analyzed. Patients were grouped as "extrusion" (n = 9, 7%) if the prosthesis extruded, "failure" (n = 22, 18%) if a reoperation was needed concerning the prosthesis, and "stable" (n = 95, 75%) if the prosthesis remained functional in the middle ear. Mean postoperative air bone gaps (ABG) for 0.5-3 kHz for the overall group and the stable group were 19.8 (±11.9) and 15.3 (±7.5), respectively. Long-term results of stable group revealed an ABG (0.5-3 kHz) below 10 dB in 25% and below 20 dB in 81% of the patients. Atelectasis was the most frequent cause of extrusion, which occurred after a mean time of 28.7 months (range 15-48 months). Mean timing for reoperation was 30.7 months (range 5-131 months) in the failure group. There was no significant difference in mean postoperative ABG among patients with or without cholesteatoma, primary or staged ossiculoplasty in cholesteatoma, presence or absence of malleus head at the time of ossiculoplasty, open or closed cavity surgeries, or the degree of pneumatization of the temporal bone. The Fisch titanium incus prosthesis is a reliable alternative to using autologous incus for interposition ossiculoplasty, with similar hearing outcomes. Using this prosthesis, a 15 dB ABG should be expected.