On Sunday morning, we're all dedicated. Want to learn more? I really, I've seen Roger's talk a couple times. And it is pretty compelling. And it kind of makes sense. And I think some of us, over the years of operating the vagina, have done some aspect of that for these types of patients. So I think there really is something to it. I also like Naza's comment with regard to a biologic. For those of us that actually used the ProLift when it was around, I really liked the posterior ProLift for that. I think, in retrospect, I almost run screaming from a room that I used the ProLift. It's such a heavy, heavy mesh. But the new lighter meshes, I think, can be cut to do the same job. So I think there really is something to this. At first, I thought, oh, you know, if you look for something, if you have a hammer, everything's a nail. But I think there are a significant proportion of women that have these symptoms that can be helped by this approach. So this morning, we're going to look at surgical treatment at SUI, evidence-based fashion. I'm going to do a little, I did a little review of the literature and updated things for those patients. These are my disclosures. For those patients that, this isn't changing here on the, where's my guy? OK. And Stephanie, I did that slide. Thank you. So we're going to understand why we're discussing non-synthetic mesh surgical approaches to the management of stress UI in the first place. We're going to look at the physiologic process of stress urinary incontinence. Because as that was more fully understood, I think techniques kind of evolved in parallel to treat SUI as we understood the pathophysiology. So we're going to do a brief history of the evolution of surgeries for stress incontinence. And we'll look at efficacy outcomes for non-synthetic mesh surgeries for stress urinary incontinence, some of them in a comparative effectiveness manner. So we know that there was a rapid adoption of the midurethral sling after its introduction in 1996. And really, it has become the gold standard. I can't, this, oh, OK. I'll try and read it up here. It's become the gold standard for the treatment of stress urinary incontinence. To go back in time, we know in 2008, the FDA released a public health notification and safety communication following 1,000 transvaginal prolapse mesh related complications in the MAUD database. I don't know if any of you ever went into the MAUD database and did complaints, but it was required of manufacturers to do that. And over time, these adverse events that were occurring accumulated. In 2011, an update to this notification strongly cautioned the use of transvaginal mesh for prolapse. And at this time, a definitive advisory claim regarding the use of synthetic mesh for the treatment of stress incontinence was not issued. And although the FDA notification didn't address sling mesh, patient perception was influenced by this, especially with evident complications that they had heard about, erosions, pain, difficulty with emptying. Although the mesh alert wasn't for midurethral slings, it was primarily for prolapse. Patient perception was altered, and a lot of provider perception was also altered. In the UK, the Scottish government initially recommended a suspension of all vaginal mesh in 2014, and subsequently called for an immediate halt in September of 2018. Everything, prolapse as well as slings. In July of 2018, the National Health Service in England announced a national pause for vaginal mesh surgery until enough evidence to support its clinical use became available. This happened in most of the UK. And it resulted in a significant decrease in surgical treatment for stress incontinence. So women that needed these surgeries, there were a lot of providers. All they were doing was midurethral slings, and patients weren't getting the treatments they wished. So in light of these patient perceptions, women still don't wish to have any vaginal mesh placed at the time of pelvic floor surgery, including incontinence surgery. And I think this does a disservice to our patients if we as urogynes are not able to offer other options. And these are options that many of us trained with when we were back in the 90s and the 80s, when we were doing our resident training as well as our fellowship training. There are also other clinical scenarios, as you know, where you may not use a mesh sling, such as at the time of a diverticular repair or at the time of a urethrovaginal fistula repair, where you may want to do an incontinence procedure on her. And you certainly wouldn't use a mesh sling for that. So it's important that we're able to offer these patients alternatives for the treatment of SUI in an evidence-based manner. So stress incontinence is, as you know, the complaint of involuntary loss of urine on effort or physical exertion, sporting events, coughing, sneezing. We all know this by various guidelines. If conservative efforts don't work, such as pelvic floor muscle therapy or the use of pessaries, or the patient just isn't interested in trying conservative approaches, she wants things fixed, then we really need to discuss, openly, proactively discuss surgery with our patients. Over the past hundred years, there have been evolving theories regarding the development of stress urinary incontinence. And as the cause and the pathophysiology becomes more understood, interventions that address this pathophysiology directly align with new treatments. And with evolving theories came evolving treatment modalities. So in the early 20th century, Kelly designed a cystoscope and visualized the urethra and saw a gaping internal sphincter with funneling of the bladder neck, saw loss of elasticity and tone, and from that evaluation, the Kelly plication was starting to be done. I remember doing Kelly plications. You kind of go up and grab stuff and bring it across and go up and grab stuff and tie it. And you got really good efficacy for 24 hours, and then she couldn't void, and then it scarred in and she developed ISD. Anyway, Bonnie subsequently stated that incontinence occurs when there's an increase of abdominal strain resulting in an interaction between the urethral sphincter and lax pubocervical muscle, allowing the bladder to drop from behind the pubis. So it loses this intra-abdominal position and drops behind the pubis. So with this knowledge, the development of urethropexies came to the forefront. And this was in late 40s as well, where the MMK was developed, and then 1961, the BIRT urethropexy. The integral theory in the 1990s reflects the interplay of structures involved in maintenance of continence, as well as aging, the type of connective tissue that is surrounding the urethra, the hormonal milieu, vaginal laxity with weakening of the transmission of muscle forces. And most of these ongoing things were occurring at the urethra and in the mid-urethral area. And thus, the development of the mid-urethral sling occurred. So these theories, these various theories that evolved over anywhere from 80 to 90 years reflected the evolving understanding of the pathophysiology and paralleled the advancement of procedures. Some of them not working so well, and some of them not hitting the bar in terms of being evidence-based. And I remember those days. I remember going and seeing patients that had surgeries, that had staming needles, that had modified pereras, that had Kelly plications. And those were the days where we didn't do, for the most part, validated measures of subjective outcomes. The doc would, the attending would walk in the room and say, I bet you're doing great, aren't you? And the lady would say, yeah, I'm doing great. And that was the outcome that is then recorded and was presented at meetings because it was the outcome that the surgeon was able to glean from their patient. So it's important to understand urethral incompetence. And I really look at it at two levels. The loss of the bladder neck support, which we call the extrinsic compression mechanism. Very important. I think that's the more classical way we look at the development of stress leakage. But also there's the intrinsic mechanism or the loss of urethral wall function. And this is typically neuromuscular dysfunction and failure of other urethral wall tissue. The striated sphincter, urethral smooth muscle, the submucosal vasculature, which really atrophies when, through menopause. The submucosa, the epithelium, the bladder neck sphincteric mechanism. So the intrinsic innervation may be aberrant. Hypogastric nerve, pudendal nerve, afferent fibers. So the intrinsic mechanism, I think really fully informs more so to that intrinsic sphincter leakage that we all recognize. And really the extrinsic is more of, we need to support this so that she doesn't leak when she coughs and sneezes. So really the bottom line is stress incontinence occurs secondary to the loss of urethral competence where the proximal urethra has lost its extrinsic support, loss of intra-abdominal positioning. Where it was previously positioned with increases in intra-abdominal pressure, there was actual coaptation at the bladder neck. And when that drops, when there's increases in intra-abdominal pressure to the bladder, that coaptation didn't occur and stress leakage happens. So, and this is what's described here. So stress incontinence occurs when the pressure in the bladder exceeds the urethral resistance. And in the setting where you see the proximal urethra supported intra-abdominally, there's facilitation of the bladder neck closure with increases in intra-abdominal pressure. And these forces basically are negated when there's a loss of that proximal bladder neck support. So SUI surgery primarily addresses the loss of this extrinsic support. So as our understanding of the pathophysiology of SUI has increased, treatments have evolved, as we said. And you know, it's kind of funny, but every damn pelvic floor abnormality gets the herb treatment, the hot herbs. And gosh, they didn't work. So we moved on to the early 1900s after the herbal baths, the sling evolved from the use of gracilis muscle to described use of fascia lata in the 1930s. And then in 1942, autologous, and looking just right at the figure here, autologous rectus fascia without muscle was passed through the retropubic space to support the bladder neck, the proximal urethra. Sling procedures, as you know, varied over time. An increase with non-autologous grafts included porcine dermis, absorbable mesh, other synthetic type materials. Early synthetic slings, as you know, had complications. They were microporous, they had mixed types of fibers, got infected, ingrowth did not occur, had very small pore sizes. And then, as I said, in the late 40s and the early 60s, we had the MMK and the BIRCH urethrapexies, respectively, that developed. And these, as you know, you could obviously see the elevation of the proximal bladder neck back into its intra-abdominal position. But other procedures, such as the modified Pereira, the Stamy, needle suspensions, Ras urethrapexy, four-corner suspensions, these were done for decades. And, you know, these were procedures where sutures easily tore through, where tissue was being grabbed indiscriminately and thought, because it went under the urethra, that it was gonna cure stress leakage. And why this, I kinda get on a high horse here, is because this is kind of an area right now where we're in, in terms of treating post-fistula repair urinary incontinence. So some of us here have gone over and done obstetric-related fistula repairs. These are women that have three, four days of labor. The head is banging on the pelvic floor, the vagina. The pubic bone, the baby dies. Somehow the baby comes out, either through C-section or brought out from below. She develops a fistula. If she's lucky enough to be at a place where the fistula can get fixed in a timely manner, that's awesome. But many of these women undergo multiple, multiple repairs. And right now, there's no evidence-based, and because of the pathophysiology they sustain at a marked labor process that they've gone through, there is so much damage there in terms of innervation and connective tissue damage. Even though the hole is closed, their urethra is totally denervated, and often is just kind of a tube of mucosa or even a tube of, it may not be any epithelium there, it may just be connective tissue. And yet, what's going on with these women, whether it's done prophylactically or even after the repair of the fistula, so the hole's closed but she's still leaking, she doesn't understand. She's thought she's had these two, three surgeries, her fistula and her leakage were gonna be cured, but then procedures such as grabbing stuff from side to side. And this tissue, I will tell you, as many of you may know, this tissue is like rock. There's no good connective tissue that you're working with. This tissue, and things that are done prophylactically, this bad tissue is put to bad tissue, which heals and makes more bad tissue. So, we need this type of evolution in an environment of women that have had marked injury to their connective tissue. So these are women not like the women we see, right? These are women that have horrible connective tissue. And the reason I bring this up is because Roger talked about innovation. I think we're gonna need more innovation in this area. We can't just go and do midurethral slings on these women. Sometimes if their tissue's healthy, they don't have estrogen, right? We can't optimize their tissue before we operate on them. So, I just bring this up because this is really important, and with good thought and with continued thinking outside of the box a bit, we may find new types of approaches, and we should never stop thinking about innovating in the care of our women, whether they're here in the U.S. with our typical type tissue that we deal with, or overseas. And I just had to say that, sorry. All right, so, and you know, you think about that when, I've given this talk a couple times, and you think about the evolution of what goes on, but that evolution's not going on over there. And it's the same stuff. And I think maybe it's because, we're gonna hear from one of the urogynes that's from Ethiopia. He put a video together for us. He's in one place, and we need more of him throughout Africa that'll help us achieve what we've done here for our patients that have stress leakage. And we now do evidence-based approaches for them. So, this is a 61-year-old. Severely bothersome UI. Obviously, I found her, she was a good friend of mine, and I took a picture of her. She wasn't interested in a pessary, and, or in PT, or she's tried PT. She's really interested in surgery. She wants to get fixed and move on. She's quite active, she runs, she works out regularly. She has not had any gynecologic surgeries, and no prolapse was noted on physical exam. She has great bowel movements. No problem with her bowel movements. She stated that despite reassurances that a polypropylene mesh sling is currently the gold standard. We all talk to our patients. They come in, oh, I don't want any of that mesh. I think we're all hearing it less, but we still hear it. You tell her it's the gold standard. You give her the AUGs, you give her the iUGA educational stuff. You tell her how many you do a year, the complications, the risk factors, but she doesn't want mesh, okay? So, how would you counsel this patient? So, in terms of the current state of the science, there are several Cochrane reviews and other systematic reviews, some with meta-analyses, some without meta-analyses that exist, and support the overall efficacy and safety of three major non-mesh approaches to the treatment of stress incontinence. That would be the retropubic urethrapexy, the pubovaginal fascial sling, and urethral bulking, and this is under certain conditions. So, let's take a look at these data. So, and again, to emphasize, procedures which do not meet this efficacy bar are going in and doing a Kelly, even a prophylactic, don't do a prophylactic Kelly, just don't do it. It's taking potentially good tissue, something you can use later, and it makes scar, and you denervate the tissue. And any of these transvaginal needle, bladder neck suspensions that we used to do, I did them every week, I did modified Pereiras, they do not hit the bar in terms of level one data. There's very little level one data for these procedures, and those that exist show inferior outcomes. So, if you take a look at the International Consultation on Incontinence, that's that big, fat book that comes out every three, five years or so. This table is from the sixth and seventh edition. Sixth edition was in 2016, and the more recent one in Melbourne in 2023. And the International Consultation on Incontinence, as you know, really does, is basically a summary of systematic reviews and meta-analyses, but they also talk about individual trials. And in terms of bulking agents, they give it a grade B. It's not appropriate for women desiring a single durable treatment for stress incontinence. So we'll discuss this a little more in a bit. I think for some women, oh, it's not working. So it's an option in some women after counseling about limited long-term efficacy with the use of bulking. And really, I think is, personally, is really a better procedure to be offered for those women that have had a previous stress incontinence surgery, or maybe those older women where they're not as physically active in that. But for this patient, I would have questions about that. Autologous fascial slings, grade A data. We have comparative efficacy data. We're going to look at one trial. Birch culpable suspension, so urethrapexy, grade A to do it. There is good comparative effectiveness data. Now, MMK, it's grade A data to not recommend it. And Mike Moen and I were talking yesterday. I mean, I never did MMKs. I learned Birches. But I had a partner who did MMKs. And all MMKs got a suprapubic tube, and they never avoided. I mean, they just never avoided. I, one time, was doing a study in some of these women. And I did a post-procedure uro on her. And she went to go sit on the uro float chair. And as she was going to sit, she started bending over. I thought she was going to fall, so I ran over. And she said, oh, no, this is how I avoid. Stuck with me for, I mean, that's how she avoided. She bent over and avoided. And there are other procedures here, including the artificial sphincter, transurethral radiofrequency. We talked about some of these newer things that are currently being studied. But right now, grade D and C type data. So this is the seventh edition, the Melbourne edition 2023 that came out. I mean, it's like 2,000 pages. You can get a PDF of it for free. Just get online, and you can get it. And I thought this would be of interest to you, that this is kind of what we're looking at here. You guys know how to evaluate these patients that have stress leakage. But treatment modalities that they have here, if initial therapy fails, and that's including PT, that's including pessaries. They recommend bulking agents as a grade B. Fascial slings and urethropexies is grade A. So the Burt-Tretcher pubic copal suspension was originally described as an elevation of the periurethral support to the pubic symphysis. We know this as an MMK. But as I just described, there are significant AEs associated with MMK. And literally, the periurethral tissue was brought up right to the pubic bone. And it's amazing any of these women ever voided. The retropubic birch, as you know, the same periurethral tissue, typically at bladder neck and maybe mid urethra, are now sutures put through that and placed into the pectineal ligament, or Cooper's ligament. It elevates and stabilizes the proximal bladder neck. And when you look at the studies, overall continence rates are 80% to 90% at one year, about 70% or greater at five years, again, depending on what the definition of cure is. So you need to look at that. If you look at the data, it's equally effective as pubivaginal slings at a year. And we're going to talk about pubivaginal slings next. At 24 months post-op, laparoscopic urethropexies, not done with mesh, but done with sutures. And many of you may be well-equipped to do that, are equally as effective as an open birch. So that's good data to know. There are complications to a retropubic urethropexy. I was in the space of Retzius a lot when I was in training. And you hit that pempiniform plexus, and that space will fill up with a liter and a half in two minutes. It's a dangerous zone to be, so you have to respect that. And also is the possibility of aberrant obturator vein and wound issues can occur as well. So some of us may remember hand in the vagina, you're opened up, suture, up into Cooper's ligament suture, and you do this bilaterally. I learned to do it with, I used Ticron when I learned to do it. And then we did the sister trial, which I'm going to present in a second. We used prolines. And I'll tell you, that was a learning curve. Because a Ticron, you can do a very directed and controlled knot tying, and proline will slip up before you know it. So you're tying, and before you know it, that pair of urethral tissues up to Cooper's ligaments. So that was a big learning curve for many of us that did birches. And this is just to show the birch bladder neck area here. So a nice full, not full thickness, you didn't go through the vaginal mucosa, but near full thickness. And then up into the pectenil ligament. And some people did both sides, some people did one side. And you typically do it at bladder neck and mid urethra, and you do it bilaterally. OK, so the pubovaginal sling. This is an abdominal vaginal procedure that is used autologous fascia, including rectus, fasciolata. Let's use some vaginal wall. Allergenic or cadaveric fascia, xenogenic pig skin, pig intestines, and synthetic materials. And the sling material used most commonly when doing a typical pubovaginal sling is autologous fascia, which we refer to typically as a pubovaginal sling. So I don't know if some of you remember, but when I was in training, pubovaginal slings were kind of the salvage surgery. Because after they had a previous procedure, maybe a urethrapexy, they developed ISD, and you would do a sling. But now, and more recently, probably for the past 25 years, it's been used as a primary procedure. And many of us have done that. So as you know, whether it's a fasciolata or a rectus fascial sling, they used to do full length. This kind of evolved into 8 to 10 centimeter lengths of fascia, where you'd put non-absorbable suture at the ends. You'd pop it through the retropubic space, either through a vertical vaginal incision or a U-type incision, and then stabilized over the fascia. And typically, the pubovaginal sling was placed at the bladder neck, which resulted in the adverse events, which I'm going to describe to you in a minute. But I think more recently, those of us that have done pubovaginal slings, I've tended to go more toward midurethra, because of what the feeling and the experience that we've had with the midurethral sling. So sometimes called sling on a string. And here you can see this birch up below, the pubovaginal sling down below that goes at proximal bladder neck or midurethra, pops up through the retropubic space, and is either sutures are affixed or the sling was affixed over the fascia. So the Cochrane data for pubovaginal sling is noted to be more variable, due to there's much more heterogeneity in populations, shorter durations of follow-up, smaller sample sizes. However, efficacy outcomes overall really are comparable between the urethra pexi and the pubovaginal sling. And the differences really between the two are primarily in the complications, where you may see increased complications in one over the other with wound infections, incisional hernias, and voiding dysfunction. So I think it's important to be aware of a landmark study, which was performed through the Urinary Incontinence Treatment Network. We haven't heard about the UITN in many years, being superseded by the Pelvic Floor Disorders Network. The Urinary Incontinence Treatment Network went from 2001 to, we finished up some studies in 2009, 2010. And women in this study were randomized, called the SISTER trial, to retropubic urethra pexi versus rectus fascial sling. And in this study, which was published in New England Journal in 2007, this is where people were starting to first get used to the idea of seeing multi-component outcome measures. And this harkens back to my previous statement, where the surgeon would walk in and say, how you doing? She's doing great. That means she's cured. And a lot of those types of surgeons were actually in this trial. So this was pretty revolutionary for some of our current leaders in urogyne. So in this trial, the primary outcome was at 24 months. It wasn't at three months. It wasn't at six weeks. And success in terms of overall continence were all these things. A negative 24-hour PET test, no incontinence in a three-day diary, negative cough and valsalva testing at 300 cc's, no symptoms, no retreatment. That was cure. Now, overall cure of continence. And then we also, the last three of these, the negative cough stress test, no symptoms, no retreatment, those were specific for stress incontinence. And if you see kind of a similarity to current multi-component outcome measures that we've done in trials in the PFDN, an objective measure, so no cough stress, no positive cough stress test, a subjective measure using validated measures, so no symptoms, and then no retreatment. That's where those three things came into play. Very important secondary outcomes in this trial were post-op urgency UI, avoiding dysfunction, satisfaction with surgery, and we actually did pre-post urodynamics, which was really fun. In this trial, the techniques were standardized. We all did the sling the same way. We all did the birch the same way. And this is where I was alluding to. Ed and I were very used to using Ticron, and we had to switch to proline. And I mean, we debated this for weeks in the network before we standardized. Everybody was doing their own thing. But everybody recognized, in order to get valid data, we had to do this in a standardized fashion. So it was really a cool time. So 655 women were randomized, half to birch urethrapexy, and half to undergo pubovaginal sling. And outcomes were pretty good, about 80% at two years we were able to get outcomes on. And what we saw for overall success, and remember, overall success, they met those six bars, 47% in the sling and 38% in the birch. And you can imagine, old school people are used to hearing, I did great, and we're a little bit hesitant to tell patients that only 50% of women are cured by this. Because patients didn't understand, obviously, that this was based on six outcome measures. But if you looked at the stress-specific outcome measures, it was 66% for sling, 49% for birch. All of these outcomes were significantly different, and the sling was better than the birch for each of these. Overall success, success with respect to stress incontinence, satisfaction was very high with the sling, and urgency urinary incontinence was a bit higher in the sling than the mesh. And Kaplan-Meier reflects better outcomes in the sling over 24 months. So a couple things, a couple caveats. Time to return to normal voiding was greater in the sling group. We didn't have to do a suprapubic catheter, though, as I've had a good discussion with Mike Moen at this meeting, and 20 sling subjects had a surgical procedure, so basically, they had to have their slings cut. But remember, these ladies are still very satisfied. There were no differences in serious adverse events between the two groups. There was more voiding dysfunction, as noted in the sling. But when you look at the numbers, I mean, we're talking 350 women in each group, and we're talking 20 women that maybe had to go back and have an adjustment or a sling cut. There were more bladder and urethral injuries in the birch group. There were no differences in wound complications, serious bleeding, and GI complications between the groups. We did see more urinary tract infections in the sling group, but there were a fair number in the birch group as well. So in summary for this landmark trial, and it's a landmark trial in so many ways, it's a landmark trial in our understanding how to do trials, how to get good comparative efficacy data, how to describe outcomes, how to do it in a way that's valid, how to do it in a way that has meaning for us and our patients. So in this study, the autologous rectus fascial sling was more effective in treating SUI than the birch. However, postoperative voiding dysfunction and NUTIs were higher in the sling. Nevertheless, satisfaction was greater. Two years post sling and success rates were lower than had been previously reported because of the multi-component nature of the definition of the outcome. Definitions are important. And we published this New England Journal. So in terms of the sling itself, how many people have done fascial auto slings and maybe still do them? Awesome. How many people have done rectus slings? OK. Probably more rectus slings around. So there are numerous types of materials, including the synthetic materials. Non-synthetic include autographs or autologous graphs, allographs, xenographs. And there is a fairly recent systematic review that looks at overall efficacy in comparing the use of autographs and allographs. And I was really heartened to hear that, really, allograph pupa vaginal slings are shown to be a very efficacious option compared to the autologous fascial slings and had high patient satisfaction. And it's important because why? Because it has less morbidity, including shorter operative time. You don't have to spend the time harvesting the fascia from wherever you're harvesting it. Lower lengths of stays. These women now all go home where we are, probably where you guys are too, whether you harvest the fascia or not. And low infection rates. So I was very heartened to hear this. And I just wanted to make sure you guys knew. If you trust the use of allograph materials, the outcomes are really pretty good. All right, let's finish up with urethral bulking. So bulking refers to a transvaginal or transurethral. I've done transurethral as well. Typically performed in the office. More recently with bulkamid, performed in the OR, where some substance is injected into the urethral submucosa, typically at the level of the bladder neck. It provides complementation of the vascular and smooth muscle urethral cushions, increasing urethral resistance. And wherever there's a sphincter, you just got to bulk it. We're bulking urethral sphincters. We're bulking anal sphincters. As I noted before in the international consultation on incontinence, it's really not recommended as a primary procedure. Although I have partners that do it as a primary procedure. I think more often it should be used more often in patients that have had a previous surgery, or older and not as active. And remember, we're doing all this in the context of our case, our woman who we're thinking about. So from ICI, a little comparative stuff. So midurethral slings, standard. High success rates, high continence rates, low complications. Most common types, retropubic and trans-opterative. Certainly we have single incisions as well. Objective successive sling procedures, there's often higher objective cure in the full length midurethral slings. Recovery time may be longer. Complications include erosion, retention, urinary tract infections compared to bulking. But they're probably more durable than a bulking procedure. Now bulking mechanism, bulking agents are injected into the urethral submucosa to create an artificial mass effect, improving that urethral closure. Kind of giving back that alpha adrenergic effect to the proximal urethra. Success rates are a little less than a sling, probably 60 to 70%. With success being defined as a reduction of leakage, not actually cure of leakage. Recovery time, typically faster, it's pretty quick. There are complications, however, including UTIs as well as temporary retention. And in terms of durability, not as durable as a sling. There are two groups of urethral bulking agents. The particulate, kind of the old fashioned, that's where I lived for a little while. So particles suspended in a biodegradable gel. So like the macroplastic, silicon polymers running through your urethra. Duracell, let's get some carbon coated zirconium beads in there. And then the coaptite, so the calcium hydroxylapatite. I was never impressed with these. It was great that you could do them in the office, but boy, I just saw anecdotally, it just didn't seem to do the job. There are also non-particulate homogenous gels like the abulcamide polyacrylamide hydrogel. And these hydrogels facilitate ingrowth of connective tissue and vasculature and innervation into the area as well, at least in theory. So you all know bulking. Whether it's done in the office or whether it's done in the OR, typically some lidocaine jelly put into the urethra. I think most of us typically do transurethral. And the needles placed maybe mid urethra, kind of tunneled to the bladder neck area. The injected material is placed and you end up with a good coaptation effect at the proximal urethra. So in terms, in summary, bulking agents should not be offered as first line for women. And an option for those with SUIs and a poor candidate for other incontinence surgeries, I'd say think about bulking. And for those women that may have recurrent or persisted stress incontinence. So I looked again just recently with regard to level one data. There's not a lot, it's mostly non-inferiority data. And this is a pretty good size trial. One year outcomes provided here where it's one of the rare times where you see that a second treatment does not meet an inferiority margin. But at one year satisfaction, which was the primary outcome, between a mid urethral sling and bulking, the bulking did not meet the non-inferiority margin. And there are complications, obviously. So let's get back to our patient. How would you counsel this patient? Who would recommend a birch for her? Laparoscopic birch? Who would recommend a pubovaginal sling? Good deal. Who would recommend a bulking? God almighty. Look at the data. Anyway, how would you counsel this patient?

stress urinary incontinence

non-synthetic mesh

autologous fascial slings

retropubic urethropexies

urethral bulking

patient preferences

voicing dysfunctions

evidence-based approach