She'll be presenting long-term re-procedure rate after midurethral sling. Hi everyone, I'm Sari Tulokas, and I'm from the University of Helsinki, and I actually have the same subject as Dr. Berger before me, which is very exciting. I have received funding from two non-profit organizations, as well as the Helsinki University Hospital. The main goal of the study was to determine the long-term re-procedure rate after NUS operations, and the main outcome for us was a new stress urinary incontinence procedure, in which we included new NUS operations, urethral probing injections, and corpus suspensions, and bladder neck needle suspensions. However, the last two were not found in our sample. As secondary outcomes, we looked into immediate complications, long-term mass revisions, and any other surgical interventions, as well as risk factors for new stress urinary incontinence procedures. However, in this presentation, I will concentrate mainly on our primary findings, due to the limited time we have. This was a responsive register study, because we wanted to get an unselected large cohort sample that would reflect the real clinical practice. The target sample was all NUS operations in our hospital district, in which we included retrocubic and trans-obturator slings, but not minislings or single incision slings. They could be done for any indication. We identified the sample from the hospital records, as well as a national care register. This is a register where all Finnish healthcare providers have to record all their in- and outpatient visits in specialized medicine. In this way, we found 3,285 retrocubic slings and 245 trans-obturator slings. We then identified the complications and the new stress urinary incontinence operations from the care register. For those patients who had a new incontinence operation or a complication, we looked them up from the hospital records and went through the patient's notes to gather more detailed information. Here is the demographics of our sample. You can see that we had a lot more retrocubic slings than the trans-obturator slings. Also, in our hospital district, we did not start doing trans-obturator slings until 2003. Therefore, they had a shorter follow-up time. Here we have the survival curve without a new procedure for stress urinary incontinence. Most of the re-procedures occurred within the first five post-operative years, but they did continue to occur throughout the follow-up time. The overall re-procedure rate for SUI was 3.2% for the whole group, but only 2.6% after the retrocubic sling and 10.6% after the trans-obturator sling. The odd ratio was 3.6 in favor of retrocubic slings. When we did a PAX regression and adjusted for the other risk factors, this difference remained significant. For the re-procedures, most of them were retrocubic slings, but we also saw quite a few urethral bulging injections and also some trans-obturator slings. And for the conclusions that we draw from our study was that the re-operations do occur even in the long term, but most of them happen within the first few post-operative years, and after that the incidence is very low. And also that the retrocubic slings have a better long-term efficacy than the trans-obturator slings. Thank you for everyone for your attention. We'll be presenting urinary tract infection prevention after mid-urethral slings in pelvic floor reconstructive surgery, a systematic review and meta-analysis. Good morning, everyone. I'm May Sanae, and it's my pleasure to present this work with you. Despite everything that's happening, mid-urethral slings are still the most commonly performed surgery for stressed urinary incontinence. Infection is the most common complication of these surgeries, and above all, urinary tract infections. But it's unclear if there's actually evidence-based interventions that we can use that decrease this rate. So the main objective was to identify interventions that prevent infection after mid-urethral sling surgery. How did we do this? We did a systematic review, and we wanted to find the intersection between three big arms. Infection, infection prevention, and mid-urethral sling. Then we assessed the quality of each study using two different methods, and then we also tried to do a meta-analysis, but could only include four of our seven studies. Our methods include looking at the major databases, and we had inclusion criteria that it must be a comparative study design. We assessed post-operative infectious complications and a method to decrease its risk, no language filters, and we actually accepted any infection definition as long as they provided the definition in the paper. We did not really include much of the grey literature, and also not different surgical or populations that are not really in our urogynecology practice. So this is the PRISMA flow diagram that shows that we started with over 1,000 papers, and we distilled that down to 47 papers after looking at the title and abstract. And of those 47, we ended up with seven papers that included reading and analyzing in more detail. So these are the studies that we looked at, and of course I won't go through each of them in detail, but of the seven studies, I'll tell you that one looked at pre-operative antibiotics. Actually, I'll step back and tell you that all of them were about antibiotics, which surprised us. There was no other infection prevention strategy, like smoking cessation, glucose, changing your gloves before you put the catheter in, cranberry, anything that we maybe think that could maybe prevent infection after mid-racial sling is not published in the literature in a systematic way. So they were all antibiotics. One study looked at pre-operative antibiotics, ANSEF versus placebo, and the rest looked at post-operative. And I have a file folder with Dr. Harmanli's name on it that I've been looking at for a couple of years, so it's very exciting to see you here. That one had to be halted early, and I can get into that if there's time. The rest of the studies were a combination of RCTs and cohort studies, a combination of infection definitions and a combination of the actual protocol for what antibiotic to use and for how long. And these are the studies. Two were from Europe, four were from the U.S. We did do a study quality analysis with our team, which included urogynecologists, statisticians, and epidemiologists. And our results, it was so wonderful to get results. We contacted all the study authors, because not all of them reported the sling separately. It was sometimes combined with other pelvic floor prolapse type of surgeries, but they were kind enough to provide us with the data of just the sling alone, and so that's where this comes from. The antibiotic group was 121, and in the non-antibiotic was 144. And as you can see, in the majority, there did seem to be some benefit. However, the slide we've all been waiting for, the forest plot, shows that in fact everything almost crosses one. So our conclusion has to be that post-operative oral nitrofurantoin, which was what we combined, was not effective at reducing UTI in catheterized women after mid-urethral sling surgery, or without concomitant pelvic floor reconstructive surgery for prolapse. We can talk about some more later if there's time. Dr. Berger? Thank you to the Society for the opportunity to present our work. Here are our disclosures. In 2011, the United States Food and Drug Administration published a communication raising concerns about safety and efficacy of mesh for pelvic organ prolapse. Explicitly excluding mid-urethral sling mesh in the warning, litigation groups, public interest groups, and many countries have targeted mid-urethral sling mesh for stress hearing incontinence, along with transvaginal mesh for prolapse. This has led to patients and doctors having increased concerns about treating stress hearing incontinence with synthetic mid-urethral sling surgery. Our objective was to measure the long-term re-operation risk after synthetic mesh mid-urethral sling surgery. We performed a retrospective cohort study, examining all surgeons performing synthetic mid-urethral sling surgeries for stress hearing incontinence within a large managed care organization of 4.5 million patients. System patients obtain all healthcare, with rare exception within this system, and have a high year-to-year retention rate. We utilize procedural and diagnostic codes as well as implant registry data to identify primary procedures as well as re-operations. A primary outcome was the overall re-operation rate after synthetic mid-urethral sling surgery. Secondary outcomes included re-operation for mesh removal and recurrent stress urinary incontinence. The period of incidence was used to calculate the re-operation risk as a function of time, and we calculated adjusted hazard ratios considering demographic and perioperative characteristics. Here we present our results. There were 17,030 primary mid-urethral slings performed during the study period. A majority were retropubic mid-urethral slings, and patients had a mean of 4.4 years of follow-up. 7,524 patients had at least five years of follow-up, while 2,106 had at least nine years of follow-up. Here we present the cumulative incidence over time for overall re-operation, re-operation for recurrent stress urinary incontinence, and re-operation for mesh revision removal. At one year, the overall re-operation rate was 2.1%, while the re-operation for recurrent stress urinary incontinence was 1.6%, and for mesh revision, 0.7%. At five years, the overall re-operation rate was 4.5%, while the re-operation for recurrent SUI was 3.9%, At nine years, the overall re-operation rate was 6%, while the re-operation for recurrent SUI was 5.2%, and for mesh revision, 1.1%. Here we present the model considering potential factors that influence re-operation risk, and we start by considering overall re-operation risk. We found that Asian ethnicity was associated with .41 adjusted hazard ratio of re-operation when compared to white race. When considering other potential confounders or potential modifiers, none were found to be statistically significant. Here we considered re-operation risk for mesh revision removal, and for this, again, no demographic or perioperative characteristics had statistically significant differences. For this, we found no demographic or perioperative characteristics revealing statistically significant differences. However, for single incision slings, there was a 1.5 adjusted hazard ratio of re-operation for recurrent SUI compared to retropubic midurethral slings in this study. There were limitations to our study, including the risk of miscoding, and that we didn't capture office procedures such as office bulking or nonoperative management. It's always possible that patients either had their primary or re-operation at an outside hospital, and we did not capture interoperative complications as these have previously been well described. Strengths included that this is a large, ethnically diverse cohort. We captured a large group of surgeons with diverse practice patterns and multiple medical centers. We linked each patient to an implant. We examined multiple relevant covariates, and we had the indication for mesh removal. So our conclusions were midurethral slings have a low long-term risk of re-operation for both mesh revision and removal, as well as recurrent SUI. We did find that single-incision slings had a 50% greater likelihood to lead to another procedure for recurrent SUI, and this supports the safety and efficacy of midurethral slings for the treatment of stress-nearing incontinence. Thank you. So we're going to shift gears a little bit. This study is around physiotherapy, and we performed a single-blind randomized controlled trial looking at the impact of physiotherapist-supervised pelvic floor muscle training as an adjunct to midurethral sling insertion for women undergoing surgery. So I have no relevant conflicts of interest to disclose. We know in rehabilitation that exercises performed before surgery can enhance surgical outcomes. This has been shown in hip and knee arthroplasty. It's also been shown in prostatectomy patients. So our question was, does pelvic floor muscle training performed preoperatively and a series of three visits postoperatively improve MUS outcomes among women who were previously pelvic floor therapy naive? So my apologies for this not being a concert diagram. It was just too busy, so you wouldn't have been able to see it. Recruitment happened at four sites at three different cities within Canada, and we recruited and screened 236 women. Among those, 104 underwent a very detailed baseline assessment where they were undergoing a clinical evaluation of their pelvic floor muscle strength and tone, an ultrasound imaging evaluation, which is beyond the scope of this study, as well as completing a 30-minute standardized pad test with a standardized bladder volume between 300 and 400 mils and a three-day bladder diary. After the screening and assessment, we had 104 women who had agreed to continue on in the RCT, and allocation was blinded and concealed. It was revealed to the protocol officer and to the patients after the baseline assessment. So women were randomized either to a PT intervention or to a control. In the PT or physical therapy intervention, they received a handout of pelvic floor muscle exercises, they received education, and they received one-on-one training where they visited the physiotherapist six times over a 12-week period. The control group received no physiotherapy intervention, but they did receive a handout. But prior to surgery, that was V2. And then they were reassessed again 12 weeks after the surgery. The follow-up visits at V3, you'll see we had a significant dropout. And I think this is related to the in-depth evaluation we did where we were asking women to also redo our detailed ultrasound imaging assessment. So our sample demographics were similar between groups at baseline. They were around 50 years of age, and their body mass index mean was 28.5, roughly, in both groups. Our primary outcomes were the ICIQ FLUTS overall score and the FLUTS UI subscale score, as well as the pad test. We also had secondary outcomes, including the filling and voiding subscale scores and three-day bladder diary, looking at both the number of leakage and urge episodes per day. The groups were similar at baseline on all of these measures. So you'll see on this graph we have Visit 1, which is the baseline, after the physiotherapy intervention but before surgery, and Visit 3, which is after surgery. In the women who were in the control group, they were significantly improved on their overall score between the baseline and V3, but not at V2, whereas the women who underwent the physiotherapy were significantly improved at each stage. So you can see the difference between the control and the treatment groups on the ICIQ FLUTS overall score at V3. When we broke down the secondary outcomes, we did see significant differences, again, between the first, second, and third visit on both the pad test and the bladder diary. And in terms of filling and voiding subscale scores, voiding subscale score was actually improved in the PT group at V2, and then it stayed consistent after surgery. Our larger finding, when we defined CURE as an ICIQ overall FLUTS score of four or less, we didn't see a difference in the success rate between the intervention and control groups. When we looked at the FLUTS urinary incontinence subscale score, we did see a significant difference between the CURE rates of the groups, with 49% of the women scoring less than four on the ICIQ UI, and in the intervention group, 73%, which was a significant difference. We concluded that when compared to an exercise handout, pelvic floor physio delivered pre- and post-operatively significantly improved subjective reported CURE rates in terms of symptoms of urinary incontinence, yet there was no difference between the intervention and control groups when we looked at the objective measures of the three-day bladder diary or the standardized pad test. Thank you. So we're open for questions now again. Go ahead. I've got a question for Linda. My name is Deb. I'm from Melbourne, Australia. So is my understanding correct that some women were on the wait list who were pelvic floor muscle training naive, and would that be usual in your setting to have such women? And the second question was, did you kind of factor in their baseline pelvic floor muscle strength in terms of modified Oxford score, or whether there was partial or complete levator avulsion, and factor that in your results? Yes, thank you. Those are both very good questions. At the start of our study, it was not unusual to have women on the surgical wait list who were pelvic floor muscle training naive. We did have some issues with recruitment, and one of those issues was that a lot of the physicians had started to insist that the women had actually undergone training before they would consider them for surgery. So that was a significant barrier to our recruitment. All of the women were naive. We managed to meet that, but we did have recruitment issues. In terms of your second question, we did evaluate all of that. The groups weren't different in terms of their modified Oxford scale scores at the start, nor their power. We did the perfect scheme as well. They were also balanced in terms of levator avulsion measured on ultrasound imaging. And what we found was that the women in the PT group had significant gains in strength and power between the first and second visits. The women in the control group, interestingly, also improved in their pelvic floor muscle strength and we did have some adherence data that showed that our control group did a lot more exercise than I would have expected. And I think it's related to the detailed two-hour assessment they did in the lab at baseline that might have biased that somewhat. Thank you and congratulations on your work. Thank you. We'll take a question from the middle. Thank you, yes. Thank you for your work. Linda Kiley, Palm Beach Gardens, Florida. So I noticed that you had what I would consider a fairly significant dropout, particularly in the PT group. You had 13 people who canceled their surgery and I'm wondering did you assess them to find out whether their physiotherapy training resolved their symptoms enough that they felt they didn't need it? Another good question. So yes, we did. We followed up with all the women who dropped out. It was basically a two-to-one ratio between the PT and the control group and all women who canceled their surgery cited significant improvement in their symptoms. We used their data in our intent to treat analysis, but we did, we do, we've been looking at the data every which way to try to tell some more stories with what we have because you're right, there's some interesting information there. Thank you. Question on the right side now. Rhonda Cotterinos, Chicago. This is for Dr. MacLean. Your exercise program was exactly the same in the handout as what was given in the PT group and it was the exact same program they did at home. So what was the difference for when the patients came to the PT visit? So when patients came to the PT visit, the PT would review their exercises and correct them to make sure that they were being performed properly. They would also do education with the women. They would teach them the knack maneuver or a pre-contraction of their pelvic floor muscles before activities that increase intra-abdominal pressure. We did offer the women in the PT group EMG biofeedback for the first two sessions as well to ensure that they were getting a strong pelvic floor muscle contraction, but that was only for two sessions. Other than that, the handout was the same. So there was certainly more contact with the physios in the PT group, but the control group got the same detailed handout. So the exercise program was strictly concentric exercise of the pelvic floor. The exercise program had a series of exercises that were listed and the physiotherapist would progress those exercises based on the patient's or participant's performance. The control group received the same handout, which had all of the exercises listed, but they weren't given any guidance on how to progress. Thank you. We'll take questions on the right side again. I've seen you waiting there. Thank you. I'm Rui Liang from Pittsburgh. I have a question for Dr. Schroeder. I'm wondering whether you have studies comparing this sling on a string with a polypropylene sling. Have you polypropylene sling, the synthetic sling? The question is, are there studies comparing your sling with a polypropylene sling? Thank you for the question. Do you have studies? There is one study that I think that Dr. Emery probably participated to compare the long sling with the short sling that is from 1998. I don't know if it's the same that you gave, Gabriel, and the name of the author. That is a known sling. But we have lots of studies comparing traditional slings with the mesh slings. This kind of small sling, we have recently some reports from Dr. Chappell, 2015. And well, it looks like, I think that we don't know what kind of complication we are supposed to treat. You know, we have different complications with the autologous sling than with the mesh slings. That's a point, in my opinion. Could I just make a comment? We published 10-year outcome data of an RCT comparing a short sling on a string with a standard retropubic TVT. At 10 years outcome, there was no significant difference between any of the outcome measures. So this sling on a string performs just as well as a fascial sling out at 10 years. There are some minor variations, if you look at the paper. We'll take one more question. Thank you. Hi, Julian Labrie from the Netherlands. I was wondering what your rationale was for redoing the physiotherapy and sling study because we've had the portrait trial, which showed no differences between people who did go undergo physiotherapy prior to slings. And we recently had the esteem trial, all very good data, 12-year over 12-months follow-up, and this is only three months. And it's, again, the same study, only showing little differences. So what was your rationale for redoing this study? So we started this study prior to the esteem trial. And in our opinion, there wasn't strong enough data to support a conclusion that there was no benefit. You have it. Thank you. Autologous slings for surgery. My name is Simon Emery. We've done lots of sling studies in Swansea. Started doing autologous fascial slings in about 1991. And we've done studies since. This is just a 17-year follow-up of one aspect of our slings. So the Aldridge sling, just a revised symbol, that's where it started. It was an attached sling. It was an attached sling. It was an attached sling. It was an attached sling. It was an attached sling. It was an attached sling. It was an attached sling. It was an attached sling. It was an attached sling. It was an attached sling. It was an attached sling. It was an attached sling. It was an attached sling. It was an attached sling. It was an attached sling. It was an attached sling. It was an attached sling. It was an attached sling. It was an attached sling. It was an attached sling. It was an attached sling. It was an attached sling. It was an attached sling. It was an attached sling. It was an attached sling. It was an attached sling. It was an attached sling. It was an attached sling. It was an attached sling. It was an attached sling. It was an attached sling. It was an attached sling. It was an attached sling. It was an attached sling. It was an attached sling. It was an attached sling. And so one end was free, and one end was attached. It didn't seem to make any difference. So we then thought, let's have them both detached, and we'll have a free sling. And so that's sling group A, which is the attached, which was replicating Aldridge's work in 1948. And then this was this free sling on a string, and that's how it works. So that's very straightforward. And that's a little picture of an introducer carrying some threads up through. And you pass it very much the same as the later development, which was, of course, the TVT retropubic sling, which rather slowed us down with our autologous slings. However, the world has moved on, and autologous slings are obviously the right thing to do. This is... Now, when we set this study up... I can't see that slide from here. When we set this study up, so we started out with 168, and we randomized them into the short and the long, and there were 84 in one and 84 in another. That was absolutely fine. That was powered nicely. However, it's not powered sufficiently for 17-year follow-up, because people die, and then you lose track of them. So we end up with 52 and 55 in the groups. And if you're used to doing this type of study, that's not going to show you what you want. And we wanted equivalence. So you have to accept that this falls below statistical significance in a pure sense. But if you're actually going to do this type of study, you are going to have to have a lot of people at the beginning. So it's difficult. So I apologise for that. So you have to make do with what you've got, really, in terms of data. And this is what we have. And so our age at follow-up was 68 and 69, so they're doing fine. And we followed them up for roughly 17 years. But it's interesting to note that you've got some people who are needing Botox, who have had Botox as an intercurrent thing, and quite a lot of people at 17 years were taking anti-muscarinics, or laterally it would be a beta-3 agonist, but using some form of medication for some urgency symptoms. If we look down here at angle pain after four days, this is going way back in the first study which we published. If you take a long sling, you're tending to be quite lateral, and you're going to have some angle pain. Take the short sling, you get much less angle pain. Details about how you actually feather it when you're taking a short 8cm sling is just... So if you feather it at the end, you'll get less angle pain. And there's much less dissection. So that was one of the studies. And this is the issue that you want to look at, which is the trend in leakage. So this is the any leak. And you start out with people being very wet. And you can see after five years... So initially, after 3 months, 6 months, 12 months, you're doing very well. There's a slight degradation in effectiveness by 5 years. And it's nice to note that between 5 and 17 years, we've essentially maintained that benefit, which is very comforting. It sort of indicates that the 5-year point is a very useful point in terms of interim long-term studies. And the urgency, you can see here at 5 years, we had more urgency at 5 years, and then slight control by 17 years. And that may be related to the use of anti-muscarinics, may be related to the use of Botox, but we can't really determine that, and we can't give you anything that you will reliably say is statistically relevant. But you've got a trend here. What we're quite pleased with, though, is that the control of stress incontinence, which was our primary outcome, was maintained. So you can look at that in a different way. And if you look at the end group, so that's at the right-hand side of the picture there, you can see there's quite a variation. Some people are perfectly well, and other people are not as well. So you get this range of... And that's how the quartiles fall out, and similarly with the UDI scores. So you get this range at the end. So some are doing extremely well, and some less well, as you see. So we conclude that there's no significant difference between long and short slings. There's a gradual reduction in control of stress incontinence over 17 years. There's overall high patient satisfaction. And we concluded a long time ago that a short sling on a string was better than a long sling, and we subsequently did other studies proving equality of performance against TBT. So this short sling does just as well as any of your favorite mesh tapes. Thank you very much. Thank you very much. Hello, good morning. I'd like to thank the chairman, ladies and gentlemen, for the opportunity to present our work today, which is looking at the long-term complications of mid-result tapes with pain being the most significant issue which has been raised by the patient. So I have no conflicts to declare. So the Monarch trial was a non-inferiority trial. You're tall. You're too tall. So this was a non-inferiority trial, which was designed by Professor Freeman and colleagues, where they wanted to compare the efficacy between the GynaeCare retropubic and the AMS trans-obturator tape. This trial was presented to ICF in 2008 and published in our journal, the IEJ, in 2011. At one-year follow-up, they found that the TOT was not inferior to the TBT. However, there remains a paucity of data and long-term comparative outcomes between these two tapes. Therefore, the objective of our study was to compare the long-term efficacy and complication rates between the two procedures, specifically using patient-reported outcome measures. So we performed a questionnaire survey of the 180 participants of the Monarch trial using patient-reported outcome measures. This is the PGII and the ICIQ flux. And we also performed a numeric rating scale pain questionnaire for vaginal and groin pain and reviewed the patient hospital records for complications. So we had 118 respondents to the questionnaires we sent out. And as Prof Emery has said, this is less than perfect. However, a review of the public literature says that a 65% response rate after 12 years is pretty good. So we're quite happy with that. There was an equal number of TBT and TOT participants that responded to our questionnaire. So 12 years on, there was a significant decline in continence for both procedures, which was much more marked with the TOT than the TBT. According to question 8a on the ICIQ, the TBT was significantly superior to the TOT in terms of cure, never leakage. Most patients, however, reported improved stress incontinence, with only a few having either ongoing stress incontinence most of the time or all of the time. According to PGII, there was a trend with improved satisfaction with the TBT compared to the TOT. However, this did not reach statistical significance. There was no difference between the groups with pain with the majority of patients having no or minimal pain. Culture-proven urinary tract infection was the most common complication in the group. So we reviewed only the notes of the participants who returned their questionnaires due to research governance in the UK. We found that there was no difference in complication rates between the two groups. 4.2% required to return to theatre for excision of tape exposure. 6.7% required a repeat mid-ureteral sink procedure or urethral injections due to failure. And there was 4.2% which required ISD because of voiding difficulty. The most common lust concern at 12 years follow-up was overactive bladder symptoms, which we've seen before in the previous presentations. So in conclusion, we can say that the TBT is superior in efficacy to the TOT. With regards to continence, there is no difference between the two regarding complication rates. And although 12% had ongoing lust concerns, the results are on balance reassuring regarding severe pain, which is the main symptom reported by the media and the main concern voiced by the patient. So we hope that this data, as well as those that have been presented at this meeting, will help to reassure patients and the national inquiries that the long-term complication rates for this tape procedure is actually low. And I'd like to thank all the authors of the MONARCH trial and you for listening. Thank you for the opportunity to be here presenting our data. I am Lucas Reiner from Brazil, from Porto Alegre. It's a pleasure for me. I have no disclosures. Well, the traditional autologous fascial sling is effective and durable. It's an effective and durable surgical option for stress-uniting continence. Complications rates are mainly related to size and position of grafts. And understanding the importance of mid-retro support allowed us to reduce the size of graft and attaching in mid-retro position. That is the source of the mid-retro sling-on-a-string idea. Our objective is evaluate outcomes and complications related to the mid-retro fascial sling-on-a-string technique for stress-uniting continence in women. We performed a retrospective observational study in stress-uniting continence in pure or predominant patients who has performed the mid-retro fascial sling-on-a-string technique. We performed a preoperative new channel with dynamic study in all these patients. We evaluate them in one month and six months visit. This is the technique. You can see the size when you compare with the traditional sling. We have a very small skin incision, about five or six centimeters. We have the mid-retro position of the sling. We have two sutures in the mid-retro to attach the graft to the ureter. The size of graft is about 1.5 or 6.0 centimeters. And it is suspended by proline sutures as you can see in the picture. We use the tension-free idea that these are the modifications related to the traditional technique. This study, we analyzed patients who performed the surgery between June 2013 to June 2018. We had 86 patients with the six-month follow-up. The mean age was 54 years. And we had 90% of improvement for stress non-incontinence symptoms at six-month follow-up. 88% of patients were characterized as subjective cure according to this criteria that you can see. That is the unstressed pine test negative at physical examination. No episode of stress or non-incontinence in the last week. And no wish of starting any other therapy for stress non-incontinence at the moment of the interview, six months after the surgery. Complications. We had 7% of void and dysfunction that we considered transitory. 2.3% of the patients, what means two patients, we do a reintervention related to the void and dysfunction because they can't avoid after the surgery. But no one of them stay under undwelling self-cauterization after three months of surgery. Reintervent just for cut the suture abdominally. We had 7% of fall infection. Urinary endurancy 4.5. UTI, seroma, abdominal vernia. We have two patients with abdominal vernia too. Even using a shortening. When you compare patients with ISD versus patients without ISD, we had a little superiority in the patients without ISD, but it was not significant. It was almost significant, but not significant. But it's interesting because there is an idea that facial is needed, should be used only for ISD patients, but we see that our patients have better results in the group without ISD. When you compare patients with prolapse surgery associated to this link, we have similar results in both groups in terms of results and complications, as you can see in this table. Well, our trial has several limitations as it is a retrospective, a winning center trial, but we consider that the retrofacial with lingual string is a safe and effective option. It has good results even in ISD and concomitant prolapse surgery patients. And we think that MFSSS is a promising mesh-free option for SUI in women. Thank you. Thank you.

stress urinary incontinence

surgical procedures

re-procedure rate

retrocubic slings

trans-obturator slings

infection prevention

midurethral sling surgery

physiotherapist-supervised pelvic floor muscle training