bipolar mode, as well as your settings, and of course, again, anatomy to make sure that you're far away from the structures that you're supposed to, that you could theoretically injure during whatever you do. I personally don't do any supracervical hysterectomies anymore. And, you know. Okay, thank you. The main teaching point around that is with the monopolar scissors, it will close the circuit. And so, if you have it detached from the body, wherever the other end of that uterus is, maybe laying low on the bowel, you feel like you're cauterizing it up atop, but what you're causing is a bowel injury as that circuit is going for its grounding source. So, things that are not attached to the body, you have to remember with the monopolar scissors. Do you follow me? It's something we forget about. And that's not the worst example because I've seen the video where the current jumped from the ovary, they were trying to work on the ovary, hit the external iliac vein, and then started bleeding. So, that's even worse. Yeah, you're right. That's even worse. Agreed. You have a question? Donna Messinger is from Maryland. For those of us born and raised in Kentucky, thank you for showing that good things do actually come out of the state despite the current environment. Thank you for a terrifying presentation. Can you comment just briefly on how you stabilize the patient from a surgery center with that vascular injury to get transported to a hospital? Well, we called the hospital right away. We basically, at that time, I made a mistake. I should have opened up the patient and held my hand on her aorta. They told us, it was a surgery center, it was very close. It took literally like 10 minutes really to bring her in. We did not open that hematoma. And then when we came to the surgery, they were already ready and ready to fix it. But I would definitely encourage all of you, this was an injury that happened maybe like 17 years ago. And I would definitely encourage all of you to open up. Never do fan and steel. Always up and down incision laparotomy and just hold pressure on aorta. Thank you very much. It was great. Thank you. Thank you. Thank you, Dr. Pacek, and thanks for being so courteous and patient with our AV issues. I appreciate that. For our last scientific session, we're going to invite our moderators up. We have Sandy Valaitis and Joe Schaefer who will moderate our last session. Thank you. We're in the last stretch, so hang in there. Introduce them. Yeah, sure. So we'd like to invite up the first paper, paper number 32, Dr. Jackson from UT Southwestern in Dallas. She'll be discussing gross and histologic anatomy of the pelvic ureter, clinical applications to pelvic surgery. All right. Thank you. We have no disclosures. Overall ureteral injury rates during gynecologic surgery range from 0.2 to 2.5%, but higher rates have been reported with incontinence and pelvic organ prolapse procedures. Although the path of the pelvic ureter is well documented, limited data exists on precise ureteral lengths between surgically relevant pelvic landmarks. Failure to identify injury intraoperatively can lead to significant morbidity. Thus, suspected injury warrants thorough intraoperative evaluation. Postoperative voiding dysfunction is a well-known short-term sequelae of gynecological procedures. This stems from the resection of pelvic autonomic nerves which course with the ureter through the ureteral tunnel within the parametria to innervate smooth muscle of the bladder and urethra. The objectives of this study were to examine the gross and histological anatomy of the pelvic ureter with emphasis on the ureteral tunnel region and to correlate findings to prevention and treatment of surgical complications. Unembalmed female cadavers were used to measure pelvic ureter lengths between surgical points of interest. These included from the pelvic brim to the crossover point of the ureter with the uterine artery, from the crossover to the ureter's entrance into the bladder wall, and from the entrance into the bladder wall to the ureteric orifice. Total ureter lengths and vaginal lengths were also recorded. Closest distances between the ureter and clinically relevant pelvic structures were also recorded. These included those from the ureter to the uterine isthmus, the lateral border of the anterior vaginal fornix and those specimens with the uterus, and the lateral border of the vaginal apex and specimens without a uterus. Microscopic assessment was performed in five specimens. As depicted in this image, four tissue blocks were obtained and processed from the left and right side of each specimen to analyze the tissue surrounding the ureter as it courses through the parametria. Nerve density was analyzed, oxygen levels were measured, and to analyze the tissue surrounding the ureter as it courses through the parametria. Nerve density was analyzed automatically in four quadrants relative to the ureter. These are representative photomicrographs of tissue isolated from the right side at the level of the uterine artery used to determine nerve density and presented in sequential slices. The top image is tissue stained with hematoxylin and eosin. Note the position of the ureter relative to the cervix and uterine artery. The middle photo is an adjacent tissue section stained with antibodies against the nerve marker beta-3-tubulin. Quadrants selected for analysis relative to the ureter are shown in this image. The same image is seen on the bottom of the screen with pixel classification. These enlarged images on the right show nerves from the left lower aspect of each photomicrograph outlined by the orange box in each image. Please note on the pixel classification image that beta-3-tubulin positive nerve fibers are represented in yellow, orange, and red and non-renal tissue is represented in blue. A total of 35 cadavers were included. 30 specimens were evaluated by gross dissection and of those 10 specimens had evidence of a prior hysterectomy. The remaining 5 specimens were used for microscopic analysis. Demographics are listed. The total ureter length on the right was a median of 26 centimeters and 27 centimeters on the left. Range is noted in parentheses. The median total vaginal length in specimens with a uterus was 9.8 centimeters and 9.2 centimeters in those specimens without a uterus. The ureter lengths between surgical points of interest are shown in the superior view of a right dissected pelvic sidewall with the ureter exposed from the pelvic brim to the ureteric orifice labeled as UO. The cardinal ligament has been transected and is held with Alice clamps to expose the ureter within the ureteral tunnel. The bladder dome was removed to expose the trigone. The vesicovaginal space was developed to show the anterior vaginal wall. The median length of the ureter from pelvic brim to uterine artery crossover was 8.2 centimeters on the right and 8.5 centimeters on the left. The median length from uterine artery crossover to entrance into the bladder wall was 3.3 centimeters on the right and 3.2 centimeters on the left. The intramural ureter length was 1.4 centimeters on both the right and left. This is a photograph of bilaterally dissected ureters with ureteral catheters in situ. For orientation purposes, the uterus has displaced cephalod and the bladder dome has been resected. The median distance between the ureter and uterine isthmus was 1.6 centimeters on both the right and left sides. The median distance between the ureter and the lateral border of the anterior vaginal fornix was 1.4 centimeters on the right and 1.5 centimeters on the left. This bar graph shows the results of automatic quantification of positive immunostaining using nerve-specific beta-3 tubulin antibodies in anterior and posterior tissue quadrants relative to the ureter. The average nerve density measured as total tissue area covered by beta-3 tubulin positive staining in posterior quadrants was 44% greater than in anterior quadrants. Limitations of this study are listed and include those inherent to any cadaver study. The histologic analysis was limited by the small sample size of five specimens. Strengths included a relatively large number of cadavers examined grossly with a diverse age group and BMI and the comprehensive assessment of using both gross and microscopic samples. Knowledge of specific ureteral lengths at various pelvic regions susceptible to injury is important in diagnosing and managing ureteral injury. Our data suggests that during retrograde catheter, if catheter resistance is encountered at approximately 1 to 2 centimeters from the ureteric orifice, the injury most likely occurred during vaginal cuff closure. If resistance is encountered after passing the catheter 4 to 5 centimeters, injury most likely occurred while securing the uterine arteries. Lastly, if resistance is met after passing the catheter 13 centimeters, the injury most likely occurred at the pelvic brim while securing the ovarian vessels. Our histologic analysis of the distal ureter and its surrounding parametral tissue revealed an increased density of nerve fibers in the posterior quadrant surrounding the ureter as shown outlined in blue. This suggests that dissection or coagulation posterior to the ureter poses the highest risk of denervation to the bladder and possibly to other structures innervated by these branches. Therefore, unless necessary, uterolysis should not be performed in this region. If uterolysis is necessary, avoiding the tissue posterior to the ureter might decrease the risk of nerve injury and therefore postoperative voiding dysfunction. Thank you and I look forward to your questions. When you were doing the measurements on the gross cadavers, did you notice any difference in your measurements as you might be retracting the uterus, like upwards and away from the side you're dissecting? Yeah. With any cadaver study, manipulation of the tissue is certainly a concern, but we really try to leave the ureter attached to the pelvic side wall and peritoneum as much as possible to get the original measurements from point to point in order to decrease that variation. I'm just wondering if there can be a surgical caveat that one might glean. Sure. Like moving the uterus to the contralateral side. We didn't specifically look at that, but that is an excellent point and something that would be a great idea to look at. Thank you. Thank you very much. Thank you. Our next presentation, Use of Orally Administered Riboflavin to Confirm Ureteral Patency During Cystoscopy at the Time of Gynecologic Surgery by Dr. Stitely and Colleagues. I'd like to thank the Scientific Committee for the opportunity to travel here from New Zealand and to present our research. We have no disclosures from our team. Tēnā koutou, tēnā koutou, tēnā koutou, katoa. This is a Maori greeting that translates to a formal greeting to three or more people, and this is repeated three times for emphasis. Acknowledgements go to co-investigators, Dr. McKenzie and Dr. Harlow, and research assistant Gay Ellis, the Gynecology and Surgical Services at the Southern District Health Board in Dunedin, New Zealand, and our funders from Healthcare Otago Trust and the AGEs, and also to the patients who volunteered to be subjects in our study. This is the background of this study. All of us know that iretial injuries can occur with gynecologic surgery. This can occur with prolapse cases, and that intraoperative recognition can optimize outcomes, and sometimes these can be treated simply with removal of a suture. A number of agents can be used to cover the urine, making the visualization of the ureter easier. Those include mesentery, methylene blue, indigo carmine, and fluorescein, which are administered intravenously, and these can have difficulties with lack of availability, and also adverse events, including anaphylaxis. Phenazepyridine is another agent that can be administered orally. However, that requires a prescription, and this is not available to us in New Zealand. This is not a registered medication where I practice, so we're looking for a suitable alternative. So the objectives of our study were to determine primary outcome, if orally administered riboflavin produces a strong yellow coloration of urine more so than placebo, and secondary outcomes, looking if riboflavin improves the ease of identifying the ureterial jet at the time of cystoscopy, and determining if more participants would have the uretary jets visualized on cystoscopy as compared to placebo. So the eligibility, whether the patient's age 18 or above, and having a planned cystoscopy as part of a gynecological surgical procedure. Exclusions included active nephrolithiasis and hyperparathyroidism, and this was due to our placebo being vitamin D. Subjects were identified from the surgery scheduling list. They were contacted by the research assistant and consented at their pre-admission clinic appointment. A permitted block randomized sequence was used, and opaque envelopes for assignment. The subjects, researchers, surgeons, and the video reviewer were all blinded to the allocation assignment. The study group received 400 milligrams of riboflavin orally the evening prior to surgery. The control group received 4,000 international units of vitamin D3 again the evening prior to surgery. During cystoscopy, the operating surgeon looked for ureteral patency for a minimum of three minutes. The cystoscopy was video recorded, and after the three-minute minimum observation period, the surgeon was allowed to, at their discretion, administer additional agents to visualize the ureters as they felt necessary for clinical care. The data forms were completed by the surgeon immediately following the procedure, and the primary outcome was on a scale of coloration of urine, one being clear, two being slightly yellow, and three being strongly yellow. Secondary outcomes were the ease of visualizing the ureteral jet, with one being disagree that it was not easy, and five, agreeing that it was easy to visualize the ureteral jet. I strongly agree. Visualization of the ureter jet bilaterally was a dichotomous variable as a secondary outcome. The video was later reviewed by a blinded investigator, and chart review at six weeks was performed to assess for ongoing, for urinary tract injury requiring a repeat evaluation or treatment. Sample size of 60 was deemed to be sufficient to detect 0.75 mean difference between the groups. On the color scale, 80% power and 0.05 significant level, and we used a 10% buffer to account for dropout. Here's the consult sort diagram that I'm sure you cannot read, but 66 randomized, 33 in each arm, and all received allocated treatment. Demographics were similar in both groups. Here's the primary outcome for strong yellow urine. Riboflavin is on the left, placebo on the right, and you can see significantly higher proportion of subjects had strong yellow urine color as rated by the surgeon. This was a statistically significant difference, a 2.4 higher likelihood of having strong yellow color in the riboflavin group. And here's the three-point scale. Again, using the Mann-Whitney test, this was a statistically significant difference, and you can see here more strong yellow and slight yellow in the riboflavin group compared to mostly clear in the placebo group. So ease of visualization, you can see here, strongly agree that it was easy to see the jets of urine from the ureter in the riboflavin group, and this again is a statistically significant result. But again, most of the time it was relatively, it was felt to be easy to be seen even in the placebo group. Here's a video of the cystoscopy. And of course this band is Chicago, and this is what it looks like in the treatment group. Triumphant music. Is this how we feel when we see this coming from both of the ureters? This is the result for seeing the jets bilaterally. There were three patients in the riboflavin arm and five in the placebo arm where they were not seen. This was not statistically significantly different. There was one confirmed obstruction in each of the arms that was related to kinking from the suture that was rectified by removing the suture. One subject in the placebo group had abdominal pain after taking the study tablets, and one had nausea in the riboflavin group, and no subject in either group required intervention for urinary tract injury at six weeks post-op. So riboflavin 400 milligrams administered orally the night before gynecologic surgery causes yellow discoloration of urine greater than seen with placebo, improves the ease of visualization of the urine jet from the ureter, and did not change the proportion of women in whom both ureters were visualized. Riboflavin is safe and inexpensive to administer, and its use preoperatively may reduce the number of patients requiring intravenous agents to visualize the ureter jet during intraoperative cystoscopy. Hei kona mai mei na mihi, which is Maori translating to goodbye and thank you, and this is a picture of my lovely wife at the top of the Greta track on the South Island of New Zealand overlooking Lake O'Hall. I'm happy to take any questions. Thank you. My name is Harvey from Queen's University in Canada. I do feel the pain for the ligoperidium. We also don't have it, although we can compound it. Two questions. One, it mostly has to do with the timing of the intake of your riboflavin. You give it to the patient the night before. I was wondering, was there a difference in how yellow the urine was noted in a patient that had her surgery and the assessment done in the morning, so more like 12 hours after rather than, say, at the end of the day because perhaps the riboflavin should have been given a bit more like the morning of the surgery? We did not assess for that, and there were cases done in the morning and cases done in the afternoon, and they were all lumped together. We did that, making this really a trial that would be clinically practical to use in practice. So we did not differentiate between morning and afternoon cases. The excretion of riboflavin renally is quite variable, but we did not differentiate. We wanted to make something that would be quite easy to clinically implement. Because if you look at your afternoon cases and see a difference, I would encourage you to do that, then perhaps a morning dose for the afternoon case would be better. And we can do that with a data set, so thank you for that suggestion. Did you decide on three minutes to wait, and if it was longer than three minutes, it was considered not adequate? So we made that as a minimum. That was an arbitrary number that we picked, and that varies, of course, based upon your renal function, the hydration status of the patient. Most of the, or all of the non-visualized cases really had gone 10 minutes or more before being administered to another agent. So we were reasonably patient. Thank you. Thank you very much. Next we'd like to invite Dr. Linder, who will show us her video on techniques and tips for cystoscopic ureteral stent placement. We present tips and techniques for cystoscopic ureteral stent placement. The authors have no disclosures. Urinary tract injury, specifically ureteral injury, is a potentially serious complication of pelvic surgery. Selective use of preoperative ureteral stents in cases of difficult anatomy, reoperations, or other challenging clinical scenarios may aid in dissection of the ureter and identification of an injury intraoperatively as opposed to postoperatively should it occur. As such, pelvic surgeons should be familiar with various techniques for cystoscopic ureteral stent placement. Here we will review techniques for cystoscopic stent placement, including basic cystoscopy and cystoscope assembly, placement of traditional external ureteral stents, lighted ureteral stents, as well as internal double J stents with use of fluoroscopy. The techniques demonstrated in this video are performed in a cadaver. Cystoscope components and assembly. As shown, the cystoscope is comprised of three components, a sheath, a lens, typically a 0, 30, or 70 degree lens, and a bridge, which can either be a single or double working channel, or a deflector, also known as an albarin bridge. Cystoscope assembly includes one of each of these components shown here. The bridge is placed on the selected lens and the adapter tightened. These are then secured to the sheath. Rubber stoppers are used to prevent fluid loss when manipulating wires or stents through the working port. Use of the albarin bridge is shown here. There are two prongs near the lens used to stabilize wires or stents to facilitate manipulation. Shown here is manipulation of an external stent. Traditional external ureteral stent placement. With all ureteral stents, it's important to know the specific markings of the product being used. These catheters have markings every 1 centimeter, with unique markings at 5, 10, 15 centimeters, and so on. The stent is inserted through the working port until it is visible intravesically. The deflector is then manipulated to capture the stent, which is directed to the ureteral orifice. Using markings and tactile feedback, the stent is advanced without fluoroscopy up the ureteral orifice roughly 24 centimeters or until gentle resistance is met. Here you can see slight resistance when the stent is around 24 centimeters. Once in place, the stent can be externalized by removing the lens and bridge while leaving the sheath in place. The sheath is then removed, leaving the stent in place. A Foley catheter can then be placed and the stent secured to the catheter to prevent it from being dislodged. In this example, we placed a single stent. However, this process can be repeated for bilateral stents. Lighted external ureteral stent placement. Lighted ureteral stents are similar in concept to traditional external ureteral stents. However, in addition to tactile feedback, they use infrared light, which can be seen with a specific camera filter to help identify the ureter. This has been recorded in the laparoscopic literature for colectomies, among other procedures, and may be useful given less tactile feedback in some of these cases. This video clip shows use of a lighted stent during laparoscopic excision of a left ovarian remnant. You can see the dissection along the lighted ureteral stent. Following dissection and removal of the remnant, the course of the pelvic portion of the ureter is shown here. Lighted ureteral stents are open-ended and can be passed over a wire. The markings are every 5 centimeters at 5, 10, 15, 20 centimeters, and so on. Following stent placement, a small light fiber is advanced within the stent. The end of this fiber is dilated to prevent over-advancement. Once in place, the stent can either be illuminated continuously or in an intermittent fashion. Here, the guide wire has already been placed, and the open-ended, lighted stent sheath is advanced over the wire. In the cystoscopic view, using markings and tactile resistance, one can determine appropriate stent advancement. Once the stent is in an appropriate position, the wire is removed. The stent can then be externalized and secured to a catheter in a manner similar to traditional external ureteral stent placement. The stent can then be externalized and secured to a catheter in a manner similar to traditional external ureteral stent placement. Following this, the light fiber can be advanced. Following this, the light fiber can be advanced. Cystoscopic internal ureteral stent placement with fluoroscopy. A typical double-J ureteral stent is shown here. There are curls on each side, one for the renal pelvis and the other for the bladder, to prevent migration. A typical double-J ureteral stent is shown here. A typical double-J ureteral stent is shown here. The stent has markings at 5 cm, 10 cm, 15 cm, 20 cm, and the final stent length. There is a dangle attached to it to help with stent manipulation. Additionally, there is a pusher with a radio-opaque end. With wire advancement, the stent is straightened. This allows for stent advancement. Likewise, the proximal curl can also be straightened. When the wire is partially withdrawn, the curl reforms, allowing for controlled stent deployment in the renal pelvis. First, the wire is advanced up the ureteral orifice. If it passes without resistance, a ureteral catheter can then be placed to perform a retrograde pylogram. If the wire could not pass, a Ruttner catheter could be used to evaluate the distal ureter. With the ureteral catheter in place, contrast can be injected for the retrograde pylogram. Shown here is the pelvic portion of the ureter. Moving the C-arm, the mid and proximal ureter, as well as the renal pelvis and calyces can be seen. Visualization of the upper urinary tract is useful in ensuring an adequate proximal curl. A sensor wire is advanced through the ureteral catheter to the renal pelvis. Fluoroscopy is used to ensure its proper position prior to removing the ureteral catheter. Using a push-pull technique, the ureteral catheter is removed with care to make sure the wire stays in position in the renal pelvis. A sensor wire is advanced through the ureteral catheter to the renal pelvis. Fluoroscopy is used to ensure its proper position prior to removing the ureteral catheter. Using a push-pull technique, the ureteral catheter is removed with care to make sure the wire stays in position in the renal pelvis. Next, the stent is advanced over the guide wire. As shown, slight tension on the wire is crucial to advancing the stent. With the stent advanced, the stent pusher can then be thread over the wire. The pusher is then used to advance the stent with adequate tension on the wire. The wire should have enough tension to keep it taut, but not pull it from the renal pelvis. Fluoroscopy is used to monitor stent advancement and the position of the wire. Once the stent has reached the renal pelvis, typically near the solid black line as was just seen on the cystoscopic view, the wire is partially withdrawn to form the proximal curl of the stent. Ideally, the stent would have a 360-degree curl to decrease the chance of migration or stent pain. If, as seen on the fluoroscopic image, the curl is inadequate, the stent can be manipulated using the dangle or wire. With re-advancement, an excellent proximal curl can be seen. With the proximal curl in good position in the renal pelvis, attention is turned to deploying the stent. The dangle attached to the stent is cut and removed while the surgeon holds the stent pusher to prevent the proximal curl from being dislodged. The wire is then completely removed, the cystoscope pointed away from the rotor orifice, and the pusher advanced to deploy the stent. As shown in the cystoscopic image, a complete 360-degree curl is seen in the bladder, and in the fluoroscopic image, the proximal curl remains in the renal pelvis. With the proximal curl in good position in the renal pelvis, attention is turned to deploying the stent pusher to prevent the proximal curl from being dislodged. With the proximal curl in good position in the renal pelvis, attention is turned to deploying the stent pusher to prevent the proximal curl from being dislodged. With the proximal curl in good position in the renal pelvis, attention is turned to deploying the stent pusher to prevent the proximal curl from being dislodged. With the proximal curl in good position in the renal pelvis, attention is turned to deploying the stent pusher to prevent the proximal curl from being dislodged. With the proximal curl in good position in the renal pelvis, attention is turned to deploying the stent pusher to prevent the proximal curl from being dislodged. With the proximal curl in good position in the renal pelvis, attention is turned to deploying the stent pusher to prevent the proximal curl from being dislodged. With the proximal curl in good position in the renal pelvis, attention is turned to deploying the stent pusher to prevent the proximal curl from being dislodged. So this is a novel treatment called SALENSA. And what it involves is applying radiofrequency energy to ablate the nerves in the subtrigonal space. And the goal is to target urgency because the hypothesis is that you have upregulated nerves, possibly C-fibers, subtrigonally, that occur in overactive bladder but in other hypersensitive cases, and that by taking those out, one should be able to get rid of the urgency but not impact normal bladder function. So the goal is to hit urgency, urgency incontinence, and urgency-induced voids. That is in the PPIUS3. That's PPIUS3 and PPIUS4 would be an urgency void. The treatment spares the urethelium and the vaginal mucosa, and the lesion is placed between those. So what we wanted to do with this presentation is to show, to demonstrate, whether there were changes in diary variables after treatment, what happened to quality of life, and to see if we could determine whether there were any prognostic factors that could tell us who's going to benefit. So this is the technique that is used. On the side on the left, you can see that there's a cystoscope that's advanced into the bladder, and then suction is applied through the device at the level of the trigone. And so the panel on the right shows you, with those little marks, where that suction will be applied. And so what happens is that, with the suction applied, you have a three-millimeter distance between the top of the device and where the electrodes will be advanced. So that distance is always the same. And then for one minute, radio frequency, which is temperature control, is applied, and then the suction released, the electrodes withdrawn, and the other side is done. And then you fill in the space in between. So on average, there will be four ablations, but it could vary from three to six, depending on the size of the trigone. What's important here, apart from, of course, having to have normal anatomy, which we see with ultrasound and also cystoscopy, is that you have to be 0.5 of a centimeter away from the ureteric orifice. That's very important. So this is a multi-center study that's carried out in Belgium, Canada, and the United States. We had 71 female patients with OAB who'd failed medical therapy. All subjects had this selective bladder denervation under cystoscopic guidance as a single procedure. We then went on to the assessments pre and post. This is not sham controlled. The assessments pre and post were three-day bladder diary, quality of life measures, King's Health questionnaire, and OABQ short form, and then treatment benefit scale, and this was looked at four weeks, 12 weeks, and 26 weeks. The actual study continues. We're following these people up for longer. So these are the baseline characteristics. As you would expect in a refractory OAB population, the mean age was 67, and they had a duration of OAB for about seven years, and they had pretty significant core mobilities, which you might expect. I mean, I was surprised at how bad this was. It's 48% smoking, 14% diabetes, 42% cardiovascular disease of some sort. So these people had impact on their quality of life with OAB, and so I think that we're talking about third-line therapy here. And then in terms of the voiding characteristics, they had about 3.6 UUIs per day and 12 voids per day, and when we split up the voids into urgency and non-urgency voids, they had two-thirds of their voids were urgency-related and one-third were not urgency-related. Presumably these were prophylactic voids or voids for convenience. And then the King's Health questionnaire baseline was 87 and OABQ was 73. About 79 percent of patients had IV sedation, the rest had general anesthesia. As mentioned, there were four ablations on average. The pre-procedure pain score was .5 out of 10. At four hours, it came down to 2.5, and at 24 hours, it was down to 1.4. So reasonably well tolerated. Now, this is an interesting slide because what we've done here, and I hope you can see it, it projects well enough, that we've got looking at the scatter plot of UUIs per day against OABQ symptom bother. And as you can see, the more UUIs they had, the more symptom bother they had. Interesting, the next panel looking at voids, there isn't a correlation between the two. However, when we cut the voids down into those that are due to urgency and non-urgency, we find a positive correlation with urgency voids, and oddly enough, a negative correlation with non-urgency voids at baseline, suggesting that prophylactic voiding, in a way, helps these patients with their quality of life. So the data at six months, which is what is displayed here, we had 63 subjects, and you can see that we had a decrease in UUIs of 70%, a responder rate of 64%, a dry rate of 30%. Urgency episodes were declined by 50%, but average voids per day were only declined by 15%. But the urgency-related voids were declined by 50%. And there was no post-void residual. We didn't have any retention of urine. And the treatment benefit was 71%. So these people seemed to benefit from this therapy. And so I'll just quickly show you the graph showing urgency in UUIs as it declines from pre-procedure to six months, and also the dry rate, the responder rate, and the TBS, which is the total benefit scale, which is just an overall questionnaire on whether they got improved or very much improved. You can see with King's Health questionnaire and OABQ, there was improvement in both concurrently with the improvement in diary variables. So what we can say is that UUI severity was the only baseline variable that could predict treatment benefits. So we looked at all the other variables, and they didn't come out in the multivariate analysis. And what was interesting also was that with the baseline data, that the correlation to, sorry, when we looked at the change in quality of life between the groups who had less severe incontinence and more severe incontinence, the only thing that changed in terms of quality of life was with UUIs. The other variables were not predictive of how the outcome was going to come out. So there was a relatively safe procedure. There were no adverse events of note. There was one patient who had unrecognized uretera seal that was ablated, and she required a double-J stent, and the obstruction was relieved after that. But what's interesting is that at six months, she had an 83 percent reduction UUI, 94 percent reduction urgency, and no urgency voids. So I think that the key message here is you must have normal anatomy and have to be very careful that there are no abnormalities of the way the uretera is moving through towards the bladder or what happens to the intramural ureter. The limitations of the study, this is uncontrolled. There's a small number of subjects with a small number of sites, and the follow-up is only for six months, so clearly we need to do some more work. But we think that the results are encouraging enough for us to move forward to a sham-controlled study. So in conclusion, then, we'd like to state that selective bladder ablation of the trigone has potential to improve bladder of diary variables, treatment benefit scale, and quality of life measures, and that there was no retention of urine, and the UTI rate was as would be expected in OAB patients. It was pretty low. And that the only thing one can say about the patients is you have to have normal anatomy. Thank you very much. The procedure looks a little bit scary. Can you discuss that aspect of it? I mean, even .5 millimeters from the UO would be generally a place where we don't want to be burning. Yeah. So, yeah, I was scared as well when we first thought about this. The first thing I thought about was a fistula, right? And what's interesting is that we did sheep work beforehand. What was interesting is sheep is a challenge model so that the distances between the vaginal wall and the urethelium can be as little as 3 millimeters. In humans, it's going to be between .5 and 1 centimeter. And there seems to be a heat sink effect whereby the urethelium doesn't get damaged even, and, you know, we haven't got enough data to be able to say this categorically, but we think that the lesion size goes down with the thickness. So the heat sink effect tends to prevent a full thickness burn. Now, in terms of how close you are to the ureter, you know, the cases where there wasn't a ureter seal, there didn't seem to be a problem, but none of the sheep had a problem. We've just more recently done a study where we actually bladed over the ureteric os in the sheep, and there was no obstruction. So, again, you know, this is early days, but what's interesting is that if this therapy holds up in terms of durability, then it really will have legs. Next question. I'm curious. I actually did a little experiment with radiofrequency myself, vaginal tissue regeneration procedure, and I was blown away by the impact of radiofrequency in that I didn't know I had overactive bladder until after I had that treatment done. I was like, whoa, this is fabulous. So the question I have for you, but the bad news is that it only lasted for three months. So the question I have for you is, knowing that, having experienced that myself, I'm kind of curious what your opinion is of the comparison of doing that kind of a procedure as opposed to a more invasive inside-the-bladder type procedure. So you mean going by the vagina rather than going from above? Going inside the bladder itself, because, I mean, based on your slides there, where you see the six-month point where it's going down, which is what they typically say, six-month point to a year is where you have to have it done again. And if that's the case, and based on what I experienced personally, what the benefit would be of doing the more invasive internal bladder procedure as opposed to inside the vagina itself. Okay. So we presented the ICS one-year data, and it looks like the efficacy is holding up. You're following up to, at the moment, up to 18 months. The lady I talked about who had the urethra seal, she's out to two years, and she has no symptoms at all. So I don't know. This is early days. We really didn't have a lot of numbers. But we will follow up. And, of course, when we do the sham-controlled study and really have long-term data, that will, you know, answer the question. But I can't tell you for now how long it will last for. I didn't quite understand your question about, were you implying that you should do less invasive procedure by going to the vagina, given... Yeah, comparing the two types of procedures. You're doing the vaginal tissue regeneration itself as opposed to going inside the bladder and using radio frequency in there instead. Yeah. I mean, obviously, if you could go by the vagina, it was less invasive than the cystoscopy, that would be great. But, of course, we'd need the data to show that. Thank you. Hi. I was just wondering, would this ever be a thought for the office in regards to pain requirements? Yes. Of course, when you're first starting, we wanted to be in a setting where we felt we had more control. We were worried also about how we'd get the anesthetic, right? So we planned to do a study where we would be able to use local anesthetic, and we were pretty convinced we'd be able to do it. But we didn't want to do it in this first set of patients. And we're working at the moment in different ways of giving analgesia to work out what would be the most optimal, but we're not there yet. Okay, second question. In regards to patients with significant prolapse, was the prolapse corrected in any way prior to these procedures being done? No. You will appreciate, of course, if you've got a significant prolapse that you might find that the trigone, when you're looking through the scope, is going down, you could put a finger in the vagina to lift it up. But as long as the actual device, which is parallel to the trigone, then the electrodes can be deployed, and you know that you'll be in the right place. So, no, you do not need to repair the prolapse beforehand. Thank you. I'm afraid we're running behind, so that'll conclude the questions. Thank you very much, Dr. Versie. Thanks very much. Thank you. Next, we'd like to invite Dr. Ross from McEwen Women's in Pittsburgh, who is going to speak about external validation of the De Novo Postoperative Stress Urinary Incontinence Calculator. Thank you for allowing us to present our research. We have no disclosures. The De Novo Stress Urinary Incontinence, or SUI, risk calculator was developed using clinical trial data from the Pelvic Floor Disorders Network to assist surgeons with the recommendation for concomitant incontinence procedure at the time of surgery for pelvic organ prolapse. To the right of the screen is a screenshot of the calculator phone app. Using clinical variables of age, body mass index, vaginal parity, diabetes, preoperative urge urinary incontinence, and preoperative stress test results, the calculator generates two probabilities for development of postoperative De Novo SUI. The probabilities reflect likelihood of developing SUI if a continence procedure is or is not done concomitantly. The calculator was developed using clinical data from the OPUS trial, which utilized native tissue vaginal apical suspensions. It was then validated using data from the CARE trial, in which women underwent open sacrocopalpexy. There is little data available on the utility of the calculator in general clinical practice or in its performance in women undergoing minimally invasive apical suspension procedures. The objective of our study was to assess the external validity of the De Novo Stress Urinary Incontinence Risk Calculator in women undergoing minimally invasive or transvaginal apical suspensions, both overall and by procedure type. This validation study used data from a preexisting database of women undergoing prolapse surgery by seven FPMRS surgeons at an academic medical center from January 2009 through August of 2015. It was comprised of women who underwent laparoscopic and robotic sacrocopalpexy and MIS or vaginal uterosacral ligament suspensions. We included patients with preoperative subjective stress continence defined as absence of patient reported symptoms of urine leakage with cough, laugh, sneeze, or exertional activities as documented in the electronic medical records. Women without symptoms who were found to have occult SUI during cough stress test systematics or urodynamics were included. Continence status and interval or stage in continence treatment was abstracted from office medical records up through 12 months after prolapse surgery. Using the calculator, we generated two scores for each patient reflecting the probability of De Novo SUI with and without a concomitant sling. A linear regression was performed for the primary outcome of De Novo SUI. Receiver operating characteristic curves were generated and from those the concordance index or C index was calculated. A C index is a value that defines the discriminative ability of the calculator or goodness of fit of a model. A value of 0.5 indicates the calculator performs no better than chance. 0.51 to 0.74 indicates moderate concordance with a score of 0.5 or greater is considered high concordance. Data from 502 women were included in our study. The mean age of the cohort was 61 years. BMI was 27.1. Reflective of our program's inclination to stage diagnostic testing and treatment of SUI, 62% of patients did not have documentation of preoperative stress testing. The calculator includes this option on its interface. We found no difference in clinical characteristics amongst women who did and did not develop De Novo SUI except a greater percent of those who developed it had a preoperative positive stress test with 11% versus 3.4%. Most patients had stage 3 prolapse. 85% had a minimally invasive sacral copepaxi with the remaining 15% a uterus sacral ligament suspension. 30 patients underwent a concomitant midurethral sling, all of whom did not develop De Novo SUI. Postoperatively, 118 patients developed De Novo SUI. Of those, 12.7% reported subjective spontaneous resolution within 12 months of surgery. 28% of patients underwent a staged sling procedure, while 22% pursued non-surgical SUI treatment. For our overall population, the SUI calculator demonstrated moderate discrimination between confidence outcomes in the setting of a concomitant sling with a C index of 0.55. The results were similar in the sacral copepaxi subgroup. In contrast, the calculator was not able to discriminate with significance the risk of De Novo SUI when a sling was not planned both overall as well as in our individual procedure groups. To better understand why the calculator was not performing well in our population, we looked at the distribution of the overall cohort's predicted and observed risk. Shown along the x-axis is the predicted SUI risk distribution in 10% increments. The y-axis is the percent of the population in each risk distribution for both the predicted risk in blue and the observed SUI risk in orange. For example, in the 30% to 40% SUI distribution category, the calculator assigned this predicted risk to 47% of women, while only 22% of women reported De Novo SUI, the observed outcome. As you can see, in our population, the outcomes were not normally distributed. This calculator highlights that it is most accurate in a population in which it was created, and in our study of women who predominantly had an MIS sacrocopalpexy, the calculator was not found to be accurate. The strengths of our study included a large sample size, seven different attending surgeons, and inclusion of contemporary minimally invasive surgical techniques for prolapse repair. The limitations included that our data for the primary outcome of De Novo SUI was retrospectively ascertained from the electronic medical record without the benefit of a standardized validated questionnaire. Also, the outcome assessments were often done by the surgeon, which introduced potential bias. In summary, we found that compared to the populations from which the calculator was formed, in a population of women who predominantly underwent minimally invasive sacrocopalpexy, the De Novo SUI calculator was moderately predictive in women planning a concomitant midurethral sling. It was, however, not able to discriminate continence outcomes in women electing expectant management. Surgeons should be aware of the limitations of the SUI calculator. The calculator remains a useful tool in preoperative counseling for minimally invasive sacrocopalpexy when a concomitant sling is planned. The calculator requires refinement to inform on a woman's risk of development of SUI if she defers a concomitant sling and instead elects an expectant strategy. We wish to thank Dr. Dennis Wallace of RCI International for help interpreting the results of our analysis. Thank you, and I welcome any questions. Excellent presentation, thank you so much. There was another presentation in the concurrent sessions that showed kind of similar outcomes, but it wasn't predictive. But did you consider that perhaps the standardization of the assessment for stress incontinence before surgery, which was a retrograde fill in the opus, could be used as a standard for the assessment for stress incontinence before surgery? Yes. Before surgery, which was a retrograde fill in the opus, folks with a 300 milliliter volume with reduction in stress testing, as well as the definition for urinary incontinence post-op, did you use the exact same preoperative assessment and postoperative definitions for your outcome? No, we did not. We attempted to kind of use this study to assess the generalizability of this calculator, which a lot of the times was just based on physician questioning the patient after surgery, incontinence, yes, no. And that's more of how we abstracted that data. Thank you. Thank you. Our next presenter is Dr. Elshatanufi. The paper is pessary versus poise impressa trial for the management of stress urinary incontinence, a randomized crossover trial. Good morning. Thank you for allowing us to present our work here, and thank you for sticking around until the bitter end. Thank you. So this is our study comparing the incontinence pessary versus the over-the-counter poise impressa. As you know, the pessary has been around for over 50 years. We have a very established relationship with how to use it and comfort for stress urinary incontinence, as well as pelvic organ prolapse. However, for the poise impressa, we don't have enough detail as far as even answering our patients' questions about the efficacy of this product. Do I move to the next one? All right. I have no relevant disclosures. So the aim of the study was to compare the incontinence pessary versus the impressa device for the treatment of stress incontinence and also to assess patients' preference. Methods. This was a randomized crossover trial. Patients were recruited from a female RFP-MRS clinic. Inclusion criteria were female patients over 18, as long as they came in complaining of symptoms of loss of urine with coughing, sneezing, laughing, and also demonstrated stress incontinence on clinical exam. Exclusion, of course, was OAB symptoms or urge-predominant mixed incontinence, as well as pelvic organ prolapse over stage 2. Also, because of our patient population that generally comes to the FPMRS clinic, some patients, after multiple exams, patients were excluded if they had significant atrophy that would preclude them from being able to tolerate an intravaginal device. So the randomization basically was to the poison impressa or the incontinence pessary. It was done by blocks of four computer-generated sequence. Baseline demographics were collected, and then we also collected the baseline severity using the international consultation of incontinence questionnaires, a short form, as well as objective data using a 24-hour pad test that was returned to the clinic for weigh-in. Also, they were able to do a baseline urinary quality of life measures, including the urinary distress inventory, as well as the incontinence quality of life. Those measures were done at baseline, and then they were done after the first intervention, which lasted for three weeks. And then they had a two-week washout, and then they were done again after the second intervention after the second three weeks. They also, after each intervention, not with the baseline, but after each intervention, they also completed a patient global impression of improvement. To achieve statistical power for 80% power and also 0.505 alpha error, 40 patients were required. And then Whitney, Hugh, and Wilcoxon signed tests were used. So, again, this is the trial flow diagram. We aimed to get 40 patients. However, I was graduating, so we had 25 patients who were determined for eligibility. Four patients were excluded because their symptoms were more OAB or OAB-ultra-predominant mixed incontinence. And then 21 patients were randomized to start out with the IMPRESA, 12 of them. And then nine started with a pessary. And then after the two-week washout, they crossed over to the second treatment. So this is our baseline characteristics. The average age was 51. Average BMI was 32. Nothing else was significant. Anyone beyond stage two prolapse was excluded. As you can see here for our preliminary results, there is no difference. There is no statistical difference between pad weight, ICIQ, the UDI6, or IQOL, between both treatment groups. However, when you look at the patient global impression of improvement, there tended to be patients who preferred the pessary over the POIS IMPRESA device. So, in conclusion, there was no subjective or objective data that we could get that was based on the validated questionnaires or even our pad weight test that we could see a difference between the two devices. However, with the patient global impression of improvement, definitely saw significant improvement with the incontinence pessary over the device. Thank you. Cost. What is the cost of the IMPRESA? So we tried to take that out of the equation for our patients so it was actually supplied. But as you are aware, the pessary is a one-time single purchase. It can last 20 years. You don't even pay for it. It's covered with insurance. As opposed to the IMPRESA, a pack of 10. And because it's over-the-counter, it's designed to look like a tampon, so it's more appealing to women or at least familiar. A pack of 10 is like $12 to $13. So if they're using one, the cost can really go up. But we just wanted to just see, based on just efficacy and preference, which one they would prefer. And it seemed that they preferred the pessary. The idea of maybe having to maintain it every day seemed to be an issue for our patients, especially with patients that were dealing also with atrophy. That was my next question. So how long did you instruct the patients to wear the IMPRESA versus the pessary? Like how often were they removed? So per the manufacturer's requirements. As you know, with the IMPRESA, because it's designed with a tampon and it has that fabric, the concern for toxic shock. So the requirement is eight hours. So they were told, pick the best eight hours. If it's when you go to the gym, pick the time around that and use it then. But, yes, after eight hours you have to remove it, and you cannot replace another one until the next day. It's a maximum of eight hours and 24 hours. Versus the pessary, they could come back in two weeks, three months. So we knew how to maintain it, our younger ladies, and it was a much more convenient option. It seemed like it, at least. Just a little seed for you. What we found in our patient following is for those women who are not sure if they want to try a pessary or not, this is a good option too. It's a one-time purchase. Pick up that pack of IMPRESA and try them just to see if you're comfortable doing the pessary thing. And if that does provide that support that you need and it works pretty effectively for you, then you can go ahead and go down that road. Absolutely. I did have some patients that came in already with the experience of the IMPRESA, but gosh, I cannot keep paying for this. And they loved their pessary after that. Absolutely. Thank you. One last question. Thank you very much for your study. I was wondering, in the thing you may have collected but didn't present, any comfort or discomfort data about either of those pessaries? Was one more comfortable than the other? So I think this is what we actually saw reflected in the PGII because, really, as far as efficacy, they seem to be equivalent. But a lot of patients, actually, they would write essays on the back of their questionnaires about how it's just having to think about this every day. And because it's got that fabric on it, it's scratchy in and out as opposed to the pessary where you could just leave it in for up to three months and a lot of them knew how to take care of it and it just didn't have that much trauma on the tissue. And it was an incontinence ring as opposed to a ring pessary with incontinence knob that you were using in your study, correct? It was an incontinence ring with a knob, yes. Thank you very much. Thank you. And now, last but not least, to conclude our event, thanks for sticking around to the very end, we'll introduce Dr. Probst who will present the data from Hartford Hospital on the timing of office-based pessary care, a randomized trial. So she's going to talk about how long they should have the pessaries in. Good afternoon. Thanks for sticking around and for allowing us to present our work. We have no relevant disclosures. Vaginal pessaries are considered a first-line management option for pelvic organ prolapse and stress urinary incontinence. Vaginal pessaries have been shown to improve prolapse symptoms, quality of life, bowel symptoms, and body image perception. Despite their widespread use, optimal timing of pessary care to prevent complications is not well studied and practices vary widely. We conducted a randomized trial of office-based pessary care of three-month versus six-month follow-up. Patients were allowed to participate if they were wearing a ring, gale horn, or incontinence dish pessary or undergoing office-based pessary care. They were excluded if vaginal epithelial abnormalities were noted on exam or if they were caring for the pessary on their own. We randomized patients in a one-to-one fashion to one of two study arms and followed them for 48 weeks. Patients in the routine arm underwent pessary care every 12 weeks for a total of five study visits. Those in the extended arm underwent pessary care every 24 weeks for a total of three study visits. At the baseline visit, demographics were collected and exam was performed. At follow-up visits, pelvic exam was performed. The pessary was removed and cleaned. The vaginal epithelium was examined for abnormalities and the pessary was replaced if appropriate. Patients were also asked about degree of bother due to vaginal discharge, vaginal bleeding, pessary discomfort, and changes in their medications. A primary objective was to determine if extending the time between pessary visits would lead to an increase in vaginal epithelial abnormalities. For the purposes of this study, we developed a classification system for epithelial abnormalities to describe our exam findings. Abnormalities of type 0 indicated that the epithelium was completely intact. Type 1 was epithelial erythema. Type 2, granulation tissue. And types 3 and 4 represented a break or erosion in the epithelium with type 3 of less than or equal to a centimeter and type 4 greater than a centimeter. Secondary objectives included degree of bother due to vaginal discharge, number of unscheduled study visits, patient satisfaction with extended pessary care, and patient characteristics associated with development of epithelial abnormalities. We conducted a power analysis and used a baseline rate of abnormalities of 7.5%, which is based on unpublished data from our division. We considered a doubling of that rate to be a clinically significant difference, and we allowed for a 5% dropout rate, and this indicated that we needed 126 subjects or 63 per arm. This is our enrollment data. We assessed 448 patients for eligibility in the study. 318 were excluded, and the majority of these, 270 were excluded for not meeting our inclusion criteria, and this was predominantly women who were caring for their pessary on their own at home. 130 patients were randomized, 64 to the routine arm and 66 to the extended arm. These are our population demographics. The patients who participated were predominantly postmenopausal, using vaginal estrogen and reported no bother from vaginal discharge at study enrollment. Those in the routine and extended arms were similar, with the exception of the pessary type where those in the routine arm were more likely to be wearing a ring pessary, and those in the extended arm were more likely to be wearing a gell horn. Moving on to our primary outcome, which was vaginal epithelial abnormalities. This was assessed in two ways. First, we looked at number of epithelial abnormalities, but given that those in the routine group were examined more often than those in the extended group, we also compared this as a rate of number of abnormalities per number of visits. So first focusing on the number of abnormalities, we compared this for our different types. So considering types 1 through 4 abnormalities, these were more common in the routine arm. Types 2 to 4 were more common in the extended arm. And types 3 and 4 were more common in the routine arm. When we're looking at rate of abnormalities per number, or number of abnormalities per number of visits as a rate, there was no difference when we considered all types of abnormalities. Types 2 to 4 were more common in the extended arm. And types 3 to 4 were more common in the routine arm. Patients reported degree of vaginal discharge based on a 5-point Likert scale with lower numbers indicating a less degree of bother. When we compared this between groups, there was no difference and degree of bother overall was low. Number of unscheduled study visits was also compared between groups and no differences were found. And the majority of patients in the extended arm told us that they preferred the extended visit window. We assessed for factors associated with development of epithelial abnormalities. And we found that patients who developed abnormalities types 1 through 4 had a longer lifetime duration of pessary use than those who didn't. When we assessed this for types 3 and 4, the duration of pessary use was not significantly associated. Considering history of epithelial abnormalities, patients who had a history of epithelial abnormality were more likely to develop types 1 through 4 abnormalities and types 3 and 4 abnormalities during the study period. There were no other factors that were associated with development of abnormalities. Other than the abnormalities noted here today, there were no adverse events related to pessary use in this study. And the rate of patient withdrawal in the study was similar between arms. Strengths of our study lie in its randomized design, ability to address gaps in literature, and our limited exclusion criteria, which can help us lead this to extrapolation in general practice. We're limited that we can't make conclusions about other types of pessaries without women undergoing self-care of their pessary. To summarize, extending the interval between pessary visits led to a similar rate of type 1 through 4 abnormalities and a lower rate of 3 and 4 abnormalities. There was no increase in bother from vaginal discharge, it was preferred by patients, and there were no adverse events associated. For women receiving office-based pessary care, we believe that routine care can safely be conducted at six-month intervals. Thank you. APPLAUSE Thank you very much for your study. This is very interesting. I was wondering, would you be able to comment on what is your recommendation with regards to local estrogen? Many of us use local estrogen with patients with pessaries in the hope of decreasing the erosion, although the data is not really there. So were your patients encouraged to use local estrogen or not? And the other thing is, how can you find statistical significance with the results you have in terms of median interquartile range of 0 to 0.5 versus 0 to 0? I'm puzzled by the statistics that you obtained. Thank you for your questions. We look specifically at use of vaginal estrogen because I think many of us commonly use it to try and prevent abnormalities. And the use of estrogen in our study was pretty high. It was in the 75% range, so most patients were using it. When we compared use of estrogen to development of abnormalities, there was no association. So we often encourage our patients to use it, so the patients that were on it or who weren't on it were really those that declined it. So I think because most of the patients in the study were using it, I can't really make conclusions about it, other than lack of an association that we found. And in terms of the interquartile ranges, in general in the study the rate of abnormalities was pretty low. And so we found that to be encouraging, but we found some difficulty interpreting those IQRs as well. Thank you. I have a question. When you were randomizing the patients, were these all new patients, naive to pessaries to begin with, or were they patients who had already been using pessaries and then you randomized them to these different intervals of follow-up? That's a good question. So we allowed any woman who was already wearing a pessary to be enrolled in the study, but we did not offer it at new visits. Because if we were going to send someone with a six-month interval, we didn't want to do that from the day that she was fit with the pessary. Thank you very much. Thank you. So this concludes our last session. Thank you very much for staying, and have safe travels. Thanks, everybody. I just want to put a quick plug and reminder that next year we have the joint Ogs iUGA meeting in Nashville, Tennessee, Music City. You saw the great video this morning, and it should be really a fantastic joint event. It will be a little bit longer. The meeting will start on Wednesday afternoon like it did in Washington, D.C., and we will probably move some of the activities to Saturday afternoon for the extracurricular things like Fellows Day and that kind of stuff. It should be a great meeting. We're really excited, and thank you, everybody, for attending. Please give your feedback. We made some changes this year and really would like to hear about what you thought of those and how we can make it better for you. Thanks so much, and we'll see you in Nashville. Thank you.

cystoscopic ureteral stent placement

SALENSA

urinary incontinence

quality of life

incontinence pessary

Poise Impressa

stress urinary incontinence management

therapy preference

safety concerns

convenience

non-invasive treatments