So it's just about six o'clock here, so I want to thank everyone for being here and welcome to today's webinar. I'm Dr. Cynthia Falk, the moderator for today's webinar. Before I begin, I'd like to share with you that we'll take questions at the end of the webinar, but you can submit them anytime into the Q&A section located at the bottom of the event window. Today's webinar is titled Voiding Dysfunction After SUI Surgery, being presented by Dr. Steven Krause and Dr. David Austin. Dr. Krause is professor and vice chairman of the Department of Urology at the University of Texas Health Science Center at San Antonio, where he heads the division of female urology, neuro urology, and voiding dysfunction. Dr. Krause has served as faculty for many postgraduate courses and topics including neuro urology, female urology, overactive bladder, male incontinence, and voiding disorders, and neurodynamics. A fellow of the American College of Surgeons, Dr. Krause is also a member of the American Urological Association, the International Continent Society, the Society of Urodynamics, Female Pelvic Medicine, and Urogenital Reconstruction, SUFU. He's on the board of directors for SUFU and for the Texas Urological Society, where he also serves as the chair of the education committees for both organizations. Dr. Krause is also the co-chair of the AUA Guideline Panels on Neurogenic Lower Urinary Tract Function, and has the SUFU OAB Clinical Care Pathway Project. Dr. Krause is actively engaged in research, and he served as the principal investigator for a variety of studies and grants, including the Urinary Incontinence Treatment Network, sponsored by the NIH NIDDK. In addition to serving on the Editorial Board of Drugs and Aging and the BMC Urology, Dr. Krause serves as a reviewer for the Journal of Urology and Neuro Urology and Neurodynamics. His clinical practice is heavily focused on urinary incontinence, overactive bladder, neurogenic bladder, and complex voiding disorders. Dr. David Austin earned a bachelor's degree in nutritional science from the University of Florida College of Agriculture and Life Sciences. He attended medical school at the University of Tel Aviv, Israel. And after medical school, he completed a preliminary year in general surgery at Brown. He then completed a residency in Obstetrics and Gynecology at Orlando Health. He began his FPRM fellowship at Cleveland Clinic, Florida, and is currently finishing his fellowship at FPRMS at UT Health, San Antonio. We'll let you get started on the presentation now. Thank you. Okay. Thanks, and I'm sorry. I guess we forwarded the bio and I probably should have edited it. There's always more than we needed to know. So thank you for joining us. And hopefully, David and I are hoping that you'll have a enjoyable time today. These are my disclosures. I'm a consultant for Exonix, Allergan, Astellas, Ovation, Incube, and Medtronic. And then Dr. Austin has no relevant financial or relevant relationships to disclose. What I'd like to do is start with a case. Actually, this is a topic near and dear just because I deal with it a lot. This is a real case from one that I had in the past. This course has been up on the Aug site for some time now. We've modified this, but it was nice to hear that this is one of the most well-attended or frequented course. So I hope to keep it that way. So hopefully our updates will be worthwhile for you. Basically, I hope you have a good time with this. This should be an interesting topic. It's unfortunately a more common topic than we really would like to say, but it is also something that we should be comfortable managing. So that being said, we'll start with this case. 37-year-old female who presents with worsening frequency, urgency, and urgent comments. She has a history of having undergone a retropubic transvaginal tape, which unfortunately required a experienced postoperative retention and required a quote, sling takedown, end quote. You, the good provider and surgeon, pull out the operative report from the other surgeon and it says, yes, the firm band was found and incised. Patient reports she experienced some improvement in her voiding symptoms and the residuals improved, but she's still not emptying very well. She still has some high residuals, at least before she was in retention. Now she's emptying, but her PVRs are high and she still has a weak stream. She doesn't have any stress incomes, so that's a good thing, but her past medical history is really not contributory to anxiety and depression. She had a vaginal hiss with a retropubic sling back in January and a quote, sling takedown in February. Men's are listed. Of course, she's an ICU nurse. You see her in the hospital. On exam, normal genitalia, normal female genitalia, there's no signs of mesh erosion and there's no real palpable hypersuspension or any kind of hyperlift by that. Her UA is clean, but her PVR is 120. So obviously this is a case of someone who has had problems voiding after her retropubic sling. And then we'll go into the topic now and then we'll come back to the case. So the first question is really, how do you want to define voiding dysfunction? It's one of those diagnoses that's really hard to characterize. It's like saying when someone has heart disease, it could be angina, it could be heart block, it could be congestive heart failure. It really is a smorgasbord of different options or different possibilities. Here are a couple of attempts. Halen back in 2010 referred to it as a diagnosis of symptoms and neurodynamic investigation is defined as an abnormally slow or incomplete micturition. Karam did another attempt, manifestations of voiding dysfunction characterized by elevated post-void residuals or retention, weak urinary stream, urinary frequency, urinary urgency or urinary urgent continence. So those are the symptoms that are often presenting and even some of the findings that you'll see on exam such as the PVR. What it doesn't really tell you is what's the cause and it could be obstructive and it could be non-obstructive. You could have a weak bladder. And basically what we do is glorified plumbing. If you're not getting any water coming out the pipe, it's either there's a blockage or the pump isn't pumping strong enough. It can be related, it can be not related to surgery but unfortunately it can be related to some of our surgeries. You can see the numbers are all over the place. Up to 20% of patients after incontinence surgeries may experience some sort of voiding dysfunction. It could be transient, it could be long-term. A literature review by Blavius gave you a wide range of anywhere from zero to 33%. Having temporary or refractory voiding dysfunction after a mid-to-medial sling. Also noting that retropubic approach was more likely to have these problems than a trans-operative approach. If you look at it by what's the incidence of lower urinary tract dysfunction requiring an intervention. So in other words, I'm not gonna really call it avoiding dysfunction unless I actually had to operate on it. Then the rates are lower than 3%, 3.1% intervention for retention, 1.3% if it was retropubic approach based on func. So the numbers you can see are all over the place and like anything, it will vary based on what definition you wanna call it. I for one would not say that just because I didn't take a sling down doesn't mean that that patient's not experiencing voiding dysfunction. So for example, if I have the straightforward index patient who had no OAB type symptoms before, did her mid urethral sling and then three months later she's got really bad frequency urgency incontinence. She never had that before, her stream's even a little weaker but her PVR is 60. I don't have to take that sling down. So based on using intervention as a definition, that's not a sling, that's not avoiding dysfunction but she's experiencing voiding dysfunction and that really does warrant treatment. So bear in mind the definition when you read the literature. Obstruction is what we're really looking for, at least we're worried about after we do some sort of mid urethral sling approach. But again, there's really varying definitions, varying standardizations. Things again, if you're looking for outflow obstruction, typically or really to make the diagnosis of bladder outlet obstruction, you have to have urine flow, voiding pressures. PVR is kind of iffy but bladder outlet obstruction is defined by physics and it's really the flow rate and the voiding pressure. So you can have someone with a low flow and a high pressure and that's very obvious obstruction. You can have someone with a normal flow but a very high voiding pressure. To me, that's still obstruction. So even if the patient comes to you with a flow rate of 18, that sounds great, PVR 50, that sounds great. But a voiding pressure of 70, that's too high. So that still would be obstruction, just not to the point where it's causing retention. Etiology is multifactorial. You can certainly have obstruction due to iatrogenic. We did the sling, it was too tight, either didn't recognize it or for whatever reason, the sling could have migrated into position. All of those can cause obstruction. Other forms, you can get an anatomic obstruction such as what we might see with assistive seal or other types of prolapse. Relative obstruction or relative is really a variable term and this is where it's kind of iffy. You can have a bladder that's hypotonic, hypotonic weak that prior to the sling was getting by. Reasonable flow rate, low PVR. You put your sling in just perfect, not tight at all. And for whatever reason, that patient goes into retention afterwards. You go back and you look and you saw that that sling is not too tight. If you had that capability, why did she go into retention? Because it's a balancing act between the outflow resistance and the actual pituitary function. And prior to you putting in a sling, the balance was in the middle, meaning that weak bladder was able to empty effectively, low flow, sorry, low PVR, high flow because there was no outlet resistance. Now you give it a little bit of outlet resistance, the appropriate amount of outlet resistance, maybe too much for that patient. Hence you put her into retention, even though it really wasn't a sling, the sling wasn't put in too tight. But that one's hard because that one is a relative thing to figure out. Functional obstruction, those patients are dysfunctional voiders, they're strained. Think about what that sling is supposed to do. It's supposed to occlude the urethra or kink the urethra during times of abdominal stress. So if you have a strained voider, someone who increases abdominal pressure to void, that sling's not going to recognize the difference between an increase in abdominal pressure due to I coughed and sneezed versus an increase in abdominal pressure due to straining to void. It's trying to do its job and it's going to kink the urethra hence cause a voiding problem because that's what it was meant to do. It wasn't expecting the patient to strain. Those are the obstructive or the emptying symptoms. You can get storage symptoms as well that we would label it overactive bladder, but it's not overactive bladder in this case. It's really frequency, urgency, urgent continence, could be overactivity. But in this case, it's now secondary to obstruction. When we say OAB, we really, that OAB diagnosis is in the absence of an obstruction. Unfortunately, we tend to kind of swap it together. So you'll get, someone will say, I got OAB due to an outlet obstruction. We should just understand what we're talking about. I'm not as big on the nomenclature. If David says to me, the sling that I just did last week now has OAB symptoms, I'm going to say, David, you did that sling, but I'll know what he meant. And I'm joking. I'll know what he meant. That means the patient's got urgency, frequency, urgent continence after the sling that I probably tensioned too tight. So storage symptoms, again, frequency, urgency, urgent continence. If you looked at that Blavius review, patients who get de novo, meaning new onset OAB type symptoms, there's a perfect example. They didn't really have OAB, but they got those symptoms of urgency, frequency, urgent continence. And I do it too. De novo OAB symptoms, 11% developed after a medium-equal sling. So that implies that that sling was either really too tight, maybe not. I don't want to, we need to acknowledge the fact that we're not saying we're putting the slings in too tight. That sling may have been perfect, but again, enough to cause the bladder to have secondary symptoms. If we looked at the UITN trials, which I was part of, you can see that in the Birch versus sling, where the Birch's have been shown to be less obstructive, the de novo overactivity rate was 4%. And this is true detruso overactivity now, versus the 7% de novo detruso overactivity in the fashion sling on. So that does lead credence to our SUI procedures can be obstructive. And when they do, there is a risk of causing overactivity. Are there predictors of water dysfunction? Just like everything else in our world, yes and no. If you looked at the UITN trials, again, that we were part of, the sister trial, which was a Birch versus sling trial, there were no preoperative urodynamic factors, predictors, sorry. And in the Tomas trial, which was the retropubic versus the transoperator mid-equal sling study, also no preoperative urodynamic predictors were seen. Other studies show that if you were a Valsalva voider, you were more likely or at higher risk of developing low flow rate. If you had a, the other risk factor was a PDATA Qmax, with Qmax less than 15, and a Q average less than 10th percentile, also suggesting some preoperative voiding parameters that were not ideal. While the urodynamic factors in the Tomas trial didn't predict anything, the approach did. Trans, a retropubic approach with a little higher likelihood of causing voiding problem than transoperative approach. And then interesting age been shown to cause increased incidence of voiding dysfunction. And as a urologist, I'll say that's interesting and also it's consistent because if you were also taking care of men and you did a terp on a guy who's over 70 something years of age, they also have a higher risk of retention after a terp. So that just suggests that the detrusor function decreases or at least has some sort of impairment with increasing age. Looking a little more closely at retropubic versus transoperator and the risk of voiding dysfunction, again, you can see lots of studies here all over the map in terms of risk of retention, approach and such. You can see postoperative retention more likely in patients undergoing a retropubic sling than transoperator sling with an odds ratio of 1.6. Barber had several studies in the 2006 felt that the TOT, the transoperator was less likely to have voiding dysfunction and the TBT was more likely to have a urethralysis. Please bear with me that my spell check corrected that to urethralysis, I apologize. But then again, in 2008, showed that there was really no difference in the retention rates and there was no differences in the post-op urgency symptoms. Dietz in 2006 saying TBTs or retropubic slings more likely to have voiding dysfunction and retropubic slings more likely to complain of poor streams. And then Wang in 2006 saying no difference. So again, it's all over the place. The signal is more that the retropubic slings are more likely to have a voiding dysfunction. And that's not surprising because if you think about between a retropubic and a transoperator, which is more likely to be successful in a case of ISD, it's probably the retropubic because it just creates a little more sharp of an angle, a little more obstructive process even though we all would say that, hence it's more likely to do the same during a voiding problem. And on that note, I think, David, I'm gonna transfer over to you. Yes. Are you able to, yeah. Let me see. Bear with us with the, we're doing this. Here you go. We're trying to share two screens here. There you go. So for the basic evaluation of voiding dysfunction, the most important factor that you wanna look at is actually the temporal relationship between the actual development of the signs and symptoms of voiding dysfunction to the incontinence surgery itself. So when you have retention kind of right after the surgery, that's pretty clear cut signs of voiding dysfunction and obstruction. And with recurring urinary tract infections, particularly when you have a high post-void residual, that's also kind of pretty clear cut signs of obstruction and voiding dysfunction. It gets more cloudy when you're kind of dealing with patients that kind of develop symptoms months after the surgery and where they may appear with diminished force of strain, position changes needing to be done to actually complete a void, or they may have irritative symptoms that you have to determine if they were due to the fact of the bladder kind of trying to overcome the obstruction or was it just developed as a matter of fact that they just have developed overactive bladder or if they've actually had these before the actual procedure and are they actually just getting worse or are they pretty much the same before the surgery? And you also wanna look at more vague symptoms such as painful voiding, pelvic pain and dysuria, which can also be signs that are associated with dysfunctional voiding. On the physical exam, you wanna look for a hypersuspension or overcorrection, particularly with fascial slings, you wanna look if there's an immobility or a fixation of the bladder neck after a sling that wasn't there before. You also wanna look for hypermobility or prolapse, which can lead to absolutely kinking and causing obstruction and voiding dysfunction. And then as we kind of discussed before, the PVR, even if they have a low PVR, that's not just a clear sign that everything is good because they may actually have a really good jitrusia contraction that actually overcome the obstruction and thus have a fairly low post-void residual. And you also wanna get a urinalysis to look for a urinary tract infection, which can mimic particularly the irritative symptoms of voiding dysfunction. So what type of diagnostic tests can we use, or do we actually need any diagnostic tests to actually diagnose voiding dysfunction? Again, it kind of comes to the presentation. So if a patient presents a couple of weeks, one or two weeks after surgery, you probably don't need much diagnostic tests. Most likely it's a sling causing the voiding dysfunction and obstruction. But there are other modalities that we can use if the patient comes in several months later and it's a little bit more questionable of what actually is causing the voiding dysfunction. And we'll kind of go over these couple of diagnostic tests. So for cystoscopy, you definitely wanna do it for patients that present with hematuria, bladder pain, recurrent urinary tract infection, particularly if there's any suspicion that there is erosion in the urethra or the bladder. You can also use the modality to kind of assess for kinking of the urethra during VASALVA. And you can see the bladder neck mobility and also urethra kinking or displacement during the cystoscopy. There's also a 2D and 3D ultrasound. And this modality kind of allows you to assess one, the location of a mid-urethral sling, but also the dynamic function of the sling. So studies have shown that if the distance between the sling and the mid-urethral lumen is less than three millimeters, that's usually kind of a sign of a urethral obstruction or in causing voiding dysfunction and irritative symptoms. But if it's greater than four to five millimeters, usually it doesn't cause much compression of the posterior urethral wall or obstruction. The other thing that you can look at is actually the dynamic function of a mid-urethral sling. And usually with at rest, the sling is typically flat or slightly curved. And with a dynamic function of like a salvo will actually transition to a C-shape. And it's suspected that if a patient presents with a C-shape sling on ultrasound at rest, that is more kind of equates to an increased tension of the sling. You can also look, they've also looked at the location of the sling along the urethra. There is not really any correlation to urgency symptoms, but it may help with surgical planning, particularly kind of determining where to place the incision in future surgeries. And then when we're looking at urodynamics, it could be non-invasive just with the urethral flow or it can be invasive with pressure flow studies. As we said before, there is no kind of standardized definition of bladder outlet obstruction in females, but we'll kind of go over some studies that have kind of looked into this criteria a little bit more. And again, there's also, it's not as common used on the GYN side, but on the urology side, there is video urodynamics. And if that is available, it can be helpful to kind of diagnose voiding dysfunction and obstruction. And we'll kind of go into some images of video urodynamics. So, as we kind of said, urodynamics may not always be helpful with the diagnosis of obstruction in urinary, after urinary surgery. Webster said that urodynamics may fail diagnosis of obstruction. Foster and McGuire said that urodynamics was not predictive of outcome. In an interesting study by Nitti and Raz, they looked at the PDET and the QMAX and found that it was not predictive of outcomes independently of the diagnosis of obstruction. They found that it was not predictive of outcomes independently or together when you're looking at patients with acontractile bladders. So in theory, they thought that patients that had acontractile bladders and a sling and they would lyse the sling, they would still have retention because again, their bladders aren't contracting and thus they're not able to actually void because their bladders aren't contracting. But interestingly, after they lyse the sling, they actually were successful and actually had improved voiding, which is kind of showing that using urodynamics can sometimes be not really helpful. And so there is a, again, there's also a time factor in this in that if you're right after surgery, you probably don't need urodynamics, but if there's more of a long period of time between urodynamics, greater than a year, or if a patient presents with irritative symptoms that with no clear-cut retention, then the urodynamics is maybe more useful. And that's kind of where it comes with the other argument of the urodynamics. Actually, David, I'm gonna ask, can we go back one slide? Yeah, I think. Let's see. I can if we can. Yeah, so I was sitting on my hands when we were talking about the NIDI-RAW study and I can't sit on my hands anymore. You know, what they were successful in is they converted patients who were acontractile before their SUI surgery. Because back, it was 94, it was probably not mid-uterine slings. They then went into retention after an SUI surgery because prior to that, they were able to successfully strain void. And then when they put their SUI surgery in place, they were no longer able to effectively strain void because the SUI surgery did its job. By doing the urethralysis and then them becoming all successful, they didn't relieve obstruction. They just made them back to where they could pee by strain voiding. But it's just to clarify, it's not a thing where those patients were obstructed. Those patients were probably not obstructed. It's that balancing act that we were referring to earlier. It was just enough outlet resistance to put them into retention. Now they remove the outlet resistance and now all of a sudden they can pee again. But I bet you they were probably leaking again too. But anyway, that's my soapbox. Back to you. So there are some three studies that was done by UT Southwestern that kind of tried to develop a criteria for bladder outlook obstruction. And they didn't really develop a nomogram, but more of cutoff values that could be used in women. And they kind of, the first day they used patients that had obstructive symptoms versus SUI symptoms. And then the last study they did was actually comparing normal female volunteers versus patients with clinical obstruction. And they found that they could use predictive parameters of a Qmax less than 12 or equal to 12 and or a PDET at Qmax greater than 25. But of note, even though the articles do say that you can use these independently or together, particularly with us, we use them actually concurrent and allow the practitioners to actually use these cutoffs, use them concurrently. So patients that would be put in the obstructive category would need to have a Qmax of less than or equal to 12 and a PDET at Qmax greater than 25. So this is kind of a urodynamics that is kind of indicative of a obstructive pattern. As you can see, the PDET is in red, which has fairly high pressures and the flow, which is in purple, which is actually pretty low flows. And that's kind of what you would see with the obstructive pattern. There was a study by NITI that actually looked at urodynamic criteria for bladder obstruction. And it was a retrospective review of 261 video of urodynamics with patients with non-neurogenic voiding dysfunction. And the criteria for obstruction was basically radiographic evidence of obstruction between the bladder neck and the distal urethra in the presence of adducer contraction at any magnitude. And they found that there is a significant difference in the urodynamic parameters in the obstructive versus the non-obstructed women. It wasn't as high of a magnitude as you would see in men, but overall they said that using the parameters alone was difficult to diagnose bladder obstruction because of the wide variation in the female pressure avoiding patterns. But there was a significant improvement in diagnosis when they added imaging of the bladder neck with the voiding along with the parameters. And this is kind of what we see with bladder obstruction. This is an image at voiding in which you can kind of see there is a dilation of the proximal urethra, and that's kind of indicative of an outlet obstruction after a sling. And the blue arrow is kind of pointing right at where the dilated proximal urethra is. So Blavitz actually combined the cutoffs of what UT did and of what NITI had previously published and came up with a nomogram that kind of uses Qmax at less than 12 with a PDET at Qmax greater than 20, an obvious radiographic obstruction with a PDET at Qmax of 20, and inability of void with the urodynamic catheters in place despite PDET greater than 20 centimeters of water. The kind of caveats of this study is that the Qmax and the PDET were actually determined with two different voids. The Qmax was actually a free flow, and the PDET was a catheterized void. The other issue is that the inability to void can be different depending on the catheter size that you're using during your urodynamic studies. So the last kind of study that we kind of use is one that you can use from the UK, and this is basically they developed a female bladder outlet obstruction index with the formula of the PDET at Qmax minus 2.2 of the Qmax, and they found that the sensitivity was 86% and the specificity was 93%, and thus if the index was less than zero, there was less than a 10% probability of obstruction. If it was greater than five, there was at least a 50% likelihood of obstruction, and greater than 18, there was greater than 90% likelihood of obstruction. So there was one study that actually looked at this, and they had patients that had outlet obstruction due to multiple different causes, such as prolapse, previous incontinence surgery, urethral diverticulum, and urethral stricture, and they looked at the preoperative avoiding video urodynamics and the postoperative pressure flows 12 months after the corrective surgery, and they did find that it kind of validated the diagnostic and the treatment response from the mammograms. So now that we know kind of how to kind of assess we're avoiding dysfunction in bladder outlet obstruction, we'll now kind of go into what we can do to treat it. Okay, so I'll take over for a little bit. So we'll talk about treatment options for basically postoperative obstruction or avoiding dysfunction, because it's not always just obstructions we've said, and we'll go over conservative options, which you see here, and then we'll move into more invasive options as well. Conservative options can be watchful waiting, which we will talk about in a second, pharmacotherapy, basically managing just the irritative symptoms, or pharmacotherapy, managing the obstructive symptoms, and we'll talk about alpha blockers and baclofen, and then we'll talk about urethral dilation. So alpha blockers in women's not, you know, alpha blockers, if you're not familiar, is typically used for treatment in men with BPH, obstruction due to BPH, but it's not just the prostate medication. There are alpha receptors at the bladder neck and proximal urethra as well. So it has been shown that men and women can get what we call a functional bladder neck obstruction, and it happens in women, and you can see here that an use of an alpha blocker can relax the bladder neck. It's not a true anatomic obstruction, but in this case, it's a functional obstruction, and it was reasonably successful. But that is in a bladder neck dysfunction, which in theory, bladder neck dysfunction or bladder neck obstruction is due to overactivity of the sympathetic system. So it makes sense that an alpha blocker would tone that down, whereas if we talk about using it for a post mid-urethral sling obstruction, you're not toning down a sympathetic system that's already turned up too much. You're hopefully relaxing a little bit more so that your relative outlet resistance may improve, but it really, it's a Hail Mary kind of thing. Baclofen has really not, it's not a mainstay medication, though you can see here that there was one study done that was presented at IUGA, a retrospective review that showed use of baclofen had a 74% decrease in post-ward residuals. So this was a retrospective study, not well controlled because it was retrospective or was not controlled. And as we saw earlier, we don't really know what happens with the effects of time. We're gonna see that as well. You may have seen an improvement in post-war residual just because of waiting it out. So you see the patient in your clinic and you gotta figure out what am I gonna do? Are you gonna start patients on treatment and you can take them to the OR and release their sling, you're gonna wait? Well, some of it has to do with, was this there even before your sling? If the patient had preoperative irritative symptoms, especially if they needed medications preoperatively, that's an important thing to know. And then the symptoms better or worse since their sling. So in a patient who had mixed incontinence and then has a sling done and their stress incontinence is resolved, but their OAB symptoms are there, but they're persistent and essentially the same, I don't necessarily believe that sling's causing any problems. You may just be seeing the reflection of the OAB component, which is still persistent. On the other hand, if they had mild OAB and then you put a sling in and now they've got severe OAB, very possible that you've done something. So you can see here, there was a study that was done by Song that kind of looked at when to intervene with possible meds. And this is meds to treat the OAB component. Basically showing that if you had preoperative urgency, these were risk factors for developing urgency after your sling. And if you had risk factors for urgency were preoperative urgency and urgency at one month. So their conclusion was, excuse me. Their conclusion was, if you have someone who had OAB symptoms after a mid-week of sling and they had OAB symptoms before the sling, they waited out for the first four weeks and then they'll put them back on the OAB medication. If they did not have OAB symptoms before the sling, and now they do, they'll wait six months before they'll start the OAB medicine. So it's a reasonable thought process and it does make some sense. Urethral dilation, we are putting it here just to be able to say we put it here. One out of seven, I wouldn't do it. You can see little benefit, poor long-term results, not well done. I would just jump, jumped. The question really is going to be, you've got this patient now that you, in your mind, you know that their sling is too tight, they're obstructed. What are you going to do? And a lot of this decision-making now is going to be a patient-physician or patient-surgeon decision. You're going to have to talk to them and make a combined decision, a combined patient decision approach. And it's going to depend on what you want to offer them, the benefits and risks of what you're going to offer them, and what their expectations are. Your expectations are going to be relative to what they're going to do. I mean, watchful waiting, sling loosening, sling incision versus an excision, and then a formal urethral lysis. And again, all those options have pros and cons. The more aggressive you are, the more invasive the surgery is going to be, the more risk of post-operative, less risk of post-operative one-use function, but the greater the risk of maybe developing stress incontinence and now even needing a second surgery after that third surgery. So these are the things that you're going to have to bear in mind when you're discussing these options with your patients. Again, like in everything in our field, you can see watchful waiting is just one of those other things that is all over the place. You can see in the TOMAS trial, 24% of the patients failed to void at the time of their surgery. If you let them wait it out for two weeks, only 6% required a catheter, sorry, by two weeks, only 6% required a catheter. And then if you keep going until six weeks and wait it out, it decreased to only 2%. It doesn't mean that they're not obstructed anymore, but their bladders either responded, compensated for it, but they are no longer voiding and no longer in tension and not needing a catheter. You can see Bailey, 2012, 20 women who were doing CIC after a midurethral sling. Patients after three months, 11 had a decrease in PBR to less than 100. And then by eight months, it went up again. It increased to 13 patients. Patients in 2015, Vonda Broek, patients with preoperative OEB symptoms had a higher risk of developing postoperative OEB symptoms if the treatment was delayed more than 70 days. So that's kind of a, makes it a little interesting. That was a little bit against what Song said, which is that they have OEB symptoms before the surgery. We can just start them on treatment right away or within a month. This is kind of saying if they had preoperative OEB symptoms and then you delay your treatment of releasing the sling, you're more likely to have more refractory pictures. So that suggests that maybe there's some bladder response to being obstructive, which is very possible. We see that again in men and women who've been obstructed for prolonged periods of time. And then that's supported by what Lang said that if you delay any corrective surgery, they were more likely to be associated with a persistent bladder storage symptom problem. So again, our options are watchful waiting, which you can basically make a decision on based on what we just talked about. You maybe wait a little while, or you can loosen the sling, or you can incise the sling, or we can do a formal uretholysis. So when can you do a sling loosening? Probably within the first two weeks. If you do it beyond the first two weeks, then the sling starting, the tissue starting to incorporate into the sling and the ability to loosen it is going to be less successful. In this case, try and get in less than 14 days. You may be able to pull it down before it has a chance to scar in place. This theoretically can be done in the office. I've not done it. David, have you been associated with anyone who's done it? Yes, one inpatient that we did. So idea being you can infiltrate the anterior vaginal wall, local, make a vaginal incision, find the sling, hook it with the right angle, and pull. You can pull. You can also spread the sling, and by spreading the sling, you are putting tension on it, which will hopefully also cause it to loosen and come down. At that point, again, if you're doing this in the office, I imagine if there's any incorporation to the tissue, as soon as you start to do this, the patient's going to be feeling it, even with the local, especially because it's going into the areas that you can't localize. If you can't mobilize it because of its fixed or pain, then you can just incise it, and then you can incise it and close up. So that would probably work. Here you can see a picture of it. You can see the vaginal incision being opened up. You can find the sling, get a right angle under it, and then either pull or make an incision. The idea being by pulling on it, you're still maintaining the backboard behind the urethra, which will hopefully reduce your risk of developing subsequent stress incisions. If we talk sling incision, you can see a variety of studies here. A lot of these, the concern here is it's a balancing between, I'm going to incise the sling so they pee better, but I want to make sure that they don't develop stress incontinence, or I worry about that, and I also want to see resolution of any overactive symptoms. Success rates for voiding dysfunction are very good. You can see most of them in the 80, 90 percentile, even more than 100 percent, but you can also see that the risk of stress incontinence goes up as well. So that is, again, something you're going to have to discuss with your patients. The good news is that you have options if it does happen. We don't really talk about it, but bulking agents in these situations may be something that you can salvage. I've done that before where we've done a sling incision, basically a small incision versus a wedge, and we'll talk about that in a second, and then they develop subsequent stress incontinence. You have that discussion with them. I would do a bulking injection first, and hopefully you can kind of touch it up and get out of dodge. You see the last one there, which is midline and vaginal trans-uterolysis, but you can see the year of that study was much older, and you're going to have major uteral slings and probably other types of incontinence procedures that were done as well, so it's a little more, and also the time to dysfunction, time to the procedure was much, much longer, almost a year, so by that time, some of those patients may have had those permanent bladder dysfunctions by being obstructed for so long. So the approach is, again, the midline or whatever your, you know, I would do midline. Most of you would be doing the midline vaginal incision anyway from the sling. You'll be able to open it up, same incision, get a right angle underneath it, and first, you may or may not see a wasting of the urethra where the sling is. What I mean by wasting is, you'll see it looks like it's too tight, like you're wearing a belt that is on too tight, and you want to put that belt on a looser hole, but in this case, get the right angle in, and there's your picture of getting the scissors underneath it, and you definitely want to, if you get that right angle in, you can protect the urethra and avoid the risk of injuring the urethra underneath it, and then if it was tight, a lot of times, you'll see the two ends have spread apart. I want to confirm, David, can you see my arrow in the pictures now? I can't. Bummer. Over the mid picture, you can't see it? Right over the sling? I think the rest of us can. Because I have also power in the slide. But someone did say they could, so I'm going to take it. So this sling was cut, one cut, and you can see how far apart the edges separated once that one single incision was made. This was not a wedge resection. This was a cut down the middle, and look how far the edges came apart. That's how tight this sling was. What I would do is, I would make this, because that's always the debate, do I just incise the sling, or do I take a wedge out? And what I would do is, I would incise the sling, and if I get an appearance that looks like this, I first look at David, and I say, David, you made that sling too tight, and you can see the edges really separated. On the other hand, if the edges didn't separate, then it's likely that the sling has already started to incorporate too much. In which case, then I will, I want this appearance. This appearance is great, but if I can't get the edges to separate like that with one incision, then I take a wedge out. So to be clear, just because I'm long-winded, make an incision. If the edges separate nicely, you're done. If the edges don't separate nicely, and they're still lined up next to each other, then I'll take a wedge out. Early versus delayed loosening, this was another study that was done looking at those who were doing CIC for at least seven days, and then went to either continued CIC for six months versus a loosening of the sling. Satisfaction rates were equal in both approaches in six months, but early sling loosening may improve or reduce the risk of, well, obviously reduce the risk of discontinuation. And remember what we talked about earlier, about the risk of permanent bladder dysfunction, either permanent voiding dysfunction, or permanent OAB-type symptoms. So the sooner you get this done, the better it's going to be. Other data, looking at this again, a study found that nearly twice as many women needed a transection after doing CIC than immobilization. I'm not as familiar, David, actually, you were more than familiar with this. Can you comment on the mobilization? So basically, I mean, the study found that the women that needed the transection after intermediate catheterization was 19% versus like the after mobilization, it was only like 10%. So it kind of showed that the transection of the sling was a little bit better than just loosening, basically. The mobilization is the term for basically sling loosening with this particular study. Appreciate that. Yeah, multiple terminology for the same thing. Yeah, so bear that in mind, because I got confused. Mobilization, not the same thing as what I, because in my mind, mobilization would have meant I moved the sling to a different location. No, this was actually with looking at the sling loosening versus the actual transection of the sling. Yeah. Okay. And then we're going to persistent obstruction. So this will be, I think you'll take over again. Yeah, I'll take over. So basically, once if you have a patient that has persistent obstruction after the incision of the sling, well, the first question is, was the sling really revised? As we mentioned with the case patient that we had at the beginning of the presentation, the operative report said the band was cut. So was that just scar tissue that was excised, or was the sling only partially excised during that particular operation? So it may be necessary to do a restudy with radio aerodynamics or cystoscopy, and maybe a formal uretholysis may be needed for patients that have failure of a sling incision, or if there is an inability to find a fascial or biologic sling that was previously placed. And so there are several different modalities for a uretholysis, a transvaginal, a supramutatal, and ruptured pubic, or even combined approaches, and each kind of have their own advantages. So basically, after the theory is basically after a prior stress incontinence surgery, the urethra may be fixed due to the pelvic bone due to dense scar tissue. So the goal of the uretholysis is actually completely free and mobilize the urethra. So with the transvaginal approach, it's basically an inverted U incision with the apex at the mid urethra and the base at the bladder neck. And basically, you're doing a medial to lateral dissection over the urethral fascia towards the endopelvic fascia and sharply periphering the ruptured pubic space, which is entered, and thus bring the urethra from the undersurface of the pubic bone. With this particular modality, you can use a Martius flap to go over the area to, in theory, prevent re-scarring after the procedure itself. And this is a bilateral Martius flap in which we basically are wrapping the urethra with the fat pad that you can get from the vulvar Martius flap. So David, can you go back to your original slide again? One more. One more? Yeah, well, three more, but yeah. So again, I think you guys can see my arrow. In this picture, we've dissected all the way around the urethra and bladder neck, gone into the space of retsus, gone all the way around and come back out again. That's what the Penrose is illustrating. And this is definitely going to unobstruct things, but it only unobstructs things at the bladder neck level. I would question how well you're going to get between the urethra and the pubis. You can't do it, but you're going to be in dense scars. It's going to be very, very hard. But let's say you've done it, or let's say the obstruction was at the bladder neck. The concern is, if you free it and everything comes down, but then you don't do anything else, what's to stop it from plastering back up there again, especially now that you've been there, that that's just a new scar tissue, which is the reason why David mentions you can go forward. Here, the Marty's flaps are basically sandwiching between the pubic bone and the urethra and the bladder neck and the pubic bone to prevent the urethra from going back up and causing another obstruction. It's acting like a cushion or a mattress. Sorry, back to you. I felt like I had to say that. It's all right. Another approach is the retropubic uretholysis, in which basically you're either entering with a low midline incision or a fan and seal incision to gain new access into the retropubic space of retsius, in which you are able to then mobilize not only the bladder neck, but also the urethra and anterior vaginal wall. But due to possible very dense adhesions, you may have to go all the way laterally to the ischial tuberosity sometimes, which then may have you develop paravaginal defects, which then would need to be repaired at the time of the uretholysis. Of note, you can do interposition of momentum between the urethra and the pubic bone, again, to kind of help prevent the scarring back of the urethra after your seizure surgery. And this is kind of one of the more evasive approaches and kind of rarely needed for mid urethral slings. This is usually more for your birches, your fascial slings, and that such. And then the supermedial uretholysis, this is done with a curved incision about one centimeter above the urethral meatus, going from the three o'clock to the nine o'clock position, in which you kind of sharply dissect the urethra, the bladder neck, and the bladder off of the pubic bone, and also the puborethral and the pubovestical ligaments medially. And the dissection is a little bit more limited laterally, which does kind of give a little bit support of the urethra and possibly helps with minimizing recurrent stress hearing incontinence. But even with all these kind of advantages, the supermedial uretholysis in the literature doesn't have as much of a success rate compared to the retropubic and the transvaginal uretholysis approaches. And also, because of the limitations of the lateral dissection, you can't really reach if you had to actually get to a space where a trans-operator sling was placed. Even though that typically doesn't lead to obstruction, if you were planning a surgery, this particular approach would not be really advantageous. This is really for the rare occasion where you're plastered up against the pubic bone, I did a fascial sling on them and it's too tight, that kind of thing. Yeah, I agree with you. Trans-operator, A, you're not even going to be near it and B, probably wouldn't help. But that being said, it is one of my favorites. Yeah, well this is actually, these pictures or images are actually thanks to Dr. Kraus and one of his particular surgeries. And as you can see, the urethra is basically completely mobilized from the pubic bone. And with your particular, you actually use the gel foam kind of as a platform to kind of help prevent the regrowth of or recurrence of the scar tissue. Yeah, so I used to not be a big, big, big Martius supporter. I just didn't like doing them. And unfortunately, these surgeries do have some bleeding associated with it. So gel foam was kind of serving multiple purposes, but I've kind of returned to Martius flaps, gotten better flaps lately. So I would kind of judge it. These patients are consented for Martius flaps just in case, but depending on what it needs, I put a thicker, one or two wedges of gel foam in or a Martius or both. But you can see, look how far down you can drop that urethra by getting in. Now the risk is bleeding. I mean, but if you're on the urethra, you start marching down the urethra when you do that, that section, you can really drop the interior wall down. And I mean, that's a, that's a handheld, that's the, um, the anchor blade of a buck Walter. We're not using the buckle here, but it was the perfect size to fit in there. You can get a big drop in if you need it. So, um, once, if you have a patient that has actually had a, uh, your, your, your use of in the past, well, there's actually two studies that actually look at patients that had repeat urethralysis after a prior, uh, surgery and to treat, uh, obstructive, uh, symptoms, uh, and superior at, uh, at all looked at, uh, basically patients that had repeat transvaginal or, um, retropubic urethralysis. And they found that the 22 of the 24 actually had normal emptying afterwards. Uh, the irritative symptoms was not as well, or as, uh, best, uh, the, the treatment was not as good with only, only two out of the 12 actually having resolution and 11 of the 16 actually continuing to need medication for, uh, for management. And also they had listed an 18% recurrence rate of their stress-bearing incontinence. McCary, um, they did, uh, repeat, uh, transvaginal urethralysis, and they had 13 of the 18 patients having resolution of their obstructive symptoms and irritative symptoms, uh, 10 of the 17 actually had resolution and six of the 17 actually had improvement. So what did we do for our patient that had a history of a sling license? That's me again, right? Yeah. Okay. So just because we're, we're coming short on time. So this is our patient again, who had the retropubic sling post-op retention, went back to the OR, firm band was in size, but that's all that we were told. And then they're continuing to have to do CIC and have high PVRs in the extreme. So we did scope, um, after someone's gone through another surgery that to me, that's already enough reason to do it. Um, make sure there was no erosion or foreign bodies within the bladder. Um, uh, this is definitely a subjective thing when, because I, I argue this is assistive scope is a poor way of diagnosing obstruction. Um, because what you may, any of you in the audience may, uh, visualize as obstruction. Another person may say, no, it's not obstructive. Um, I try and standardize as best as possible and working with, with, with the residents and such. I usually tell them if you feel like a speed bump, when you're going over with the sling, that's kind of about as objective as you can get. If you feel that speed bump, that's a very subjective of an obstruction for your flow Q max of 13. So we did your dynamics on her, your flow was Q max 13, a Q average of six. She voted one 46 and her PVR was 100. So already a flow of 13 is too low for me. Um, and her PVR is 100. Is she obstructed? Normally I would, I would survey you guys, but for the interest of time, you can't still tell her flow rate of 13. If it's associated with a high pressure, that's obstructed. On the other hand, if it's associated with a low pressure or making tractile bladder, then she's not obstructed. But in this case, you can see here, her bladder is actually relatively stable. Um, but her voiding pressures on the aerodynamics, she's got a Q max of 12 and a P debt at Q max of 35. So her max flow rate was 12 and her detrusor pressure at max flow was 35. That clearly meets those obstructive criteria. Um, we didn't do it, but we probably, if we put it into the, uh, Solomon equation, I'm pretty sure she'd be obstructed as well. Um, and then a picture is just worth a thousand words. This is another picture, another fluoro shot of different patient. You can see here, very dilated bladder neck, and it kind of comes, comes abruptly to a stop. The obstruction is going to be right here and everything behind it's backing up. And again, this is all under high pressure, which is why your bladder neck and urethra are starting to dilate out. So what are we going to do? So we did a repeat transvaginal urethralysis now with the expectation that we were going to do an extensive urethralysis. Um, but when we got in there, we actually still found the old sling in place. Um, in the, remember in the process of doing that transvaginal urethralysis, you're going to go down laterally and pierce through the endopelvic fascia, um, as if you were doing a fascial sling, you know, you have to pierce through there to get in there. Um, and in the process of getting there, we found the sling. So it's actually taught me something because in the middle of the urethra would have been really hard to find it after someone's already been there, not once, but twice doable. But instead I went laterally and we went by going laterally. We found the sling palpable very easily, found it X actually kind of expected to find it there because according to them, they only incised it anyway, but found it and then traced it back. And as we traced it back to the midline, we found that still attack attached. Um, and by dissecting all the surrounding tissue off, you can see that the urethra was quote wasting. So what we did again, incised the sling, but at this point incising just the sling itself didn't stop the wasting. So as I mentioned earlier, if the waste appearance doesn't get better, then we took a wedge out. But because this lady had already gone a couple second time now, this was a more extensive, we did more. She wanted to be, she just didn't want to take a chance on not being able to pee again. So we took the whole, the whole vaginal component of the sling out. Retention resolved. Empties were great for some stream, no further irritating symptoms, but mild SUI, did a bulking injection on it, got a little bit better, but then it came back. It's not bad enough for her to do, redo surgery. Um, so that's that case we are ending up on time, but maybe we have enough time for one quickie 66 year old female with urgent continents and recurrent UTIs. And that's another way these patients will present, um, either due to the elevated residual or for worse. Um, she has urgent comments using five pads a day, plus nighttime pads. She's failed several trials of OAB medicine, not jury times five. She leaks at night while she's sleeping. If you didn't know about the UTIs right off the bat, that sounds just like refractory OAB. And if she didn't have any history of a sling, I wouldn't do anything more than just check the VR and keep going. But she is getting recurrent UTIs. And she does tell you she had a sling done, a trans-operator sling done about three years prior and the, all the OAB symptoms and the recurrent UTI started after that past medical history. She's diabetic. Um, she had kidney cancer. She had a sling in the past. Um, you can see the meds that she's on on exam. She's got no erosion, no hypersuspension, no stress incontinence. Her PPR is only 85 and she's got a dirty urine. She gets scoped. She's got no evidence of erosion, no evidence of obstruction. You do her aerodynamics. She's got a Q max of 30, a Q average of seven, what a volume of 192 and a PVR of 90 with a fluctuating pattern suggesting possible straining. However, on pressure flow study, you can see she's got decreased capacity. She's got an unstable contraction that's terminal prompting her to need to void or leak if she wasn't in your bathroom. Her Q max is 21, her P debt at Q max is 21. So she doesn't really meet those obstructive criteria. She's close to it by the pressure, but nowhere near close to it with the flow. She voided 147 and she's got a PVR 40. So I'm really not sure what's going on here. And the floral picture, it does suggest some dilation, but it's not as clear cut obstruction as some of the other cases that we've seen. So it's really not clear if she's obstructed. She could be just based on her history and the symptoms and the temporal relationship. She's not likely obstructed based on a cystoscopy. She's not clearly obstructed based on aerodynamics. So what would you all do? And again, for the interest of time, I might survey you, but we reviewed her options, treating her OAB as refractory OAB versus doing a urethralysis. And she elected to do an SNM trial and her symptoms did improve. She just didn't want to take the risk of stress incontinence and she didn't need the PVR to improve because she was already emptying well. Interestingly, she got implanted, OAB symptoms get better. And I am not implying that sacral nerve modulation improves UTIs, but that did get better too by any means. And on that note, it is exactly time, but I'm willing to stay on if there was questions. I saw comments coming in, but I couldn't respond. I was afraid that I would take it away from you or something. Well, thank you, Dr. Kraus and Dr. Austin for the presentation. We do have a few minutes for questions here. And a reminder to the participants, you can submit your questions there, the Q&A section on the bottom right of your screen here. So the first question we have here is actually about the Martius flaps and the location, I think, and you mentioned it was about, the question is they go anterior to the urethra to prevent repeat scarring. Is that correct? And to go to that, how often are you doing a Martius flap when you're having to really do a urethralysis with that kind of dissection? So I can't tell you we had to do that many urethralysis now anyway. I would say it hit its surge in the mid-2000s, probably when more people than not should have been doing midriple slings. Now that it's probably more restrictive to people who are more comfortable with it and know what they're doing, the incidences have been much, much less, at least in our part. I would say if you're trying to answer that question, if you're looking for a situation, I wouldn't do it right off the bat. I would do a release of the sling, just like David had mentioned. And if they come back and they have persistent obstruction and on exam, they're hypersuspended where you want that urethra, it's too high up. You want it to drop down. I would then plan for a transvaginal urethralysis, like David had mentioned, or retropubic or a supramietal. I'm not sure retropubic these days. And then I would kind of do it by ear. If the urethra drops, I would entertain doing something. I don't know, David, what do you think? I mean, I don't know. I don't really have that much experience with using the Martius flap with this particular situation. I think I've done it once, but I haven't really been doing that many urethralysis either. So I would have to say it's kind of hard to say if there's a particular clear-cut sign of when to do it and when to not. And I don't remember reading anything in the literature. I mean, in my experience, when we were doing more of these, I really wasn't crazy about doing Martius flaps. And plus, it does take an option away from you in the future. So I did put wedges of gel foam in. It did prevent the urethra from coming back up. And it hasn't been that many. It's more anecdotal than anything else, but that was enough to do the job, I think. We have a couple of comments here. One of them is talking about translabial ultrasound and using that to... The comment just says that this person's found it very helpful to complete the picture and using for surgical planning to look at, as you guys mentioned, the position of the sling, looking for birch sutures, if there's still those people that we see are having the birch procedure done. And so there's a lot of other comments here as well. Thank you for a good overview on an important topic. Yeah. I mean, there's not a lot of literature on it, but it is something, at least for helping identify, even sometimes when you have a patient that doesn't really know what type of sling they've had, sometimes you can do with, particularly with the 3D ultrasound, but even with the 2D, you can actually see, like with a transoptery will kind of more look like a gall wing kind of presentation. Whereas you will actually see like a V shape for a retropubic. So again, it's a little bit more just kind of academic, but definitely for finding the actual location of the sling or identifying if they even have a sling. Cause sometimes they'll say, oh, I have a bladder suspension. And you're like, is that, was it like sutures or was that actually with a sling? So sometimes just helping identify what exactly is going on is, it's helpful. All right, here, let's see here. Here's another question that just came in. So if you do this sling release or urethralysis and they have recurrence of their, or sorry, relieves their obstruction, but they have recurrence of their stress incontinence, what do you do next? Especially if the bulking doesn't really work or it doesn't really last. You want to try it and then I'll go. Yeah. I mean, I guess again, it's more of how the, basically what the patient's bother is. So, I mean, if it's really that severe, you can offer repeating the bulking procedure cause you can do it more than one time. If it really did not help at all, the bulking, and you can always offer them another sling procedure. A sling procedure. I don't know about you, but it's kind of like how, how severe the symptoms of the stress urinary incontinence is for them. So I would agree a hundred percent. And I, you know, I'm not a big, big bulking guy, but if person, but I, this is where bulking, I think, has a reasonable, you know, use. And I would offer it. I typically offer it to them twice. If they got one bulking injection, I always warn them. They're probably going to need another one. If they get no response after the second one, then I usually tell them bulking is probably not going to work. We need to try something else. On the other hand, they get one bulking injection and they just don't want to do it again. I will offer them another stress incontinence surgery. The question is what stress incontinence surgery you're going to do. My worry is going to be that now that they've had not one, but two surgeries at the mid urethral level, there's probably more scar tissue there than you would like. And now if you're going to put another mid urethral sling there, wedged between, now you've got the urethra, now the wedge of scar tissue all the way around there from having been there twice, and now another mid urethral sling, is it going to be as effective? And I would worry that it might not be, but I guess I would do it by exam. If the physical exam shows a lot of hypermobility, I'd probably be comfortable trying another mid urethral sling. But if they don't, then I'm worried that a retropubic, and this would be just a retropubic sling, by the way, I wouldn't offer them a trans-operative. But if they don't have a lot of hypermobility, then while normally I would offer a retropubic sling to someone who has minimal hypermobility, in this case I wouldn't. I would want to go fascial, number one, because they need something a little bit better. Number two, I can go to the bladder, neck, proximal urethra, and there's no, you know, theoretically that should be virgin territory. So be easier surgery to do, I don't have to worry about getting into scar. I have done a sling once where there was removal of a sling, and in the placement of a new one, there was so much scar tissue, we actually wanted to take the scar tissue out. We did a urethralysis before putting in a new sling. And by going to the bladder, neck, proximal urethral area, you can avoid that risk. I hope that answers. And that's just what I would do. I'm not, that's my gut. All right here, it looks like just to be mindful of everyone's time as it's getting there. On behalf of AUG's Education Committee, I'd like to thank Dr. Krause and Dr. Austin and everyone for joining us today. Our next webinar will be Optimizing Education in the Operating Room, presented by Dr. Jorge Carilion on January 13th, and I hope all of you can join us there. Everybody have a good night and happy holidays. Thanks everyone. Thank you.

Voiding Dysfunction

SUI Surgery

Mid-urethral Sling

Stress Urinary Incontinence

Bladder Outlet Obstruction

Watchful Waiting

Pharmacotherapy

Urethral Dilation

Alpha Blockers

Baclofen