At the center, polyacrylamide hydrogel (PAHG) was the preferred bulking agent, and the report refers specifically to the utilization of this particular bulking agent versus the use of mid-urethral sling, anterior fascial sling, or a Burch culposuspension procedure. 279 patients were treated with a procedure during that time by 5 fellowship-trained surgeons, all of whom had been in practice for at least 10 years of post-training experience. The study period began in May 2019, and 109 patients underwent interventional treatment in the 20 months prior to PAHG being incorporated into the center’s SUI treatment pathway in April 2021, compared with 170 patients treated in the 27 months thereafter. Before PAHG. 40% of women proceeded with surgery, and 60% of patients were treated with bulking agents. After PAHG was introduced and became the predominant bulking agent within the study center, 31% of patients who underwent an interventional treatment chose surgery, while 69% initially chose urethral bulking. It is interesting to look at the breakdown by surgeons, by procedure initially chosen.
There was a considerable variance. One surgeon used bulking as the initial procedure 91% of the time, mid-urethral sling 7% of the time, and Burch procedures 2%. Another surgeon used bulking agents 51% of the time, mid-urethral slings 32% of the time, and anterior fascial slings 17% of the time. The authors felt, which seems reasonable, that the difference among the surgeons reflected the complexity of the patients they saw. There were some other interesting data points included in the article. The authors further report in the full manuscript that women who initially underwent urethral bulking, 7.7 % subsequently proceeded to mid-urethral sling placement and 2% to an anterior fascial sling, with notable variation in initial procedure selection across individual surgeons. Among new patients presenting with SUI who underwent an interventional treatment, the proportion treated with urethral bulking increased from 56% to 69.1% The authors cite the recent AUA-SUFU updated guideline statement on the management of female stress urinary incontinence, which stating that urethral bulking can be offered alongside slings as a first line option to the index patient with SLU., specifically, “ Bulking agents may have a role in patients who wish to avoid more invasive surgical management, lengthier recovery time after surgery, or who experience insufficient improvement Following an anti-incontinence procedure. Patients should be counseled on the expected need for repeat injections.” The guideline also states that there is not enough data yet to recommend one bulking agent over another.
In that context, these utilization trends point to a broader implication: when multiple acceptable first-line procedural options exist, what evidence, and what definition of ‘success’, is most relevant for matching a specific procedure to a specific patient? This question extends beyond female SUI and is equally salient in other functional conditions, including male benign prostatic obstruction. This particular question was addressed by a “Think Tank” at the International Consultation on Incontinence- Research Society (ICI-RS) meeting in the summer of 2025.2 In a thoughtful discussion directed at SUI, the authors agreed that, notwithstanding the differences in patient histories, symptomatology, and urodynamics or videourodynamics, the definition of “success” after surgical treatment has always been a challenge. They specifically cited one review, which compared hard outcomes such as pad usage and pad weight to patient reported outcome measures (PROMS) and pointed out that more than 44 different PROMS were utilized in the studies included. The patient's global impression of improvement (PGI I) was the most frequently utilized.
They also noted that the definition, which incorporated no reported urine leakage, a negative cough, stress test, and no retreatment, misclassified patients with minor symptoms as treatment failures, whereas a definition that incorporated patient defined cut off values in various International Continence Society Questionnaires more accurately distinguished between surgical success and failure. Ultimately. They agreed with the fact that women are less likely to opt for surgical treatments associated with high recurrence rates, hospital stays or increased pain. Other factors that affect the choice of therapy include perceived symptom severity, reactions to anesthesia, potential complications, and impact on personal life. This all highlights the value of true shared decision making and a complete disclosure of all known data regarding all procedures discussed. One very interesting question that they raised is whether patients could set their own goals that can then be evaluated post-surgery to give a more nuanced patient defined and reported outcome measure by which to compare certain procedures for certain types of patients who desire different goals. My conclusion is that we are far away from predicting the likelihood of “success” of a specific procedure for a particular patient with SUI, or BPH, for that matter.
Written by: Alan Wein, MD, PhD, FACS, Professor of Clinical Urology, Department of Urology, Desai Sethi Urology Institute (DSUI), University of Miami Miller School of Medicine, University of Miami Health Systems, Miami, FL
References:
- Burg, M et al, Trends in the Treatment of Stress Urinary Incontinence in a Tertiary Care Center After v the Introduction of Polyacrylamide Hydrogel, Neurourology and Urodynamics, 2025, https://doi.org/10.1002/nau.70205
- Ockrim, J et al, What Evidence Do We Need From Objective and Subjective Outcomes in Order to Recommend Specific Operative Procedures for Men to Relieve BPO and Women With SUI? ICI-RS 2025, Neurourology and Urodynamics, https://doi.org/10.1002/nau.70178