Midurethral Sling Research Articles

Impact of pelvic floor distress on non-invasive urodynamic findings in women

Objective (s)To compare non-invasive urodynamic findings in women with and without pelvic floor distress and to investigate the patient characteristics affecting maximum flow rates. Study designThis is a retrospective study including data derived from a prospective cohort study evaluating free uroflowmetry findings in asymptomatic and symptomatic women with urinary dysfunction attending the gynecology outpatient clinic for routine annual control, infertility, abnormal uterine bleeding and pelvic floor dysfunction. Data regarding baseline characteristics, questionnaires, urogynecologic examination findings and free uroflowmetry results were retrieved. Women were grouped according to the Turkish validated Pelvic Floor Distress Inventory (PFDI-20); women who scored 0 or 1 points for each item (“no” or “not at all”) were considered as asymptomatic in terms of pelvic floor dysfunction, and women who scored 2 or more points to any item were accepted as symptomatic. Baseline characteristics, clinical examination findings and free uroflowmetry data were compared among the groups using Student’s-t or Mann-Whitney U tests, Chi-square test or Fisher’s exact tests, where appropriate. Correlations and their significance, and patient characteristics affecting Qmax were investigated using the Pearson test. A multiple linear regression model was used to identify independent factors affecting Qmax. ResultsThe study population (n = 186) comprised asymptomatic (n = 70, 37.6%) and symptomatic (n = 116, 62.4%) women according to the scores of the PFDI-20. Corrected Qmax, TQmax, Tvv and PVR were found significantly lower in asymptomatic women (p ≤ 0.001). In asymptomatic women, PVR was <100 mL in 98.5%, and <50 mL in 80%. In multivariate linear regression analysis parity, obstructive subscale score of the UDI-6, previous mid-urethral sling surgery and hysterectomy were found to affect Qmax negatively, whereas VV was found to affect Qmax positively. Conclusion(s)Although significantly different, overlapping wide ranges of non-invasive urodynamic findings have been observed in women with and without pelvic floor distress in the present study population. Maximum urinary flow rates were significantly affected by patient characteristics such as parity, obstructive symptoms, prior incontinence surgery and hysterectomy. There is need for further larger studies considering all possible factors that may affect voiding.

Autologous fascial slings – efficacy and future challenges. An analytic review

Stress urinary incontinence (SUI) consists a clinical entity affecting approximately 1/3 of women worldwide. Therefore, management and therapeutic mapping should be planned assiduously. Surgical treatment for SUI has been an optimal surgical intervention for over 50 years, beginning from Burch colposuspension and Kelly’s plication, to midurethral slings, tension free vaginal tapes, trans obturator tapes and autologous fascial slings. Even though synthetic midurethral slings represented the most common surgical approach since the mid 90’s, due to their minimally invasive character, nowadays, lots of concerns have been raised among medical community concerning their serious long-term complications such as, mesh erosion, vaginal extrusion, urethral erosion and injury, groin, thigh or pelvic pain, recurrent infections and dyspareunia. These complications forced FDA (Food and Drug Administration) to issue a warning against their use, leading the implementation concerning autologous facial slings come back in to the surface. Despite the fact that the use of autologous fascial slings depicts a more invasive and challenging approach to treat SUI, there are notably more benefits regarding postoperative outcome, as well as decreased rate of potential complications when compared to TVT (Tension-free Vaginal Tape) and TOT (Trans Obturator Tape). Although, more trials and data must be conducted in order to be considered as main approach. Aim of this analytic review consists efficacy’s depiction of the autologous fascial slings according to recent bibliography and the role they could play in the near future concerning optimal therapeutic strategy of SUI.

Pelvic ultrasound finding of late-onset bladder erosion after transobturator tape for female stress urinary incontinence: A case report.

Mid-urethral sling is a gold-standard procedure for stress urinary incontinence because of its high efficacy and low complication incidence. Moreover, mesh erosion into the bladder is a rare complication. The 63-year-old patient visited our gynecology clinic with complaints of gross hematuria and was diagnosed with bladder erosion by ultrasound 6 months after transobturator tape procedure. The 2D ultrasound found the sling in the bladder wall perforation, which can lead to the formation of bladder stones. Meanwhile, 3D ultrasound showed the left side of the sling crossed the bladder mucosa at 5 o'clock. The sling and bladder stones were removed by holmium laser. The patient underwent a follow-up pelvic ultrasound at 6 months, which showed no erosion mesh under the bladder mucosa. Pelvic ultrasound could accurately evaluate the location and shape of the tape, which is important for a reasonable surgical plan.

Cost-effectiveness of Prophylactic Retropubic Sling at the Time of Vaginal Prolapse Surgery

ABSTRACT The increasing proportion of elderly Americans has brought about an anticipation of 50% rise in prolapse surgeries by 2050. It is anticipated that 25% to 40% of patients undergoing surgeries will develop de novo stress urinary incontinence (SUI) after prolapse repair. The Outcomes Following Vaginal Prolapse Repair with Midurethral Sling (OPUS) found a 36% reduction in the risk for de novo SUI, but also demonstrated increased risk of bladder perforations, urinary tract infections, and incomplete bladder emptying symptoms (N Engl J Med. 2012;366:2358–2367). As a result, pelvic reconstructive surgeons often vary their approach toward prophylactic MUS at the time of vaginal prolapse repair (VPR). Although a cost-effectiveness analysis found universal MUS placement to be the most cost-effective strategy over both selective and staged strategies (J Urol. 2013;190:1306–1312), this analysis did not include an arm for the less-costly option of using a selective approach via a prolapse-reduced cough stress test (CST). In addition, Richardson analysis of patients undergoing sacral colpopexy lacks generalizability for VPR surgeries (which account for two thirds of all prolapse surgeries). The manuscript described here therefore tested the cost-effectiveness of 3 generalizable MUS utilization strategies for preventing de novo SUI within 1 year post-VPR. Three approaches were compared: (1) staged strategy performing VPR with later MUS placement only for de novo SUI; (2) universal sling placement at the time of VPR; and (3) selective sling placement with MUS at the time of VPR when occult SUI was observed at the time of preoperative prolapse-reduced CST. A representative population of women with symptomatic pelvic organ prolapse (at least stage II) was modeled. Included in the VPR model was colpocleisis, apical suspension, or anterior colporrhaphy, with or without hysterectomy. The base assumption was that all VPRs were uncomplicated and anatomically successful. Subsequent treatment pathways were formed based on the 3 aforementioned options if de novo SUI was to occur. A 2017 systematic review by van der Ploeg was used for obtaining literature to gain point estimates concerning the risk for postoperative SUI (Int Urogynecol J. 2016;27:1029–1038). The search was performed via PubMed through January 2017, and exclusionary criteria were as follows: studies examining urodynamics preoperatively, abdominal prolapse repairs, duplicate studies, and studies lacking clear definitions for VPR, MUS, or SUI. Using data from 3 previous studies, for a selective MUS, the authors estimated the rate of de novo SUI after VPR with a negative preoperative CST to be 33.6%. The authors determined the existence of 4 possible adverse outcomes following MUS: (1) persistent SUI, (2) sling lysis required for voiding dysfunction, (3) mesh exposure requiring excision, and (4) anticholinergic medications required for de novo overactive bladder. Information on costs was gathered Physician Fee Schedules from the 2020 Centers for Medicare and Medicaid Services. Incremental cost-effectiveness ratio was the primary outcome modeled, defined as the ratio of the cost difference compared with the difference in quality-adjusted life years between scenarios. Results indicated that costs were as follows for various approaches: $1051.70 per patient for staged strategy, $1093.75 for selective MUS, and $1125.54 for universal MUS. The incremental cost-effectiveness ratio value for selective MUS calculated at $2664/quality-adjusted life years, rendering it the most cost-effective and preferred strategy. The variable with the greatest effect on model cost was the proportion of patients experiencing postoperative SUI electing to undergo repeat surgical intervention via MUS placement. Strengths of the study include its use of high-quality Centers for Medicare and Medicaid Services data for costs and point estimates. Because these data hails from the large portion of older Americans covered by Medicare (the most at risk for prolapse surgery), it avoids the inclusion of large variabilities innate to individual hospital systems. In addition, a 1-way sensitivity analysis was performed based on all case assumptions, thereby demonstrating the robustness of the study model. Limitations of the study included the expected hindrance of estimations and assumptions about event incidences. A 1-year time horizon was analyzed, although this may be reasonable because risks of complications dwindle over time. Furthermore, the study only considered women with de novo SUI to have the options of no treatment or MUS placement, disregarding costs of alternative procedures such as pelvic floor physical therapy, pessary, repeat MUS, urethral bulking, or other surgical interventions. Finally, all possible common outcomes after VPR were not included, such as urinary tract infections, pain, or postoperative urinary retention requiring short-term catheterization. In this study, the overall preference for treating de novo SUI via vaginal prolapse surgeries was the selective prophylactic midurethral sling. Patient counseling should occur to inform about the risks and benefits related to prophylactic sling surgeries (including the possibility of de novo SUI after VPR). Decisions regarding treatment strategy ought to be made using each patient’s priorities and treatment goals in discussion with her surgeon.

Weight gain after mid-urethral sling for stress urinary incontinence: a secondary analysis of the trial of mid-urethral slings

Weight gain after mid-urethral sling for stress urinary incontinence: a secondary analysis of the trial of mid-urethral slings

Impact of midurethral sling at time of prolapse surgery on overactive bladder symptoms and urinary biomarkers

Impact of midurethral sling at time of prolapse surgery on overactive bladder symptoms and urinary biomarkers

The effect of postoperative weight change on outcomes following midurethral sling for stress urinary incontinence

The effect of postoperative weight change on outcomes following midurethral sling for stress urinary incontinence

Synthetic Mid-urethral Sling for the Treatment of Urinary Incontinence in Women with Neurogenic Lower Urinary Tract Dysfunction: A Multicentric Retrospective Study.

To assess the efficacy, safety, and predictive factors for failure of synthetic mid-urethral slings for the treatment of urinary incontinence in a large cohort of women with neurogenic lower urinary tract dysfunction. Women aged 18 years or older who received a synthetic mid-urethral sling for stress urinary incontinence or mixed urinary incontinence in 3 centres between 2004 and 2019 and who had a neurological disorder were included. Exclusion criteria were less than 1 year of follow-up, concomitant pelvic organ prolapse repair, previous synthetic sling implantation, and no baseline urodynamics. The primary outcome was surgical failure, defined as recurrence of stress urinary incontinence during follow-up. Kaplan-Meier analysis was used to estimate the 5-year failure rate. Adjusted Cox proportional hazard model was used to identify factors associated with surgical failure. Complications and reoperations during the follow-up have also been reported. A total of 115 women with a median age of 53 years were included. The median follow-up duration was 75 months. The 5-year failure rate was 48% (95 CI 46-57%). Age above 50 years, negative TVT test and transobturator route were associated with surgical failure. 36 patients (31.3%) underwent at least 1 reoperation for complications or failure, and 2 required definitive intermittent catheterization. Synthetic mid-urethral slings may be an acceptable alternative to autologous slings or artificial urinary sphincters for the treatment of stress urinary incontinence in a selected group of patients with neurogenic lower urinary tract dysfunction.

Hysteroscopy-guided transurethral resection for urethral exposure of mid-urethral slings

Introduction and hypothesis.The mid-urethral sling (MUS) is a safe and effective treatment for women with stress urinary incontinence (SUI), but there is a long-term risk of exposure into the urethra. Although momentum has shifted from open vaginal repair to endoscopic approaches, research evidence is limited. Therefore, we present our experience with hysteroscopy and endoscopic scissors for the management of this complication. Methods:This case series describes patients who underwent surgery to treat urethral MUS exposure. All surgical procedures were performed under local or general anesthesia, using a hysteroscope to locate and visualize the MUS, endoscopic scissors to release visible exposure, and forceps to remove any material. Patients were routinely asked about symptom relief at 6 weeks. Results:Of the seven patients who underwent the hysteroscopic procedure, six needed a second session because mucosal bleeding or bulging caused poor visualization of the urethra. Six patients reported improvements after surgery. Of the four who reported recurrent SUI, two were successfully treated with a bulking agent. Although three of four patients who underwent cystoscopy during follow-up had residual MUS, all reported symptomatic improvement. Conclusion:The hysteroscopic approach appears to be an alternative for treating urethral MUS exposure. Patients should be informed that the procedure can be performed under local anesthesia, but that multiple sessions or procedures may be needed. Future research should consider whether symptom relief or the absence of MUS at cystoscopy defines success.

Does trocar puncture of the bladder during midurethral sling impact postoperative urinary storage and voiding symptoms?

The incidence of trocar bladder puncture during midurethral sling (MUS) surgery varies widely. We aim to further characterize risk factors for bladder puncture and examine its long-term impact on storage and emptying. This is an Institutional Review Board-approved, retrospective chart review of women who underwent MUS surgery at our institution from 2004 to 2018 with ≥12months of follow-up. Unless prolonged catheterization was necessary, a voiding trial was performed prior to discharge, or the next morning in outpatients, regardless of puncture. Preoperative and postoperative details were obtained from office charts and operative records. Of 1,500 women, 1,063 (71%) had retropubic (RP) and 437 (29%) had transobturator MUS surgery. Mean follow-up was 34months. Thirty-five women (2.3%) sustained a bladder puncture. RP approach and lower BMI were significantly associated with puncture. No statistical association was found between bladder puncture and age, previous pelvic surgery, or concomitant surgery. Mean day of discharge and day of successful voiding trial were not statistically different between the puncture and nonpuncture groups. There was no statistically significant difference in de novo storage and emptying symptoms between the two groups. Fifteen women in the puncture group had cystoscopy during follow-up and none had bladder exposure. Level of the resident performing trocar passage was not associated with bladder puncture. Lower BMI and RP approach are associated with bladder puncture during MUS surgery. Bladder puncture is not associated with additional perioperative complications, long-term urinary storage/voiding sequelae, or delayed bladder sling exposure. Standardized training minimizes bladder punctures in trainees of all levels.

Cost-effectiveness of urethral bulking polydimethylsiloxane-Urolastic® compared with mid-urethral sling surgery for stress urinary incontinence: A two-arm cohort study.

To investigate the cost-effectiveness of urethral bulking polydimethylsiloxane-Urolastic® (PDMS-U) compared with mid-urethral sling (MUS) surgery for stress urinary incontinence (SUI) at 1-year follow-up. Prospective, two-arm cohort study with 2-year follow-up. International multicentre. Women with moderate to severe SUI. Primary outcome was subjective cure (Patient Global Impression of Improvement). objective cure (negative cough stress test), Urogenital Distress Inventory (UDI-6), complications and re-interventions. Cost-effectiveness outcomes: total costs, quality-adjusted life year (QALY) using IIQ7-scores (Incontinence Impact Questionnaire) and EQ-5D-5L, incremental cost-effectiveness ratio (ICER) and monetary benefit (adjusted for baseline confounders). In all, 131 PDMS-U and 153 MUS surgery patients were treated. Subjective cure rates for MUS surgery and PDMS-U were, respectively: 101/112 (90%) versus 40/87 (46%), adjusted odds ratio (aOR; for age, body mass index [BMI], severity, type of urinary incontinence and previous SUI procedure) was 4.9. Objective cure rates for MUS surgery and PDMS-U were respectively: 98/109 (90%) versus 58/92 (63%), aOR 5.4. Average total costs for PDMS-U and MUS surgery were €3567 and €6688. ICER for MUS surgery cost €15 598 per IIQ QALY and €37 408 per EQ-5D-5L QALY. With a willingness to pay (WTP) of €25 000, MUS has a 84% chance of being cost-effective using IIQ, whereas PDMS-U has a 99% chance of being cost-effective using EQ-5D-5L. MUS surgery is more cost-effective in realising improved disease-specific quality of life (QoL), while PDMS-U is more cost-effective in realising improved generic QoL.

FIGO recommendations: Use of midurethral slings for the treatment of stress urinary incontinence.

Stress urinary incontinence (SUI) is a global problem. It can significantly adversely impact a woman's quality of life. The use of synthetic mesh in vaginal surgery is controversial, especially when used for pelvic organ prolapse surgery. Although negative effects have been reported, the synthetic mesh midurethral sling (MUS) is considered to be safe and effective in the surgical treatment of SUI. To provide evidence-based data and recommendations for the obstetrician/gynecologist who treats women with SUI and performs or plans to perform MUS procedures. Academic searches of MEDLINE, the Cochrane Library, Embase, and Google Scholar articles published between 1987 and March 2020 were performed by a subgroup of the Urogynecology and Pelvic Floor Committee, International Federation of Gynecology and Obstetrics (FIGO). The obtained scientific data were associated with a level of evidence according to the Oxford University Centre for Evidence-Based Medicine and GRADE Working Group system. In the absence of concrete scientific evidence, the recommendations were made via professional consensus. The FIGO Urogynecology and Pelvic Floor Committee reviewed the literature and prepared this evidence-based recommendations document for the use of MUS for women with SUI. Despite the extensive literature, there is a lack of consensus in the optimal surgical treatment of SUI. These recommendations provide a direction for surgeons to make appropriate decisions regarding management of SUI. The MUS is considered safe and effective in the treatment of SUI, based on many high-quality scientific publications and professional society recommendations. Comprehensive long-term data and systemic reviews are still needed, and these data will become increasingly important as women live longer. These recommendations will be continuously updated through future literature reviews.

Robotic Burch colposuspension: anatomical and technical considerations.

Up to 13.6% of women will undergo surgical treatment for stress urinary incontinence during their lifetime. Midurethral slings are the mainstay of stress incontinence treatment; however, diversity of surgical options is needed to serve the large number of patients desiring treatment. The Burch colposuspension remains a viable treatment option for appropriately selected patients. Currently, information on procedural standardization and tools for surgical training on robot-assisted colposuspension is limited. We describe a stepwise robotic approach aimed at enhancing procedural reproducibility, while decreasing risks of intraoperative injury and postoperative complications. We analyze perioperative outcomes of our technique in a retrospective cohort of patients who underwent robot-assisted colposuspension at our institution. Seven key procedural steps are defined to optimize safe dissection in the retropubic space and to reduce the potential for surgical complications. These include methods of avoiding bladder, urethral, and neurovascular injury, as well as enhancing adequate suture fixation that prevents urethral obstruction and adverse postoperative urinary and pain-related symptoms. Surgical outcomes for 20 patients are reported and reveal low rates of perioperative complications. Robot-assisted colposuspension requires thorough knowledge of the retropubic space and the application of standardized techniques may reduce the risk of injury and optimize procedure efficiency and reproducibility.

Retreatment of Stress Urinary Incontinence After Midurethral Sling With Prior Urethral Bulking.

There is limited current literature regarding the retreatment of stress urinary incontinence (SUI) after midurethral sling (MUS) placement with prior urethral bulking. The objective was to evaluate the retreatment and perioperative complications of MUS placement with prior urethral bulking compared with MUS placement without prior urethral bulking. This was a retrospective cohort study of patients within the Southern California Permanente Medical Group who underwent MUS placement from January 2009 to December 2020. Patients who underwent prior urethral bulking were compared with a control group without prior urethral bulking in a 1:1 ratio matched by age and MUS procedure date. The primary outcome was the retreatment of SUI after MUS placement with prior urethral bulking. Secondary outcomes were perioperative complications. Regression models were used to evaluate associations between retreatment and perioperative complications while controlling for confounding variables. Eighty-five patients who underwent MUS placement with prior urethral bulking were identified and matched with 85 control patients who underwent MUS placement without prior urethral bulking. Patients who underwent MUS placement without prior urethral bulking were more likely to have concomitant surgery. Linear regression analysis controlling for the effect of concomitant surgery revealed no difference in estimated blood loss and operative time between the 2 groups. In logistic regression analysis, there was no difference in the retreatment rate and perioperative complications between groups. We found that the unique treatment combination of MUS placement with prior urethral bulking for recurrent SUI seems to have a similar retreatment rate and perioperative complications as MUS placement without prior urethral bulking.

C-Clamp Technique: A Retrospective Review of a Novel Technique to Prevent Bladder Injury in Retropubic Midurethral Slings.

Synthetic mesh midurethral slings have become the criterion-standard treatment for stress urinary incontinence with urethral hypermobility in women. Iatrogenic bladder injury is a known risk of the procedure. Our objective was to show that a novel "C-clamp technique" can significantly reduce the risk of bladder and urethral injury at the time of bottom-up retropubic synthetic mesh midurethral sling placement. We conducted a retrospective review of the electronic medical records using Current Procedural Terminology coding of a single surgeon who performed synthetic mesh midurethral slings. Medical records were reviewed for demographic and clinical data for all bottom-up retropubic synthetic mesh midurethral slings placed using a novel C-clamp technique. All operative reports were reviewed for bladder and urethral injury at the time of implantation of the synthetic mesh midurethral sling using the C-clamp technique. Two hundred one consecutive bottom-up retropubic synthetic mesh midurethral slings were placed using the C-clamp technique from April 2012 through June 2022. The average age was 51 years (29-86 years); the average weight was 82 kg (46 -139 kg); and the average body mass index was 31 kg/m2 (15-57 kg/m2). No patients sustained a bladder or urethral injury at the time of implantation of a retropubic synthetic mesh midurethral sling using the C-clamp technique. The novel C-clamp technique shows promise in eliminating the risk of iatrogenic bladder and urethral injury at the time of implanting a bottom-up retropubic synthetic mesh midurethral sling.

Novel autologous tissue coated midurethral sling versus synthetic sling in treatment of female stress urinary incontinence; prospective randomized controlled trial

Novel autologous tissue coated midurethral sling versus synthetic sling in treatment of female stress urinary incontinence; prospective randomized controlled trial

Single-incision mini-slings versus standard mid-urethral slings in the surgical management of female stress urinary incontinence: An updated systematic review and meta-analysis

Single-incision mini-slings versus standard mid-urethral slings in the surgical management of female stress urinary incontinence: An updated systematic review and meta-analysis

Cost-effectiveness Analysis: Autologous Rectus Fascial Sling Versus Retropubic Midurethral Sling for Female Stress Urinary Incontinence.

There are limited data on the economic comparison between retropubic midurethral sling and autologous fascial sling. This study aims to evaluate the cost-effectiveness of autologous rectus fascial sling compared with retropubic midurethral sling from both hospital and health care perspectives. A decision tree model was developed with 1 year of follow-up. We included variables such as objective success rate, complications and subsequent treatments, and retreatment for incontinence. The model included the index procedure and 1 retreatment for stress urinary incontinence. Cost estimates were calculated from both hospital and health care perspectives. The outcomes were expressed in incremental cost-effectiveness ratio (ICER) or cost per quality-adjusted life-year (QALY). An ICER <$50,000/QALY was considered cost-effective. From a hospital perspective, the overall cost of retropubic midurethral sling was higher than autologous rectus fascial sling ($2,348.94 vs $2,114.06), but was more effective (0.82 vs 0.80 QALYs). The ICER was $17,452/QALY. From a health care perspective, the overall cost of autologous rectus fascial sling was higher than retropubic midurethral sling ($4,656.63 vs $4,630.47) and was less effective. Retropubic midurethral sling was the dominant strategy, with ICER of -$1,943.32/QALY. If the success rate of autologous rectus fascial sling was ≥84.39%, or the cost of retropubic midurethral sling surgery was > $2,654.36, then autologous rectus fascial sling would become cost-effective. Retropubic midurethral sling is the cost-effective treatment from the hospital perspective and the dominant treatment from the health care perspective. However, changes in the costs and success rates of surgical procedures can alter the cost-effectiveness results.

Risk factors for stress urinary incontinence recurrence after midurethral sling revision

Risk factors for stress urinary incontinence recurrence after midurethral sling revision

Comparing Single-Incision Midurethral Sling with Bulking Agents for Female Stress Urinary Incontinence: Rationale for a Non-Randomized Controlled Trial

Objectives: Midurethral slings are considered the gold standard for the surgical treatment of stress urinary incontinence (SUI), with an efficacy up to 80%. Another therapeutic option is the use of bulking agents, which create an artificial mass in the urethral submucosa, with an efficacy varying from 64% to 74%. Although bulking agents have a lower risk of complications than midurethral sling surgery, they are mainly used in case a midurethral sling is not an option or if midurethral sling surgery failed to cure stress urinary incontinence. In this study, we offer all patients with SUI in secondary care a choice between a single-incision midurethral sling procedure and treatment with a bulking agent. We want to examine patient preference and patient satisfaction for both procedures. We expect that offering both interventions in combination with standardized counselling will result in high patient satisfaction. Design: In this non-randomized controlled trial, 266 patients will be objectively counselled for both interventions, after which all patients will choose between single-incision midurethral slings and polyacrylamide hydrogel (PAHG), followed by the standard care procedure for women with SUI. Participants/Materials, Setting, Methods: From January 1, 2021, onward, all consecutive adult patients (between 18 and 80 years of age) attending the outpatient gynaecology department with objectively confirmed, moderate to severe SUI will be eligible for enrolment in this non-randomized study. The primary outcome is patient satisfaction at 1 year, measured by the Patient Global Impression of Improvement; secondary outcomes are patient satisfaction at 3 months, objective and subjective cure at 3 months and 1 year, adverse events, post-operative pain, and cost-effectiveness. Differences in outcome measures will be assessed through logistic and linear regression analyses, both unadjusted and adjusted with covariate adjustment using the propensity score. Results: No results are available yet. Limitations: The major disadvantage of this study design is the potential confounding bias. We intend to eliminate this bias by applying propensity scoring. Conclusion: By designing a non-randomized patient preference trial, we not only expect to demonstrate high patient satisfaction with both interventions but also provide insight into the possible role of PAHG-injections in the treatment of female SUI as a first-choice non-conservative treatment.