To mesh or not to mesh, that was the question at the Sunday afternoon plenary session. The crossfire debate focused on a scenario that has garnered media attention over the past decade: the management of stress urinary incontinence (SUI). The pause on mesh use for vaginal surgery, including SUI, in many parts of Europe and Australia coupled with the emergence of a newer-generation urethral bulking agent, has sparked a resurgence in interest and increased utilization of these bulking agents, particularly in these geographical regions.¹

The topic was well-suited for a lively debate moderated by Dr Howard Goldman of Cleveland Clinic with debaters Dr Ekene Enemchukwu of Stanford University and Dr Alex Gomelsky of Louisiana State University Shreveport advocating for synthetic slings, and Dr Maude Carmel of University of Texas Southwestern Medical Center and Dr Nirit Rosenblum of New York University Langone Medical Center advocating for urethral bulking.

The case was a 55-year-old healthy, sexually active woman with worsening SUI. She tried and failed pelvic floor physiotherapy. She wasn’t interested in a vaginal insert, and she preferred to avoid a bigger surgery, such as an autologous pubovaginal sling or Burch colposuspension. The 2023 AUA/Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction SUI guideline amendment states that the remaining surgical options include urethral bulking agents and midurethral synthetic slings. So which treatment is best for this patient?

Dr Enemchukwu kicked off the debate by advocating for the midurethral sling as the optimal choice, citing its minimal invasiveness, brief recovery period, broad applicability across SUI subtypes, low morbidity, durability, and high success rate in achieving dryness. Notably, it is the most extensively researched SUI treatment available, rivaling traditional pubovaginal slings in efficacy while demonstrating lower complication rates.² Citing multiple prospective cohort studies, she noted its long-term success rates, reported as high as 91.3% at 17 years, with a satisfaction rate of 98%³ (Figure 1). In an Australian retrospective study spanning 18 years, she highlighted the low complication and reoperation rates for various indications including pain (1.2%), bladder/urethral exposure (0.3%), voiding dysfunction (3.4%), and recurrent SUI (2.6%).¹ She emphasized the importance of adequate training prior to embarking on SUI surgery and concluded that in the hands of an experienced surgeon, the procedure carries low risk and substantial benefit.

Dr Carmel countered with a review of the improved efficacy and safety profiles of polyacrylamide hydrogel (PAHG) vs older-generation bulking agents.⁴ In noninferiority trials comparing tension-free vaginal tape (TVT) midurethral slings to PAHG, TVT exhibited higher objective (95% vs 66.4%) and subjective (83.2% vs 23.4%) cure rates, and subjective improvement and patient satisfaction rates were comparable (100% vs 91.6%) at 1 year (Figure 2 and 3). Notably, complication rates were lower with PAHG at 3 years (24% vs 43.5% for TVT)⁵ (Figure 4). In the 7-year efficacy trial, although nearly 20% required a subsequent procedure, she argued that the overall cure/improved rates were acceptable at 65.2% and the majority (63.4%) of patients only required one injection.⁶ She concluded that PAHG should be considered as an alternative treatment option due to its high satisfaction rates, low complication rates and ease of retreatment, when necessary.

In his rebuttal, Dr Gomelsky questioned the rationale behind performing a urethral bulking procedure for this patient. He pointed to the 16% cure rates observed in the 7-year efficacy trial, with 49% showing only improvement, as well as the high retreatment rates (32% receiving a “top-up” at a median of 9 months).⁶ He concluded that the lack of long-term data and the nonzero risk of complication requiring surgical intervention (eg, stone, abscess),^7,8 combined with limited data and a lack of consensus on the role of urethral bulking from our international clinical societies, makes the midurethral sling the better option.

Dr Rosenblum fired back with a compelling photograph depicting a sling erosion, highlighting its rare yet potentially serious consequences. Rather than focusing solely on the technical outcomes, she highlighted the importance of empowering women through individualized, patient-centered care, focused on shared decision-making and nuanced discussions of the patient’s goals and expectations. Presenting data on women’s preferences, she emphasized their desire for a shorter recovery time, symptom improvement, and fewer adverse events, with 62% of women in one study willing to trade cure for a less invasive procedure.⁹

Dr Goldman concluded the plenary crossfire debate by emphasizing the importance of assessing the patient’s goals, risk tolerance, and considerations regarding durability. The session culminated in an audience poll, prompting attendees to consider what they would choose if faced with a similar decision for themselves, their spouse, or their family member. As highlighted throughout the session, all debaters seemed to concur that when selecting an SUI management strategy, the potential positive impact on quality of life must be considered within the context of the patient’s goals, values, preferences, and desires.