Rising Rates of Urethral Bulking: A Retrospective Study of a National Database

Objectives: Surgical management of stress urinary incontinence has evolved with the introduction of synthetic midurethral slings and urethral bulking. This study aims to analyze trends in procedures from 2012 to 2022.

Methods: The American College of Surgeons National Surgical Quality Improvement Program Database was used to identify patients who had undergone a sling operation or urethral bulking for stress incontinence as identified by CPT code. This database included inpatient and outpatient procedures from nearly 700 hospitals around the United States. Descriptive statistics and independent paired T-tests were performed to evaluate frequencies and patient characteristics associated with each procedure.

Results: A total of 81,657 patients in the database received either midurethral sling or urethral bulking from 2012 to 2022. The number of slings performed was highest in 2017, decreased in 2020 and has since steadily risen (Figure 1). The rate of urethral bulking has steadily increased from 2019 to 2022 (Figure 2). Patients having urethral bulking were more likely to be older with an average age of 56 years versus 64 years with sling (p < 0.001). There was no significant difference in body mass index, rate of diabetes, or smoking status between the groups.

Conclusions: Slings continue to be the most common choice for surgical management of stress incontinence. Their prevalence peaked in 2017. There was a significant decrease in the number of slings performed in 2020, likely secondary to the delay of elective surgeries in the setting of the COVID pandemic. However, in subsequent years the number of slings has not recovered to pre-pandemic levels in this database. Meanwhile, urethral bulking has become increasingly common, perhaps due to the increase in diversity and efficacy of urethral bulking products available on the market. For example, polyacrylamide hydrogel gained FDA approval in 2020. While older age was associated with having bulking performed, there was otherwise no significant difference in patient characteristics such as BMI, diabetes, or smoking status. Further research is needed to evaluate the driving forces of these trends.