Office vs or Periurethral Bulking: Does Treatment Setting Matter?

Objectives: Periurethral bulking (PUB) with polyacrylamide hydrogel (PAH) to treat stress urinary incontinence (SUI) may be performed in the operating room (OR) or clinical office setting. Whether the procedure setting contributes to clinical outcomes is unknown. We examined whether treatment failure differs between PUB performed in the office versus OR. Additionally, we sought to identify variables associated with treatment success. We hypothesized that treatment failure is greater for office PUB.

Methods: We performed a single institution retrospective chart review of patients undergoing primary PUB-PAH in the office or OR (9/1/22 – 9/30/23). Non-PAH PUB was excluded. The primary outcome was 6-month treatment failure, defined using the following composite: 1) unchanged SUI symptoms as documented in the medical record or 2) SUI retreatment by PUB, SUI surgery, incontinence pessary, or pelvic floor physical therapy for persistent SUI symptoms. Secondary outcomes included 12-month treatment failure and 6- and 12-month SUI retreatment rates. Statistical analysis included chi-square, Fisher’s Exact, independent T, and Mann-Whitney U tests as appropriate. Assuming a 6-month composite treatment failure of 33% for OR cases, based on literature review, and 66% for office cases, we required sample sizes of 57 OR cases and 29 office cases (80% power, alpha = 0.05).

Results: There were 68 OR and 37 office cases during the study period. Demographic and clinical characteristics, SUI diagnostic modality, positive cough stress test bladder volume, and pre-procedure postvoid residual did not differ between groups (p > 0.05) (Table 1). OR patients were more likely to have fibromyalgia (p = 0.048) and pelvic pain (p = 0.028) compared with office patients. Surgeon was associated with treatment setting (p < 0.01) (Table 2). OR patients were more likely to receive antibiotic prophylaxis (p < 0.001) and greater PAH volume (p = 0.048), whereas office patients were more likely to have a cough stress test during the procedure (p < 0.001) and have their procedure aborted (p = 0.014). Six-month treatment failure did not differ between groups (33.8% vs. 35.1%, p > 0.99), nor did 12-month treatment failure (p = 0.43), 6- or 12-month retreatment (both p > 0.99), nor post-procedure urinary tract infection rates (p = 0.78). The OR group exhibited a trend towards increased urinary retention (p = 0.052). Patients with treatment failure at 6 months were more likely to have fibromyalgia (p < 0.001).

Conclusions: The 6- and 12-month treatment failure rates did not differ between PUB-PAH performed in the OR versus office setting. Patients undergoing PUB in the OR may be more likely to experience urinary retention. Because office bulking is not associated with higher treatment failure and is less resource intensive, we suggest office bulking when cost, feasibility, and patient tolerance allow.