The ULP (urethral ligament plication ) is a new operation for cure of SUI which does not require a tape. The ULP operation is based on a live anatomical study of the PUL (pubourethral ligament) [1] and the same restoration of the two closure mechanisms behind the TVT MUS (midurethral sling) [2].   Fundamental to both MUS and ULP operations is the surgical principle developed in experimental animals, harnessing the tissue reaction of an implanted foreign body (such as a tape), to create neocollagen to reinforce weakened PULs [3]and to prevent the PUL lengthening during effort which opens bladder neck to cause urine loss on effort . Whereas the MUS creates an entirely new PUL neoligament, the ULP operation’s wide-bore polyester sutures confine all 4 branches of the PUL to prevent elongation, and add new collagen to strengthen the ligaments .

Patients were computer randomized. Registration, EC and informed consent obtained, no funding. TOT technique : standard outside/in.  ULP Learning curve:11 patients.
ULP Technique  Two 4cm incisions were made in the distal vaginal sulci, from external urethral meatus to bladder neck. A No 2 collagen-creating polyester suture was inserted  into the 4 PUL attachment points, Figure1 (right). The sagittal view, left, shows a single suture confining all 4 parts of PUL .
Caption 
Figure 1 Surgical repair PUL, single wide-bore polyester suture, sagittal & frontal views 
Right - live anatomy:   PUL insertions and suture attachments: 1: medial to PUL; 2: behind symphysis: origins of PUL, PVL (pubovesical ligament-not shown); 3:EUL. 4: lateral attachment to PCM. Tape measure shows the surgery is carried out in a 4 sq.cm space.
 
Left cadaver figure Suture confines 4  PUL insertion points: A=anterior pubourethral ligament (EUL); I=intermediate pubourethral ligament; P=posterior pubourethral ligament; LA=levator ani (m. pubococcygeus);; SP=symphysis pubis; U=urethra; EUM=external meatus; (by permission, Robert Zacharin).

RESULTS  at 12 months
The ULP was superior to conventional TOT in all measures
•	Cure rates: 90.7% cure vs 81.5% (p<0.05);  UDI6 0.61 vs 1.17; 
•	Operating time 18 minutes vs 26 minutes; 
•	Complications TOT: pain 7.4%; mesh extrusion trimming (7.4%) with 50% failure. ULP: nil important .

•	low cost ($2 for polyester sutures);
•	safe, direct vision surgery (no blind insertion instruments to damage organs, nerves,blood vessels) 
•	minimal facilities 
•	local anesthetic option
•	especially suited to emerging nations.

. Petros PE. The pubourethral ligaments-an anatomical and histological study in the live patient. Int Urogynecol J. 1998;9:154-157
. Petros PE, Ulmsten U. An Integral Theory of female urinary incontinence. Acta Obstet Gynecol Scand. 1990;69 Suppl 153:1-79.
Petros PE, Ulmsten U, Papadimitriou J. The Autogenic Neoligament procedure: A technique for planned formation of an artificial neo-ligament.  Acta Obstet Gyn Scan. 1990;69 Suppl 153:43-51.