The majority of studies examining efcacy of SNS are prospective and limited by the lack of direct comparators. In a randomized double-blind crossover trial, the ability to postpone defecation, frequency of incontinent episodes, symptom severity score, and quality of life signicantly improved during the “device on” versus “device off” phase [37]. When SNS is compared to optimal medical therapy in a randomized trial, the SNS group demonstrated signicant improvement in quality of life, reduction in weekly incontinence episodes (from 9.5 to 3.1), and achieve­ment of perfect continence in 47.2% [38]. In contrast, the medically managed group demonstrated no improvement in fecal incontinence or quality of life. Meurette etal. compared 15 patients with SNS to 15 matched patients who had received arti­cial bowel sphincter (ABS) [39]. While both groups demonstrated improvement in continence scores from baseline, SNS had higher postoperative incontinence scores (9.4 vs 5.7). However, constipation and symptoms of outlet obstruction were more frequent following ABS.Furthermore, there was no signicant morbidity with SNS, while 53% of patients in the ABS group required additional surgical intervention due to mechanical failure, ulceration, or erosion of the anal canal. The FENIX mag­netic sphincter augmentation (MSA) is a novel therapeutic option for FI that serves to increase anal sphincter tone. The SaFaRI trial is a randomized controlled, unblinded trial in Europe that seeks to compare efcacy of the FENIX MSA to SNS for moderate to severe incontinence [40]. Additional randomized trials comparing SNS to other therapies, such as the ongoing SaFaRI trial, may provide the clinical evidence required to design a denitive treatment algorithm.