Endoscopic Injection With Polydimethylsiloxane for the Treatment of Pediatric Urinary Incontinence in the Neurogenic Bladder: Long-Term Results

PURPOSE

We report the long-term results of endoscopic injection of PDMS in correcting urinary incontinence in children with neurogenic bladder.

MATERIALS AND METHODS

We performed a single center, retrospective study of patients receiving endoscopic injections of PDMS. All procedures were performed as outpatient surgery using endoscopic guidance. Procedure tolerance was assessed at 15 days, and efficacy was evaluated at 3 months, 6 months and annually thereafter. Success was defined as periods of dryness between bladder voiding of more than 4 hours during the daytime without the need to wear pads. Improvement was defined as periods of dryness greater than 2 and less than 4 hours with occasional protection.

RESULTS

A total of 49 children (21 boys and 28 girls) have received 1 or more injections of PDMS since 1995. Etiology was spina bifida in 41 patients (84%), with surgery (enterocystoplasty and/or bladder neck reconstruction) performed previously in 27 patients. Mean patient age was 14 years (standard deviation 4.8). Mean volume of PDMS per treatment was 3.6 ml. At the end of the 6-year mean followup 16 patients (33%) were continent and 7 (14%) were improved. Continence was unchanged in the remaining 26 patients (53%). After a significant deterioration of the results the outcome remained almost unchanged from 18 months of followup. Bladder neck surgery, bladder hyperactivity if medically controlled and gender have no influence statistically on the long-term results.

CONCLUSIONS

Injection of PDMS for incontinence of neurogenic origin is a reliable technique that achieves long-term continence in almost a third of the patients. This procedure can be used either as first line treatment or in addition to other surgical techniques. The initial success of the procedure seems predictive of success in the long term, and results are stable after 18 months of followup.

Treatment of acne scars with liquid silicone injections: 30-year perspective

BACKGROUND

This article addresses the use of liquid injectable silicone as both an immediate and long-lasting treatment for broad-based, depressed acne scars. The only filler substance that maintains precision and permanence in improving and/or correcting these types of acne scar defects is medical-grade liquid silicone.

OBJECTIVE

We describe five patients with a history of acne scarring who showed improvements from injections of liquid silicone at the initial treatment session and lasting over a 10-, 15-, and 30-year follow-up period.

METHODS

Monthly liquid silicone injections using a technique known as the microdroplet, multiple-injection approach.

RESULTS

This article documents the safety, effectiveness, and precision of silicone in addition to highlighting the fact that its permanence is what distinguishes it from other filler materials.

CONCLUSION

As a precise and permanent filling substance used for soft tissue augmentation, liquid injectable silicone can improve and/or eliminate depressed, broad-based acne scars through a technique known as the microdroplet, multiple-injection

Current role of injectable agents for female stress urinary incontinence

AIM

The current role of injectable agents in the management for female stress urinary incontinence is reviewed.

MATERIALS AND METHODS

Published manuscripts for collagen, silicone microparticles, carbon beads, hyaluronic acid dextranomer and two investigational agents were evaluated.

RESULTS

While injectable agents were used in the past for pure intrinsic sphincter deficiency there is good evidence that patients with hypermobility respond similarly. Collagen has been the most widely reported agent to date. Comparative studies with surgery have demonstrated inferior efficacy but a recent study showed a similar quality of life outcome. Newer agents have been designed for superior efficacy and durability. However, of the new agents carbon beads was not shown to be superior and the results of randomized trials of silicone microparticles and hyaluronic acid dextranomer compared to collagen have not yet been reported. All currently used agents appear to be very safe.

CONCLUSIONS

Injectable agents have been shown to have efficacy in the management of stress incontinence in women and should be readily available as a treatment option. The definite superiority of one agent over another has not yet been established.

Do early injections of bulking agents following radical prostatectomy improve early continence?

Bulking agents belong to the treatment options of stress urinary incontinence in both genders for a long time, but early injection of bulking agents following radical prostatectomy to improve early continence is a new treatment modality and the results of the first years will be presented in this study. From 1996 to 2001, 55 incontinent patients, of whom 44 suffered from post-prostatectomy incontinence (PPI), have been treated by bulking agents in our clinic and evaluated later on, using a semistandardized questionnaire. Mean age was 65.5 years and the mean follow-up was 32 months. Of 44 patients with PPI, 29 suffered from incontinence of the third, 10 from incontinence of the second and 5 from incontinence of the first degree. We examined the influence of transurethral injection of bulking agents on direct postoperative continence (short-term results) and on continence at the time of follow-up (long-term results) (mean 32 month). An improved early continence (short-term result) was achieved in 30 patients. At follow-up, 19 patients were completely dry, 18 reported an improved continence. Especially the time of treatment, referring to radical prostatectomy, had a significant influence on treatment results with better results in the subgroup of 34 patients that have been treated early (mean 23 days) compared to 10 patients that received delayed treatment (mean 26 months) following radical prostatectomy. The preoperative degree of incontinence had a significant influence on short-term results, and not on long-term results. The amount of bulking material and the number of injections had no significant influence on short-term results, but repeated injections resulted in statistically worse long-term results. In summary, early transurethral injection of bulking agents is an effective and minimal invasive therapy option to improve early continence in patients with PPI. Time to improved continence due to training of the sphincter externus muscle cannot be shortened, but the quality of life during this time can be improved. In case of a severe lesion of the sphincteric muscle, continence cannot be improved for a longer period and the results are poor. In these cases, procedures like implantation of an artificial urinary sphincter may be required.

[Penile silicone granuloma]

OBJECTIVES

To report our experience with one case of penile silicone granuloma, that has clinical interest for its unfrequent presentation.

METHODS/RESULTS

We report the case of a patient with sexual dysfunction secondary to subcutaneous injection of liquid silicone in the penis resulting in a penile granuloma and migration of the particles to the penile root and midline scrotal raphe. We proceeded to the surgical excision of the granuloma and migrated particles, repairing the penile defect with scrotal skin.

CONCLUSIONS

Subcutaneous injection of liquid silicone is a practice that does not have any justification because of its devastating effects and requires major perations for the elimination of the injected material.

[Subureteral polydimethylsiloxane injection for the endoscopic treatment of vesicoureteral reflux]

INTRODUCTION

Endoscopic subureteral injection has been successfully used to treat vesicoureteral reflux (VUR) in children. The aim of this study was to review our results with subureteral polydimethylsiloxane injection in terms of effectiveness, long term follow-up and morbidity.

MATERIAL AND METHOD

Twenty-eight children with VUR were treated with this technique. VUR was unilateral in eight patients (28.6%) and bilateral in 20 patients (71.4%). Indications for endoscopic treatment were the same as those for open surgery. The polydimethylsiloxane implant was injected transureterally below the ureteral meatus in 50 ureters on an outpatient basis. Reflux grade was low (II-III) in 36% and high (IV-V) in 64%.

RESULTS

The mean follow-up was 18 months (12 months-4 years). VUR was corrected in 43 ureters (86%) corresponding to 21 patients. Reflux resolved in 40 ureters after one polydimethylsiloxane injection (80%) and in 43 ureters (86%) after two injections. An endoscopic retreatment to correct the reflux was performed in six ureteral units. Cystoscopic findings in these patients with endoscopic failure were mound displacement toward the bladder neck in five ureters and marked volume loss on the mound in one. All these patients underwent a second subureteral dose, which controlled VUR in three ureters (50%).

CONCLUSIONS

Our results confirm that endoscopic subureteral polydimethylsiloxane treatment is a simple procedure with low morbidity that is well tolerated by the patient. In our experience, it can be used in double ureters. The effectiveness of this procedure seems to be related to the grade of reflux, the cystoscopic appearance of the ureteral orifice, volume loss and mound displacement.

Injectable Skin Fillers

The list of injectable skin fillers available for soft tissue augmentation is constantly growing, giving aesthetic surgeons more options in the treatment of scars, lines, and wrinkles. Each type of filler is distinct with regard to intended use, placement technique, duration in tissue, ease of use, and cost. Physicians who are well acquainted with the strengths and weaknesses of each class of filler will be best equipped to use this rapidly expanding class of agents in serving their patients. The authors review the most commonly used injectable skin fillers and discuss their differences in terms of composition, source (eg, human, animal), intended use, placement technique, tissue duration (nonpermanent, semipermanent, or permanent), side effects, and specific advantages and disadvantages.

Soft Tissue Implants and Fillers

The number and variety of soft tissue implants and fillers at the clinician's disposal continues to increase rapidly as new materials and bioengineering techniques evolve. The ideal implant for all purposes does not yet exist, so the clinician must be familiar with a wide variety of products for each application. Continued advances in synthetic, allogeneic, and autologous products and experience with existing products will further augment the surgeon's armamentarium in the coming years.

Assessment and management of fungating wounds: a review

Fingating wounds always present a management challenge. Not only is it often difficult to manage the physical aspects of the wound - pain, bleeding, exudate and odour - but also the psychological impact of a fungating wound on the patient and their family or carers is often considerable. This review examines current practice in relation to fungating wounds, and emphasizes the central important of assessment, communication and sensitivity in nursing management.

The histologic host response to liquid silicone injections for prevention of pressure-related ulcers of the foot: a 38-year study

This study analyzed the histologic effects of and host response to subdermally injected liquid silicone to augment soft-tissue cushioning of the bony prominences of the foot. A total of 148 postmortem and surgical specimens of pedal skin with attached soft tissue were obtained from 49 patients between July 1, 1974, and November 30, 2002. The longest period that silicone was in vivo was 38 years. The specimens were then processed into paraffin blocks and examined for specific findings. The variables considered included distribution of silicone within the tissue, host response, migration to regional lymph nodes, and viability of the host tissue after treatment. The host response to silicone therapy consisted primarily of delicate-to-robust fibrous deposition and histiocytic phagocytosis, with eventual formation of well-formed elliptic fibrous pads. The response in the foot appears different from that in the breast and other areas of the body previously studied. No examples of granulomas, chronic lymphoplasmacytic inflammation, or granulation tissue formation were seen, with only rare foreign-body giant cells present. Silicone injections in fat pads for the treatment of atrophy and loss of viable tissue show a histologically stable and biologically tolerated host response that is effective, with no evidence of any systemic changes.

Silicone granuloma of the face treated with minocycline

Siliconoma represents a granulomatous foreign body reaction to silicone, which is often used for soft tissue augmentation. Although considered as biologically inert for a long time, silicone has been implicated in various undesirable local and systemic reactions, sometimes with a latency period of up to several decades. Treatment of siliconomas is difficult and granulomas involving the face are a therapeutic challenge. We present a 43-year-old woman with a severely disfiguring facial silicone granuloma who was successfully treated with minocycline.

Mechanisms of impaired vascular response to ANG II in perivascular injured carotid arteries of ovariectomized rat

The rabbit carotid artery, injured by silicone collar, presents a perivascular inflammatory response and alterations in vascular responsiveness. Considering that angiotensin II (Ang II) plays an important role in cardiovascular physiology and pathology and that cardiovascular disease increases in postmenopausal women, the aim of this study was to investigate whether the Ang II contractile response in ovariectomized rat carotid artery is modified after a vascular injury by silicone collar. The positioning of the silicone collar around the common carotid artery for 14 days leads to an increased cross-sectional area of adventitial layer with inflammatory cells and an extensive angiogenesis. The Ang II-induced contraction was significantly decreased in collared arteries when compared with contralateral arteries. The reduction in the constrictor effect of Ang II in collared arteries was not modified by the presence of indomethacin (a non-selective inhibitor of cyclooxygenase) or PD 123,319 (a selective antagonist of the Ang II AT2 receptor). Moreover, while endothelium removal induced an increase in the Ang II responsiveness of both arteries (collared and contralateral), the Emax induced by Ang II was still lower in collared arteries. However, the "in vitro" pretreatment of the arteries with an inhibitor of nitric oxide synthase enzyme (L-NAME) significantly enhanced the maximal contractions response to Ang II only in injured arteries. Furthermore, the expression of iNOS (inducible nitric oxide synthase) was observed in the adventitial layer of collared arteries, indicating that the NO formed in the adventitial layer has an important role in injured arteries. Moreover, our data show impairment of extracellular calcium mobilization, mediated by Ang II, in the collared artery, although the intracellular calcium mobilization was not modified by the injury. In conclusion, the increased production of NO and a decrease in the calcium influx displayed by Ang II in the collared artery appears to counteract and reduce the biologic effect of Ang II.

The long-term outcome of the endoscopic subureteric implantation of polydimethylsiloxane for treating vesico-ureteric reflux in children: a retrospective analysis of the first 195 consecutive patients in two European centres

OBJECTIVE

To determine the long-term efficacy of endoscopically implanting polydimethylsiloxane (PDS, Macroplastique, Uroplasty BV, Geleen, the Netherlands) for treating vesico-ureteric reflux (VUR) in children.

PATIENTS AND METHODS

We retrospectively reviewed the records of 195 children treated with PDS over the past 10 years in two European centres (Netherlands and UK) and conducted follow-up investigations where deemed necessary. In the Dutch centre patients were treated according to a prospective approved study protocol.

RESULTS

Of the 195 treated children, 155 had a successful outcome; in all, 311 refluxing renal units were treated, with an overall success rate of 82.3% in a mixed group of patients with unilateral or bilateral VUR and duplex systems.

CONCLUSION

The long-term data from these two independent centres confirms the viability of PDS and the technique for treating VUR in children. We conclude that the material is safe and effective and can be used in VUR grades II-V. Treating patients with grade I VUR is recommended in those cases where there is no spontaneous resolution and 'breakthrough' infections.

Comparison between porcine dermal implant (Permacol) and silicone injection (Macroplastique) for urodynamic stress incontinence

The objective of this study was to compare the efficacy of porcine dermal implant injection (Permacol) and silicone injection (Macroplastique) in the treatment of female urodynamic stress incontinence (USI) in a prospective randomized trial. Fifty women with urodynamically proven stress incontinence were recruited and randomised to receive either Permacol or Macroplastique injection. Twenty-five patients were enrolled in each case. An International Continence Society (ICS) standard 1-h pad test was carried out prior to the injection and a subjective analysis of incontinence made using a Stamey scoring system. In addition, a Kings College Hospital Quality of Health Questionnaire (KCQ) was completed. The women were followed up at 6 weeks and 6 months and the same methods used to gauge the success or failure of the operation. Preoperatively there were no significant differences in pad losses, Stamey score or King's score between the two groups. The mean age of the women was 61 years (range 28-80 years). At 6 weeks there were significant reductions in the mean and median values in pad losses, Stamey score and King's score in both Permacol and Macroplastique patients but the effects were more pronounced in Permacol patients than Macroplastique patients. Of the Permacol patients, 64% were improved on quantified pad losses out of which 60% were dry whereas 54% of Macroplastique patients were improved on pad losses of which 41.6% were dry. Of the Permacol patients, 64% and 60% had reduction in Stamey and KCQ score, respectively, whereas Macroplastique patients had 46% reduction in one or more grades of Stamey scores and 42% reduction in KCQ scores. At 6 months the results in the Permacol patients appeared to be sustained but not for Macroplastique patients. This study has shown that Permacol injection when used as a urethral bulking agent appears to have a higher cure rate for urodynamic stress incontinence than Macroplastique and these results persist until the follow-up period of 6 months. The use of Permacol injection is an attractive alternative in the treatment of urodynamic stress incontinence.

A case of HIV-associated facial lipoatrophy treated with 1000-cs liquid injectable silicone

BACKGROUND

Patients infected with the HIV may experience HIV-associated lipodystrophy, a symptom of which is facial lipoatrophy, a dramatic loss of subcutaneous facial tissue. This visible manifestation of HIV infection causes significant psychosocial pain for patients and has been associated with impaired compliance with medical regimens.

OBJECTIVE

To improve the appearance of facial lipoatrophy in a safe, long-lasting, expeditious, and relatively economical manner.

METHODS

An HIV-associated lipodystrophy patient with facial lipoatrophy underwent multiple sessions of soft-tissue augmentation therapy with liquid injectable silicone (LIS) using the microdroplet serial puncture technique.

RESULTS

Administration of LIS by the microdroplet serial puncture technique produced satisfactory improvement of areas of facial atrophy. The treatment time is limited, the patient discomfort and morbidity are minimal, and results are long lasting. Patients report significant satisfaction with treatment.

CONCLUSION

LIS administered by the microdroplet serial puncture technique is a safe and effective method for treating HIV-associated facial lipoatrophy and compares favorably with other methods of tissue augmentation.