Long-term outcome of transurethral injection of hyaluronic acid/dextranomer (NASHA/Dx gel) for the treatment of stress urinary incontinence (SUI)

Transperineal and endovaginal ultrasound for evaluating suburethral masses: comparison with magnetic resonance imaging

OBJECTIVE

To evaluate the utility of pelvic floor ultrasound (US) in the detection and evaluation of suburethral masses, using magnetic resonance imaging (MRI) as the reference standard.

METHODS

This was a retrospective analysis of US and MRI scans of all women with a suburethral mass on clinical examination at a single urogynecology clinic over a 13-year period (February 2007 to March 2020). All women were examined using two-dimensional transperineal US (2D-TPUS) with or without three-dimensional endovaginal US (3D-EVUS). All patients underwent unenhanced T1-weighted and T2-weighted MRI, which was considered the reference standard in this study. Presence of a suburethral mass and its size, location, connection with the urethral lumen and characteristics were evaluated on both pelvic floor US and MRI. Agreement between pelvic floor US and MRI was assessed using intraclass correlation coefficients (ICC; 3,1).

RESULTS

Forty women suspected of having a suburethral mass on clinical examination underwent both MRI and US (2D-TPUS with or without 3D-EVUS). MRI detected a suburethral mass in 34 women, which was also detected by US. However, US also identified a suburethral mass in the remaining six women. Thus, the agreement between US and MRI for detecting a suburethral mass was 85% (95% CI, 70.2-94.3%). The ICC analysis showed good agreement between MRI and 2D-TPUS for the measured distance between the suburethral mass and the bladder neck (ICC, 0.89; standard error of measurement (SEM), 3.64 mm) and excellent agreement for measurement of the largest diameter of the mass (ICC, 0.93; SEM, 4.31 mm). Good agreement was observed between MRI and 3D-EVUS for the measured distance from the suburethral mass to the bladder neck (ICC, 0.88; SEM, 3.48 mm) and excellent agreement for the largest diameter of the suburethral mass (ICC, 0.94; SEM, 4.68 mm).

CONCLUSIONS

2D-TPUS and 3D-EVUS are useful in the imaging of suburethral masses. US shows good-to-excellent agreement with MRI in identifying and measuring suburethral masses; therefore, the two modalities can be used interchangeably depending on availability of equipment and expertise. © 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology. - Legal Statement: This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

Second-Line Surgical Management After Midurethral Sling Failure

Currently, the midurethral sling (MUS) is widely used as a standard treatment in patients with stress urinary incontinence (SUI). Several studies have reported the failure rate of MUS to be approximately 5%–20%. In general, sling failure can be defined as persistent SUI after surgery or a temporary improvement in incontinence followed by recurrence. Failure is also often considered to include cases requiring secondary surgery due to mesh exposure, postoperative voiding difficulty, de novo urgency/urge incontinence, and severe postoperative pain. Because of the lack of large-scale, high-quality research on this topic, no clear guidelines exist for second-line management. To date, transurethral bulking agent injections, tape shortening, repeat MUS, pubovaginal sling (PVS) using autologous fascia, and Burch colposuspension are available options for second-line surgery. Repeat MUS is the most widely used second-line surgical method at present. Bulking agent injections have lower durability and efficacy than other treatments. Tape shortening demonstrates a relatively low success rate, but comparable outcomes if the period from first treatment to relapse is short. In patients with intrinsic sphincter deficiency, PVS and retropubic (RP) MUS can be considered first as second-line management because of their higher success rate than other treatments. When revision or reoperation is required due to prior mesh-related complications, PVS or colposuspension, which is performed without a synthetic mesh, is appropriate for second-line surgery. For patients with detrusor underactivity, a readjustable sling can be a better option because of the high risk of postoperative voiding dysfunction in PVS or RP slings.

Retrospective analysis after endoscopic urethral injections of glutaraldehyde-cross-linked-collagen or dextranomer/hyaluronic acid copolymer in bitches with urinary incontinence

OBJECTIVES

To evaluate the outcome of endoscopic injection of two different bulking agents, glutaraldehyde cross-linked collagen and dextranomer/hyaluronic acid copolymer into the urethral submucosa in female dogs with urinary incontinence caused by urethral sphincter mechanism incompetence.

MATERIALS AND METHODS

Retrospective review of records and follow-up communication with owners of dogs that received an endoscopically guided urethral bulking procedure. In each dog, either cross-linked collagen (2007 to 2011) or dextranomer/hyaluronic acid copolymer (2012 to 2015) was used. At least three injections were made in a circular arrangement in the midurethral region until the urethral lumen was closed.

RESULTS

Complete questionnaires were available from 50 of 100 pet owners. The mean interval between the treatment and interview was 67 (range: 57 to 114) months in the cross-linked collagen group and 19 (range: 2 to 48) months in the dextranomer/hyaluronic acid copolymer group. The mean duration of continence was 45∙8 months (range: 12 to 84 months) in the cross-linked collagen group and 20∙5 months (range: 12 to 48 months) in the dextranomer/hyaluronic acid copolymer group. The success rate at 6 months or more after the procedure was 71% after the injection of cross-linked collagen and 58% after injection of dextranomer/hyaluronic acid copolymer. One minor complication (transient haematuria) occurred in one dog. There were no major complications.

CLINICAL SIGNIFICANCE

Urethral injection of dextranomer/hyaluronic acid copolymer in bitches with urethral sphincter mechanism incompetence is a useful alternative to cross-linked collagen injection, which is no longer available in the European market. Dextranomer/hyaluronic acid copolymer injection is a minimally invasive alternative to surgical procedures and has a low complication rate.

Two-year follow-up of an open-label multicenter study of polyacrylamide hydrogel (Bulkamid®) for female stress and stress-predominant mixed incontinence

INTRODUCTION AND HYPOTHESIS

Polyacrylamide hydrogel (PAHG, Bulkamid®) is a promising urethral bulking agent. This article presents the 2-year follow-up results of a multicenter study of PAHG injections for treating stress and stress-predominant mixed urinary incontinence.

METHODS

Submucosal injection of PAHG was performed in 135 women with urinary incontinence, with subjective and objective assessment of the efficacy and safety 24 months postinjection.

RESULTS

At 24 months, the subjective responder rate was 64 % (a statistically non-significant reduction from 67 % at 12 months). The decreased number of incontinence episodes and urine leakage were maintained compared with the result from the 12-month evaluations, as were objective result rates and quality of life data. No safety issues occurred.

CONCLUSIONS

PAHG is an effective and safe treatment option for women with stress-predominant mixed urinary incontinence, with maintained medium-term responder rates.

Management of Recurrent or Persistent Stress Urinary Incontinence after Mid-urethral Sling

The mid-urethral sling (MUS) procedure is the most common treatment modality for women with stress urinary incontinence (SUI). Although this procedure is highly successful, 5-20% of patients undergoing MUS experience persistent or recurrent SUI, regarded as surgical failure. However, little is known about methods to evaluate and manage patients who fail MUS procedures. The surgical options in these patients include bulking agent injection, shortening of pre-implanted tape, pubovaginal sling and repeat MUS. Of these secondary procedures, repeat MUS is the most widely studied, although this has been limited to small case series without long-term follow-up. Repeat MUS for prior MUS failure has shown relatively good success rates, ranging from 55 to 90%, with better outcomes obtained using the retropubic rather than the transobturator route. Persistent or recurrent SUI may also be successfully managed with less invasive techniques, such as tape shortening and periurethral injection of a bulking agent. Transurethral injection therapy for primary SUI has shown success rates of more than 65% at 1 year; however, these decreased significantly thereafter to around 30% at long-term follow-up. Since the optimal management of recurrent or persistent SUI after MUS has not yet been established, long-term, prospective, randomized trials are warranted.