Polyacrylamide hydrogel (Bulkamid®) for stress urinary incontinence in women: a systematic review of the literature

Minimally Invasive Treatment of Stress Urinary Incontinence in Women: A Prospective Comparative Analysis between Bulking Agent and Single-Incision Sling

INTRODUCTION

The study aims to compare the efficacy and safety of bulking agents and single-incision slings in the treatment of urinary incontinence in 159 patients during a 29-month follow-up period.

MATERIAL AND METHODS

Of the 159 patients suffering from stress urinary incontinence, 64 were treated with bulking agents (PAHG Bulkamid®) and 75 with a single-incision sling (Altis®). The ICIQ-UI-SF (Incontinence Questionnaire-Urine Incontinence-Short Form), PISQ-12 (Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaires short form), FSFI (Female Sexual Function Index), FSDS (Female Sexual Distress Scale), and PGI-I (Patient Global Improvement Index) were used to assess efficiency and quality of life.

RESULTS

The bulking agents showed high efficacy and safety during the 29-month follow-up. Post-operative complications were recorded in both groups, with only two significant differences. The Bulkamid group experienced no pain, while 10.8% of the ALTIS group experienced groin pain and 5% experienced de novo urgency. Furthermore, patients treated with bulking agents experienced reduced nicturia (0.78 vs. 0.92 in patients treated with single-incision slings.). In both groups, we noticed a significant improvement in QoL (quality of life), with a halved ICIQ-UI-SF (International Consultation on Incontinence Questionnaire-Urine Incontinence-Short Form) score which was completed to assess the impact of urine symptoms. After 24 months of therapy, the Bulkamid group saw a decrease from 14.58 ± 5.11 at baseline to 5.67 ± 1.90 (p < 0.0001), whereas the ALTIS group experience a decrease from 13.75 ± 5.89 to 5.83 ± 1.78. Similarly, we observed an improvement in sexual function, with the number of sexually active patients increasing from 29 to 44 (56.4%) in the Bulkamid group (p = 0.041) and from 31 to 51 (61.7%) in the ALTIS group (p = 0.034). According to the most recent statistics, the PISQ-12, FSFI, and FSDS scores all demonstrated an improvement in women's sexual function.

CONCLUSIONS

In terms of efficacy and safety, bulking agents had notable results over the 29-month follow-up period. Furthermore, the patients treated with bulking agents reported a lower incidence of postoperative complications and a no discernible difference in terms of quality of life and sexual activity compared to the ones treated with single-incision slings. Bulking agents can be considered a very reliable therapeutic option based on accurate patient selection.

Prevalence and management of urinary incontinece after pelvic organ prolapse surgery (sacrocolpopexy). A literature review

INTRODUCTION

Stress urinary incontinence (SUI) is frequently associated with pelvic organ prolapse (POP) and may occur after its surgical treatment.

AIM

To determine the incidence, risk factors and management of SUI during and after POP surgery through a review of the available literature.

MATERIALS AND METHOD

Narrative literature review on the incidence and management of SUI after POP surgery after search of relevant manuscripts indexed in PubMed, EMBASE and Scielo published in Spanish and English between 2013 and 2023.

RESULTS

Occult SUI is defined as visible urine leakage when prolapse is reduced in patients without SUI symptoms. De novo SUI develops after prolapse surgery without having previously existed. In continent patients, the number needed to treat (NNT) to prevent one case of de novo SUI is estimated to be 9 patients and about 17 to avoid repeat incontinence surgery. In patients with occult UI, the NNT to avoid repeat incontinence surgery is around 7. Patients with POP and concomitant SUI are the group most likely to benefit from combined surgery with a more favorable NNT (NNT 2).

CONCLUSION

Quality studies on combined surgery for treatment SUI and POP repair are lacking. Continent patients with prolapse should be warned of the risk of de novo SUI, although concomitant incontinence treatment is not currently recommended. Incontinence surgery should be considered on an individual basis in patients with prolapse and SUI.

Preparation and optimization of agarose or polyacrylamide/amino acid-based double network hydrogels for photocontrolled drug release

The high water content and biocompatibility of amino-acid-based supramolecular hydrogels have generated growing interest in drug delivery research. Nevertheless, the existing dominant approach of constructing such hydrogels, the exploitation of a single amino acid type, typically comes with several drawbacks such as weak mechanical properties and long gelation times, hindering their applications. Here, we design a near-infrared (NIR) light-responsive double network (DN) structure, containing amino acids and different synthetic or natural polymers, i.e., polyacrylamide, poly(N-isopropylacrylamide), agarose, or low-gelling agarose. The hydrogels displayed high mechanical strength and high drug-loading capacity. Adjusting the ratio of Fmoc-Tyr-OH/Fmoc-Tyr(Bzl)-OH or Fmoc-Phe-OH/Fmoc-Tyr(Bzl)-OH, we could drastically shorten the gelation time of the DN hydrogels at room and body temperatures. Moreover, introducing photothermal agents (graphene oxide, carbon nanotubes, molybdenum disulfide nanosheets, or indocyanine green), we equipped the hydrogels with NIR responsivity. We demonstrated the light-triggered release of the drug baclofen, which is used in severe spasticity treatment. Rheology and stability tests confirmed the positive impact of the polymers on the mechanical strength of the hydrogels, while maintaining good stability under physiological conditions. Overall, our study contributed a novel hydrogel formulation with high mechanical resistance, rapid gel formation, and efficient NIR-controlled drug release, offering new opportunities for biomedical applications.

A comprehensive review on hydrogel materials in urology: Problems, methods, and new opportunities

Hydrogel materials provide an extremely promising group of materials that can find an increasingly wide range of use in treating urinary system conditions due to their unique properties. The present review describes achievements to date in terms of the use and development prospects of hydrogel materials applications in the treatment and reconstruction of the urinary system organs, which among others include: hydrogel systems of intravesical drug delivery, ureteral stents design, treatment of vesicoureteral reflux, urinary bladder and urethral defects reconstruction, design of modern urinary catheters and also solutions applied in urinary incontinence therapy (Figure 4). In addition, hydrogel materials find increasingly growing applications in the construction of educational simulation models of organs and specific conditions of the urinary system, which enable the education of medical personnel. Numerous research efforts are underway to expand the existing treatment methods and reconstruction of the urinary system based on hydrogel materials. After conducting the further necessary research, many of the innovative solutions developed to date have high application potential.

A diagnostic conundrum: Is it a periurethral diverticulum/cyst or a bulking agent (Bulkamid)?

INTRODUCTION

Urethral bulking agents are commonly used to manage female stress urinary incontinence (SUI) as they have been suggested to be safe, efficacious, and a minimally invasive surgical option. Bulkamid is a newer bulking agent that has been introduced and promoted in the market for use. It is non-particulate in nature with high tissue biocompatibility, and consequently, it is difficult to differentiate between Bulkamid and a periurethral cyst on magnetic resonance imaging (MRI). This, therefore, presents a diagnostic dilemma.

METHODS AND MATERIALS

Here we describe two cases with previous injections of Bulkamid referred to our Centre for management of a presumed periurethral diverticulum based on MRI findings. Both patients were reviewed and examined in outpatient clinics with MRI findings discussed at MDT, further imaging was required.

RESULTS

We found that a limited noncontrast computed tomography (CT) pelvis, followed by a voiding cystometrogram (VCMG), and then a repeat limited noncontrast CT pelvis effectively differentiated between Bulkamid and these presumed periurethral diverticulae. The theory behind this was that during micturition, the contrast would pass through to the urethral diverticulum and appear as high-density (bright) material within the periurethral region (the pre-VCMG was required to prove that any high-density material was due to the contrast and not pre-existing high-contrast material).

CONCLUSION

A CT scan done in conjunction with a VCMG is likely to be more effective in differentiating between Bulkamid and a true periurethral diverticulum than an MRI scan. Appropriate diagnostic evaluation of periurethral lesions can lead to time-saving and cost-effective patient management as this will bypass the need for unnecessary investigations and possible unwarranted surgical intervention.

Enhanced tendon healing by a tough hydrogel with an adhesive side and high drug-loading capacity

Hydrogels that provide mechanical support and sustainably release therapeutics have been used to treat tendon injuries. However, most hydrogels are insufficiently tough, release drugs in bursts, and require cell infiltration or suturing to integrate with surrounding tissue. Here we report that a hydrogel serving as a high-capacity drug depot and combining a dissipative tough matrix on one side and a chitosan adhesive surface on the other side supports tendon gliding and strong adhesion (larger than 1,000 J m^-2) to tendon on opposite surfaces of the hydrogel, as we show with porcine and human tendon preparations during cyclic-friction loadings. The hydrogel is biocompatible, strongly adheres to patellar, supraspinatus and Achilles tendons of live rats, boosted healing and reduced scar formation in a rat model of Achilles-tendon rupture, and sustainably released the corticosteroid triamcinolone acetonide in a rat model of patellar tendon injury, reducing inflammation, modulating chemokine secretion, recruiting tendon stem and progenitor cells, and promoting macrophage polarization to the M2 phenotype. Hydrogels with 'Janus' surfaces and sustained-drug-release functionality could be designed for a range of biomedical applications.

Hydrogels for Tissue Engineering: Addressing Key Design Needs Toward Clinical Translation

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The new therapeutic option for female stress and stress-predominant mixed urinary incontinence: Periurethral hypertonic saline (10%) injection

OBJECTIVES

We aimed to evaluate the safety and efficacy of periurethral hypertonic saline (10% NaCl) injection in the treatment of stress urinary incontinence (SUI) and stress-predominant mixed urinary incontinence (S-MUI) in women.

METHODS

This was a prospective study conducted between January 2014 and April 2018 with 64 women (44 SUI and 21 S-MUI). Patients with SUI and S-MUI were evaluated using the Urinary Distress Inventory 6. Quality of life was evaluated with the Incontinence Quality of Life Scale and lower urinary tract symptoms of the women were evaluated with the International Consultation on Incontinence Questionnaire Female Lower Urinary Tract Symptoms Modules. Incontinence status and treatment success were assessed via the Stamey incontinence grade and pad test.

RESULTS

The subjective success rate was 58.5%, and the objective success rate was 81.5%. The rate of reinjection was 21.5%, and the mean duration of reinjection was 8.92 months (3-19 months). Minor adverse effects were observed in 30.4% of the 79 injections. International Consultation on Incontinence Questionnaire Female Lower Urinary Tract Symptoms Modules and Incontinence Quality of Life Scale scores improved remarkably starting from the first month. Urinary Distress Inventory 6 scores in the S-MUI group also improved.

CONCLUSIONS

The results indicate that hypertonic saline injection is an effective and safe method in the treatment of SUI and S-MUI. Since hypertonic saline is a much cheaper and more accessible substance compared to bulking agents, it seems to be a viable alternative for urinary incontinence treatment in women.

Comparing risk of repeat surgery for stress urinary incontinence after mid-urethral slings and polyacrylamide hydrogel

INTRODUCTION

Over the last two decades synthetic mid-urethral slings (MUS) have become established as the main surgical method for correcting stress urinary incontinence (SUI). However, transurethral injections with polyacrylamide hydrogel are gaining popularity. We used surgical codes from a national registry to explore potential differences in risk of later surgery for SUI comparing retropubic slings, obturator slings, and polyacrylamide hydrogel injections.

MATERIAL AND METHODS

This cohort study used surgical codes from The Norwegian Patient Registry. All women recorded as having had surgery for SUI coded as retropubic sling, obturator sling, or polyacrylamide hydrogel injection from 2008 until end-of-study censoring in 2017, were included. Main outcome was time to any recorded new SUI procedure later in the study period. Unadjusted comparison between groups was done using Kaplan-Meier. A Cox regression analysis was then performed to adjust for hospital unit size and patient age at surgery.

RESULTS

The unadjusted analyses showed significant differences between the chosen index method and the risk of later SUI surgery favoring retropubic slings (p < 0.01). The proportions of patients without any recorded new SUI procedure at 1 and 5 years were 99.3% and 97.7% for retropubic MUS, 98.7% and 96.1% for obturator MUS, and 82.7% and 72.4% for polyacrylamide hydrogel injections. The majority of women having a repeat procedure for SUI after a polyacrylamide hydrogel injection underwent repeat treatment within 1 year (63%). After adjusting for age at time of surgery and hospital size, obturator slings (hazard ratio 1.8, 95% CI 1.4-2.4) and polyacrylamide hydrogel (hazard ratio 23.1, 95% CI 17.6-30.3) remained associated with a higher risk of later incontinence surgery.

CONCLUSIONS

Both retropubic and obturator slings have low long-term risks of repeat incontinence surgery compared with polyacrylamide hydrogel injections. Retropubic slings were found to have superior longevity of the surgical result.

Periurethral injection with polyacrylamide after previous TVT surgery

INTRODUCTION AND HYPOTHESIS

The aim of this registry study was to assess the clinical utility of using periurethral bulking with polyacrylamide hydrogel in women with stress urinary incontinence (SUI) after previous midurethral sling surgery.

METHODS

The study period was 2007 through 2019. Using data from the Norwegian Female Incontinence Registry we included 57 women who had received Bulkamid® because of insufficient improvement or recurrent SUI after previous retropubic TVT surgery. The primary outcome was cure of SUI, and secondary outcomes were patient satisfaction, degree of leakage, change in urgency incontinence (UUI), free flow rate, postvoid residual volume, and complications. Descriptive statistics were used to characterize data and Wilcoxon signed-rank test to compare pre- and postoperative results for pairs, with level of significance at p < 0.05.

RESULTS

Pure SUI was seen in 19 (33.3%) while 38 (66.7%) had mixed incontinence. Postoperatively 72.9% had a negative stress test and 73.7% were satisfied with treatment. There was only 1 complication in 67 injections (1.5%). De novo UUI occurred in five patients, corresponding to 8.8% of the whole study group, but 26.3% among those with no preoperative UUI problems. Among the patients with preoperative UUI, 39.5% were cured of this problem and a further 36.8% were improved.

CONCLUSIONS

The cure rate and satisfaction rate of periurethral bulking with polyacrylamide after previous MUS are favorable and complications are rare. There seems to be a risk of overactive bladder symptoms developing in women with no such symptoms preoperatively.

Surgical Management of Stress Incontinence

The aim was to describe contemporary surgical procedures for the treatment of stress urinary incontinence (SUI) in women. The 4 most commonly performed surgical procedures for the treatment of SUI were reviewed using standardized terminology. We addressed the history and evolution of the procedures as well as the mechanisms of action by which they work. Efficacy and safety data were also presented. Midurethral Sling, Pubovaginal Sling, Retropubic Colposuspension, and Urethral Bulking are safe and effective procedures. Midurethral Sling, Pubovaginal Sling, Retropubic Colposuspension, and Urethral Bulking are contemporary procedures for the treatment of SUI in women.

Degradable and Removable Tough Adhesive Hydrogels

The development of tough adhesive hydrogels has enabled unprecedented adhesion to wet and moving tissue surfaces throughout the body, but they are typically composed of nondegradable components. Here, a family of degradable tough adhesive hydrogels containing ≈90% water by incorporating covalently networked degradable crosslinkers and hydrolyzable ionically crosslinked main-chain polymers is developed. Mechanical toughness, adhesion, and degradation of these new formulations are tested in both accelerated in vitro conditions and up to 16 weeks in vivo. These degradable tough adhesives are engineered with equivalent mechanical and adhesive properties to nondegradable tough adhesives, capable of achieving stretches >20 times their initial length, fracture energies >6 kJ m-2 , and adhesion energies >1000 J m-2 . All degradable systems show complete degradation within 2 weeks under accelerated aging conditions in vitro and weeks to months in vivo depending on the degradable crosslinker selected. Excellent biocompatibility is observed for all groups after 1, 2, 4, 8, and 16 weeks of implantation, with minimal fibrous encapsulation and no signs of organ toxicity. On-demand removal of the adhesive is achieved with treatment of chemical agents which do not cause damage to underlying skin tissue in mice. The broad versatility of this family of adhesives provides the foundation for numerous in vivo indications.

Bulkamid® injection in men: Cadaver study of operative technique and putative mechanism of action

Objective:

Post-prostatectomy incontinence (PPI) is relatively common and of variable degree. Treatment of small-volume persistent PPI with a male sling or an artificial urinary sphincter is overly invasive, and the concept of intraurethral injection is very appealing in this situation. Bulkamid® is a nanoparticulate polyacrylamide and water polymer gel which is being used successfully in female stress urinary incontinence. We assessed the feasibility and effects of a four-point intraurethral technique on maximum urethral pressure (MUP) in male cadavers.

Methods:

Urethral pressure profile (UPP) was measured twice on two male fresh-frozen cadaver models before and after a four-point injection of 2 mL of Bulkamid® intraurethrally at the level of the sphincter in 0.5 mL aliquots using a 21Ch cystoscope with a 12° telescope and a 23G needle.

Results:

A clear UPP trace was recordable in both cadavers. The mean MUP at baseline was 38 cm H2O, and the mean MUP following Bulkamid® intraurethral injection increased to 55 cm H2O.

Conclusions:

Bulkamid® intraurethral injection in male cadavers is a simple technique that increases MUP. This increase in MUP may allow for treatment of low-volume PPI in men following prostate cancer treatment and warrants further study in the clinical situation.

Level of evidence:

Level 4.

Easy way to treat female stress urinary incontinence with bulking agents (with video)

Since the recent controversy about vaginal mesh implants, surgeons should use safe and effective devices and procedures to treat female stress urinary incontinence (SUI). We propose to describe the noninvasive and ambulatory technique of the urethral bulking procedure. Bulking agents are a simple, minimally invasive technique that can be offered in the treatment of female SUI.

Biocompatible and self-recoverable succinoglycan dialdehyde-crosslinked alginate hydrogels for pH-controlled drug delivery

We fabricated polysaccharide-based hydrogels, which are biocompatible, self-recoverable and pH-sensitive. Succinoglycan dialdehyde (SGDA) was first synthesized from bacterial succinoglycan directly isolated from Sinorhizobium meliloti and then hydrazine-functionalized alginate (HZ-Alg) was prepared to form SGDA-crosslinked alginate hydrogels (SGDA/HZ-Alg) without any catalyst. Due to structural characteristics of SGDA, SGDA/HZ-Alg were effectively obtained in a short time even at low concentrations (0.94-1.57 wt%) where they exhibited self-recoverable and tunable rheological properties corresponding to efficiency of recovery from 93.2%-97.9%. Moreover, SGDA/HZ-Alg showed the pH-responsive degradation as well as pH-controlled release behavior for 5-fluorouracil. 5-Fluorouracil was released approximately 98 % at pH 2.0 within 12 h, but not completely released even after 24 h at pH 7.4. The WST-8 assay results also demonstrated that SGDA/HZ-Alg did not show any cytotoxicity against HEK-293 cells. Since the suggested hydrogels are biocompatible, rheologically self-recoverable and tunable, and pH-controllable, they would be potential biomaterials for the hydrogel-based drug delivery systems.

Urethral bulking agents: a retrospective review of primary versus salvage procedure outcomes

PURPOSE

Urethral bulking agents (UBA) have traditionally been offered as salvage procedures for recurrent stress urinary incontinence (SUI). We compare the success of UBA in patients that had undergone a previous procedure for SUI (Salvage-UBA) to the SUI surgery naïve (Primary-UBA). We hypothesised a positive effect in both Primary and Salvage-UBA with potentially poorer rates of response in the salvage group.

METHODS

Retrospective case series of patients having their first UBA (2010-2018). Primary outcome was to assess any difference in patient reported success between groups. Patient-reported improvement was assessed on a 4-point scale: 'cured, improved, no change, worse' and treatment 'success' defined as 'cured' or 'improved'. A multivariate analysis, adjusting for plausible differences between groups, was undertaken in IBM SPSS Statistics (2016).

RESULTS

135 Primary-UBA and 38 Salvage-UBA were performed. Complete follow-up was obtained for 114 patients (66%): 86 Primary and 28 Salvage. Median follow-up time: 33 months. In 2012, 47% (8/17) of all UBA were Salvage-UBA, whilst in 2018, the majority were Primary-UBA (92%, 46/50). Success was not significantly different between Salvage-UBA 75% (21/28) versus Primary-UBA 67% (58/86) (Wald χ² = 0.687, df = 1, p = 0.407). Top-up rates were similar: 14% (n = 4/28, Salvage-UBA) versus 15% (n = 13/86, Primary-UBA) (χ² = 0.011, df = 1, p = 0.914).

CONCLUSION

The number of women opting for UBA has increased substantially. No significant differences were noted for success with Salvage-UBA compared to Primary-UBA.

Joint Report on Terminology for Surgical Procedures to Treat Stress Urinary Incontinence in Women

INTRODUCTION AND HYPOTHESIS

Standardized terminology for surgical procedures commonly performed to treat stress urinary incontinence in women is needed to facilitate research, clinical care, and teaching in female pelvic medicine and reconstructive surgery.

METHODS

This report combines the input of members of the American Urogynecologic Society and the International Urogynecological Association, assisted by external referees. Extensive searches of the literature were performed, including Instructions for Use brochures and original source documents where possible. Historical context was considered along with procedural modifications, and expert opinion was included when appropriate.

RESULTS

A terminology report for the procedures commonly performed to treat stress urinary incontinence in women was produced. Included procedures are midurethral sling, retropubic colposuspension, pubovaginal sling, urethral bulking, and artificial urinary sphincter. Appropriate figures have been included to supplement and help clarify the text. Ongoing review will be performed periodically to keep the document updated and widely acceptable.

CONCLUSIONS

This document is a literature and consensus-based terminology report for surgical procedures to treat stress urinary incontinence in women. Future publications in female pelvic medicine and reconstructive surgery should use this standardized terminology whenever possible.

An animal experimental study on pubourethral ligament restoration with platelet rich plasma for the treatment of stress urinary incontinence

Introduction

Minimally invasive methods for injured ligament and tendon restoration have been developed and gained popularity in recent years. Injury and relaxation of the pubourethral ligament (PUL) can lead to stress urinary incontinence (SUI). The aim of this study was to investigate the impact of injecting platelet rich plasma (PRP) into the PUL following its surgical transection resulting in SUI, confirmed by leak point pressure (LPP) measurements pre- and post-intervention in an experimental animal model.

Material and methods

Twenty female adult Sprague-Dawley rats were assigned in 2 groups: 1) treatment group with transection of the PUL and application of PRP at the time of transection and at one month follow-up and 2) a control group, with transection of the PUL only. Leak point pressures (LPPs) were measured prior to transection, immediately following the transection and at 1 and 2 months in both groups.

Results

The median LPPs for the control group were: LPP – preT: 35.6 (29.8–44.8) cmH₂O, LPP – postT: 14.6 (5.8–19.0) cmH₂O, LPP – 1 month: 27.3 (19.2–33.8) cmH₂O, LPP – 2 months: 29.0 (27.0–34.0) cmH₂O, whereas for the PRP group were: LPP-preT: 40.5 (33.2–46.3) cmH₂O, LPP – postT: 15.7 (3.0–24.0) cmH₂O, LPP – 1month: 31.6 (24.8–37.4) cmH₂O, LPP – 2 months: 36.8 (32.5–45.4) cmH₂O. PRP injections on transected PULs significantly increased LPPs at one month follow-up [31.6 cmH₂O vs. 27.3 cmH₂O, p = .043]. This effect was confirmed at two months [36.8 cmH₂O vs. 29.0 cmH₂O, p <.001].

Conclusions

Injection of PRP into transected PULs significantly improved LPPs at one and two months' follow-up. However, further experimental and clinical research is needed to evaluate the safety and efficacy of this treatment, in clinical practice.

Highly Conductive, Stretchable, and Cell-Adhesive Hydrogel by Nanoclay Doping

Electrically conductive materials that mimic physical and biological properties of tissues are urgently required for seamless brain-machine interfaces. Here, a multinetwork hydrogel combining electrical conductivity of 26 S m^-1 , stretchability of 800%, and tissue-like elastic modulus of 15 kPa with mimicry of the extracellular matrix is reported. Engineering this unique set of properties is enabled by a novel in-scaffold polymerization approach. Colloidal hydrogels of the nanoclay Laponite are employed as supports for the assembly of secondary polymer networks. Laponite dramatically increases the conductivity of in-scaffold polymerized poly(ethylene-3,4-diethoxy thiophene) in the absence of other dopants, while preserving excellent stretchability. The scaffold is coated with a layer containing adhesive peptide and polysaccharide dextran sulfate supporting the attachment, proliferation, and neuronal differentiation of human induced pluripotent stem cells directly on the surface of conductive hydrogels. Due to its compatibility with simple extrusion printing, this material promises to enable tissue-mimetic neurostimulating electrodes.

Cutaneous complications associated with breast augmentation: A review

Breast augmentation is one of the most popular and safe cosmetic procedures performed by plastic surgeons worldwide. Although breast implants are available in a number of different materials, silicone-filled implants remain the most common type. However, prior to the development of breast implants, various materials were injected into the soft tissues of the breasts to increase breast volume, which caused cutaneous complications and disfigurement. This review details the history of breast augmentation, the current methods used in augmentation surgery, and associated cutaneous complications.

Injection of Urethral Bulking Agents

Urethral injection is a safe and minimally invasive method of treating female stress urinary incontinence with multiple bulking agents currently commercially available. Although there are numerous studies that demonstrate efficacy, long-term success is not yet proven. This article aims to describe the mechanism of action and properties of various agents, patient selection factors, available techniques for injection, outcomes of urethral injections, and complications associated with the procedure.

A double-blind, randomized, placebo-controlled clinical trial evaluating the safety and efficacy of autologous muscle derived cells in female subjects with stress urinary incontinence

PURPOSE

The purpose of the study was to assess safety and efficacy of autologous muscle derived cells for urinary sphincter repair (AMDC-USR) in female subjects with predominant stress urinary incontinence.

METHODS

A randomized, double-blind, multicenter trial examined intra-sphincteric injection of 150 × 10⁶ AMDC-USR versus placebo in female subjects with stress or stress predominant, mixed urinary incontinence. AMDC-USR products were generated from vastus lateralis needle biopsies. Subjects were randomized 2:1 to receive AMDC-USR or placebo and 1:1 to receive 1 or 2 treatments (6 months after the first). Primary outcome was composite of ≥ 50% reduction in stress incontinence episode frequency (IEF), 24-h or in-office pad weight tests at 12 months. Other outcome data included validated subject-recorded questionnaires. Subjects randomized to placebo could elect to receive open-label AMDC-USR treatment after 12 months. Subject follow-up was up to 2 years.

RESULTS

AMDC-USR was safe and well-tolerated with no product-related serious adverse events or discontinuations due to adverse events. Interim analysis revealed an unexpectedly high placebo response rate (90%) using the composite primary outcome which prevented assessment of treatment effect as designed and thus enrollment was halted at 61% of planned subjects. Post hoc analyses suggested that more stringent endpoints lowered placebo response rates and revealed a possible treatment effect.

CONCLUSIONS

Although the primary efficacy finding was inconclusive, these results inform future trial design of AMDC-USR to identify clinically meaningful efficacy endpoints based on IEF reduction, understanding of placebo response rate, and refinement of subject selection criteria to more appropriately align with AMDC-USR's proposed mechanism of action.

Patients' perspectives on urethral bulk injection therapy and mid-urethral sling surgery for stress urinary incontinence

INTRODUCTION AND HYPOTHESIS

The aim of this study was to identify all treatment decision factors that determined the preference for peri-urethral bulk injection therapy (PBI) or mid-urethral sling (MUS) surgery in patients with primary stress urinary incontinence (SUI). Second, we explored what patients expect from treatment for SUI and whether patients would consider PBI as a primary treatment option.

METHODS

In a qualitative design, 20 semi-structured, face-to-face interviews were conducted in women with primary SUI. Exclusion criteria were: previous PBI or MUS surgery; predominating urgency. Interviews were guided by three open-ended questions and a topic list. PBI treatment and MUS surgery were described in detail, and the efficacy was stated as 70% and 90%, respectively. Data saturation was reached when no new treatment decision factors were identified in three consecutive interviews. Interviews were audiotaped and fully transcribed. Thematic analysis by a coding process was done independently by two researchers.

RESULTS

Sixteen procedural, personal, professional, social and external treatment decision factors were identified. Regarding expectations about treatment for SUI, women believed 'becoming dry' was wishful thinking. The majority of patients accepted a small degree of persistent urinary incontinence after treatment. Regardless of their treatment preference, patients indicated that women should be informed about PBI as a primary treatment option.

CONCLUSION

Patients with primary SUI are open to PBI as an alternative treatment option even with lower cure rates compared with MUS surgery performed under general or spinal anesthesia. Patients indicated that women with primary SUI seeking treatment should be informed about PBI as a treatment option.

The use of polyacrylamide hydrogel in the setting of failed female stress incontinence surgery

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A systematic review on vaginal laser therapy for treating stress urinary incontinence: Do we have enough evidence?

INTRODUCTION AND HYPOTHESIS

Current treatment strategies for stress urinary incontinence (SUI) raise concerns about safety and efficacy. The purpose of this systematic review was to present available evidence related to vaginal laser therapy as a treatment option for SUI.

METHODS

We searched the MEDLINE (1966-2017), Scopus (2004-2017), Clinicaltrials.gov (2008-2017) and Cochrane Central Register of Controlled Trials (CENTRAL) (1999-2017) databases for relevant studies in this field. We aimed to include all observational studies (prospective and retrospective, randomized and nonrandomized) that reported outcomes on vaginal laser therapy as a treatment option for SUI.

RESULTS

Thirteen studies were included that recruited 818 patients who underwent laser therapy for SUI. The methodological quality of most included studies was low, as they were either individual case-control studies, case series or poor-quality cohorts (Oxford Level of Evidence 3b and 4). According to the existing evidence, laser therapy may be a useful, minimally invasive approach for treating SUI. However, the methodological limitations of included studies render them prone to significant bias, limiting their scientific integrity.

CONCLUSIONS

As the demand for minimally invasive approaches for treating SUI increases, it is expected that more patients will seek alternative treatments over current standards (midurethral slings). Given the limitations of the existing studies, it seems that conducting future trials is necessary to elucidate this field.

Para-Urethral Injections with Urolastic® for Treatment of Female Stress Urinary Incontinence: Subjective Improvement and Safety

INTRODUCTION

Female stress urinary incontinence (SUI) is often treated surgically. Urethral bulking agents are a minimally invasive alternative, especially in patients suffering from intrinsic sphincter deficiency, but often with limited long-term efficacy. Urolastic® is a non-deformable, non-resorbable silicone elastomer that is used as an injectable. Its properties might result in a more durable response after injection. If this durability factor can be combined with a low complication rate, this can become a useful treatment option. We therefore assessed the subjective improvement and safety after treatment with Urolastic®.

MATERIALS AND METHODS

In 2 Dutch hospitals, 65 patients were treated with Urolastic®. The subjective improvement was assessed and the medical charts were reviewed for complications that appeared during the follow-up period. The complications were classified using the Clavien-Dindo classification.

RESULTS

We found that 76-88% of the patients showed subjective improvement at 12-25 months follow-up. The rate of improvement experienced was 50-70%. The rate of complications classified as Clavien-Dindo >II was 24-33%. The 12 patients with 75-100% subjective improvement after 2 months, showed 85% improvement after a median of 25 months.

CONCLUSIONS

With careful patient selection, Urolastic® seems to be a safe, durable and effective treatment option for female SUI.

Polyacrylamide Hydrogel as a Bulking Agent for the Endoscopic Treatment of Vesicoureteral Reflux: Long-Term Results and Safety

PURPOSE

Polyacrylamide hydrogel has been shown to offer good short-term success for the endoscopic treatment of vesicoureteral reflux. Our objective was to provide long-term results of its efficacy and safety.

MATERIALS AND METHODS

We performed a prospective study using polyacrylamide hydrogel to treat all grades of vesicoureteral reflux. Every patient underwent endoscopic injection of polyacrylamide hydrogel followed by 3-month postoperative renal ultrasound and voiding cystourethrogram. Renal ultrasound was repeated at 12 and 36 months. Treatment success was defined as the absence of de novo or worsening hydronephrosis and the absence of reflux. Safety elements included new or worsening hydronephrosis, calcifications of the injected material and urinary tract infections.

RESULTS

A total of 76 patients (123 refluxing renal units) were assessed. Median age at surgery was 45 months and median followup was 36 months. Median injected volume of hydrogel per refluxing renal unit was 1.0 ml. The overall success rate 3 months after a single injection was 71%. During long-term followup 68 of 70 eligible patients underwent 12-month ultrasound and 40 of 46 underwent 36-month ultrasound. No upper tract deterioration or bulking agent calcifications were reported. Nine (12%) and 2 patients (3%) presented with nonfebrile and febrile urinary tract infections, respectively.

CONCLUSIONS

The success rate of polyacrylamide hydrogel for endoscopic treatment of vesicoureteral reflux is comparable to published results of dextranomer hyaluronic acid. The long-term safety data and potential lower cost of polyacrylamide hydrogel provide further support for the use of this nonparticulate bulking agent to treat reflux.

Treatment of complications from polyacrylamide hydrogel breast augmentation

Polyacrylamide hydrogel (PAHG) is a medical soft tissue filling agent utilized for the treatment of a variety of soft tissue defects. However, postoperative complications occur that have to be alleviated. The aim of the present study was to examine the treatments of postoperative complications of mammoplasty augmentation with PAHG. Open suction techniques and partial mastectomies via periareolar incisions were performed in 28 patients who had been injected with PAHG for breast augmentation. The PAHG was removed precluding breast complications resulting from the hydrogel injections. The symptoms disappeared completely, and the results were satisfactory following removal of the PAHG. In conclusion, the periareolar approach is valuable and removes PAHG to the greatest extent.