Stress incontinence injection therapy: what is best for our patients?

Application of urethral injection of calcium hydroxyapatite as a natural bulking agent for improvement of urinary incontinence in children with spinal dysraphism

PURPOSE

The aim of this report is to evaluate the efficacy of endoscopic injection of calcium hydroxyapatite (CaHA) into the bladder neck and posterior urethra in children with refractory urinary incontinence due to spinal dysraphism.

METHODS

A retrospective study was performed on patients with neuropathic bladder due to spinal dysraphism who had undergone submucosal urethral injections of CaHA from 2010 until 2019. All patients were totally incontinent without voiding per urethra and did not respond to 1-year standard pharmacotherapy with anticholinergic drugs. All children underwent a precise physical exam and urodynamic studies. Patients underwent urethrocystoscopy and injection of pure soluble CaHA into the bladder neck and posterior urethra except for the verumontanum. The outcomes were determined as no change, improvement (social continent), or cure (total continent).

RESULTS

Fifteen children (ten boys, five girls, mean age of 7.6 years) with a history of spinal dysraphism and refractory urinary incontinence were included. Endoscopic injections of CaHA were performed one or two times for each patient. At the median follow-up of 2 years (interquartile range = 6), seven (46.7%), three (20.0%), and five (33.3%) of the patients were total continent, social continent, and total incontinent, respectively. In four patients, intradetrusor botulinum toxin injection was performed simultaneously with CaHA injection. Also, one patient experienced a febrile urinary tract infection between two CaHA injections. Among 15 patients, 9 had atonic/hypotonic bladders both before and after CaHA injections; at the last follow-up, 4 of these children (44.4%) were totally continent. No injection-related or other complications were observed in the patients.

CONCLUSION

Injection of CaHA into the bladder neck is relatively safe, reproducible, and effective for total dribbling urinary incontinence in children with spinal dysraphism. The bladder neck reconstruction with or without a urethral sling or other surgical procedures could be postponed until puberty in selected cases. However, further multicenter clinical trials are highly recommended.

Factors associated with polyacrylamide hydrogel outcomes in women with stress urinary incontinence

Knowledge of factors associated with superior outcomes in women treated with urethral bulking agents for stress urinary incontinence (SUI) remains limited. The aim of this study was to examine associations between post-treatment outcomes in women who had undergone polyacrylamide hydrogel injections for SUI, and physiological and self-reported variables captured during pre-treatment clinical evaluation. A cross-sectional study was undertaken in female patients treated for SUI with polyacrylamide hydrogel injections by a single urologist between January 2012 and December 2019. Post-treatment outcome data were gathered in July 2020 using the Patient Global Impression of Improvement (PGI-I), Urinary Distress Inventory-short form (UDI-6), Incontinence Impact Questionnaire (IIQ7), and International Consultation on Incontinence Questionnaire Short Form (ICIQ SF). All other data were gathered from women's medical records including pre-treatment patient-reported outcomes. Associations between post-treatment outcomes and pre-treatment physiological and self-reported variables were investigated using regression models. One hundred seven of the 123 eligible patients completed post-treatment patient-reported outcome measures. Mean age was 63.1 years (range 25-93 years), and median time between first injection and follow-up was 51 months (inter-quartile range 23.5-70 months). Fifty-five (51%) women had a successful outcome based on PGI-I scores. Women with type 3 urethral hypermobility pre-treatment were more likely to report treatment success (PGI-I). Poor bladder compliance pre-treatment was associated with greater urinary distress, frequency and severity (UDI-6 and ICIQ) post-treatment. Older age was associated with worse urinary frequency and severity (ICIQ) post-treatment. Associations between patient-reported outcomes and time between first injection and follow-up were trivial and not statistically significant. Severity of pre-treatment incontinence impact (IIQ-7) was associated with worse incontinence impact post-treatment. Type 3 urethral hypermobility was associated with a successful outcome, whereas pre-treatment incontinence impact, poor bladder compliance and older age were associated with poorer self-reported outcomes. Long-term efficacy appears to hold in those who responded to initial treatment.

Deflux® (NASHATM/Dx) urethral bulking injections: Outcomes over a decade in women with stress urinary incontinence

Objectives:

Urethral bulking injections are thought to be a low risk minimally invasive but temporary treatment option for women with stress urinary incontinence (SUI) with increasing prominence especially in the current era of the mesh controversy. However, little is known about their long-term effects. This study aims to evaluate the efficacy and long-term outcomes of Deflux®, a non-animal stabilised hyaluronic acid/dextranomer (NASHATM/Dx) gel, when used as a urethral bulking agent in the treatment of SUI in women.

Methods:

All women with SUI treated with Deflux® from 2001 to 2007 were analysed. The success rates, duration of efficacy and short- and long-term complications of the treatment were recorded.

Results:

A total of 142 women with a follow-up of up to 13 years (mean 8.8 years) were included. Subjective treatment success was achieved in 92/142 (65%) patients. In those who achieved continence, the mean efficacy was 4.7 years. Side effects were uncommon with 12 (6%) of 209 experiencing transient urinary retention and 11 (5%) of 209 experiencing pseudocyst formation. All pseudocysts were treated successfully with an incision and drainage under either general or local anaesthetic. Sixty (42%) of 142 patients went on to have subsequent definitive incontinence surgery, and Deflux® treatment was found not to have negatively impacted the operation.

Conclusion:

Deflux® urethral bulking injections appear to be efficacious and safe when used as a treatment for SUI in women with a longer duration of efficacy than previously thought and a low side effect profile. This study provides a valuable timeline to help manage the expectations of patients considering urethral bulking treatment.

Level of evidence:

4

Safety and efficacy of polydimethylsiloxane (Macroplastique®) in women with stress urinary incontinence: analysis of data from patients who completed three years follow-up

Introduction and hypothesis

This study aimed to report 3-year completed follow-up of the safety and efficacy of Macroplastique® (MPQ) in women with stress urinary incontinence (SUI) due to intrinsic sphincter deficiency (ISD).

Methods

This is a retrospective analysis of all women who completed 3-year follow-up post-MPQ injection(s) at ten medical centers. We used the ROSE registry data report of Macroplastique® [Macroplastique® Real-time Observation of Safety and Effectiveness (ROSE) registry P040050/PAS001 on 2017]. Subjective incontinence outcome and adverse effects were assessed.

Results

The study included all patients (n = 70) who completed 3-year follow-up after the last MPQ injection. Twenty-four of 70 (34%) patients had two injections; 21/70 (30%) patients reported Stamey grade 0 and 28/70 (40%) reported Stamey grade 1. The overall patient satisfaction was 68% who completed 3-year follow-up. The composite success rate (I-QoL, PGI-S, and Stamey grade improvement) was 51.4%. No serious adverse events (AE) were reported within the completed 3-year follow-up.

Conclusions

MPQ was found to be safe and efficacious for the treatment of SUI secondary to ISD in women. The overall high satisfaction rate was sustained from baseline to 3 years post-injection. Most complications were minor and transient without sequelae.

Can magnetic resonance imaging differentiate among transurethral bulking agent, urethral diverticulum, and periurethral cyst?

PURPOSE

To evaluate magnetic resonance imaging findings that differentiate among periurethral bulking agents (primarily collagen), urethral diverticulum, and periurethral cyst.

METHODS

We searched our radiologic database retrospectively from 2001 to 2017 for periurethral cystic lesions, identifying a total of 50 patients with 68 lesions. Final diagnoses in 68 lesions were bulking agents (27), urethral diverticula (29), and periurethral cysts (12). Two abdominal radiologists, blinded to clinical history, independently evaluated T1, T2, and post-contrast images. The readers assessed number, morphological features, location, connection to urethra and mass effect, signal intensity, and enhancement for each lesion. Fisher exact test and logistic regression analysis were performed for each univariate significant feature. The operative and pathologic reports were the reference standard.

RESULTS

Magnetic resonance imaging features found more often in bulking agents versus urethral diverticulum were multiple lesions (P = 0.011), upper or upper-mid-urethral location (P ≤ 0.0001), lack of internal fluid/fluid level (P = 0.002), no urethral connection (P = 0.005), T1 isointensity, and T2 mild hyperintensity compared to muscles but lower T2 signal than urine (P < 0.0001). Most cases of urethral diverticula and periurethral cysts were detected at mid- and lower urethra. Urethral diverticula were larger than bulking agents and periurethral cysts (P = 0.005 and P = 0.023) (mean diameter = 24, 16, 15 mm, respectively). Most bulking agents (93%) and urethral diverticula (90%) showed mass effect on urethra, while periurethral cysts (75%) did not (P < 0.0001).

CONCLUSION

Signal intensity and lesion characterization on magnetic resonance imaging can significantly differentiate bulking agent from urethral diverticulum and periurethral cyst. Radiologists should consider differential diagnosis of a bulking agent, especially when distinguishing characteristics described here are present to prevent incorrect diagnosis and ultimately unnecessary surgical intervention.

Complications of urethral bulking therapy for female stress urinary incontinence

AIMS

To review, report, and discuss the complications associated with urethral bulking therapy in female stress urinary incontinence.

METHODS

An extensive nonsystematic literature review on complications associated with injectable bulking agents used in the clinical practice was conducted. We reviewed articles published in English and indexed in the PubMed, Embase, and Google Scholar databases. Original articles, case reports, and case series were taken into consideration. Data regarding the safety of injectable bulking agents and the complications associated with their utility within the context of urethral bulking therapy for female stress urinary incontinence were extracted and discussed.

RESULTS

Approximately, 1/3 of the patients experience some type of a complication after urethral bulking therapy. The majority of these complications are of low grade, transient, do not necessitate additional surgical intervention, and amenable to treatment with conservative measures such as clean intermittent catheterization and antibiotics. However, more serious complications such as abscess formation, delayed hypersensitivity reactions, and vaginal erosion have been reported. Some of the injectable bulking agents have been withdrawn from the market because of their unfavorable adverse effect profile.

CONCLUSIONS

Urethral bulking therapy can be considered as a low-risk procedure. However, it is not without complications which can be severe in rare instances. The search for the ideal urethral bulking agent is ongoing and future comparative studies assessing the safety and efficacy of these compounds in randomized controlled settings are warranted.

A bioactive injectable bulking material; a potential therapeutic approach for stress urinary incontinence

Stress urinary incontinence (SUI) is a life changing condition, affecting 20 million women worldwide. In this study, we developed a bioactive, injectable bulking agent that consists of Permacol™ (Medtronic, Switzerland) and recombinant insulin like growth factor-1 conjugated fibrin micro-beads (fib_rIGF-1) for its bulk stability and capacity to induce muscle regeneration. Therefore, Permacol™ formulations were injected in the submucosal space of rabbit bladders. The ability of a bulking material to form a stable and muscle-inducing bulk represents for us a promising therapeutic approach to achieve a long-lasting treatment for SUI. The fib_rIGF-1 showed no adverse effect on human smooth muscle cell metabolic activity and viability in vitro based on AlamarBlue assays and Live/Dead staining. Three months after injection of fib_rIGF-1 together with Permacol™ into the rabbit bladder wall, we observed a smooth muscle tissue like formation within the injected materials. Positive staining for alpha smooth muscle actin, calponin, and caldesmon demonstrated a contractile phenotype of the newly formed smooth muscle tissue. Moreover, the fib_rIGF-1 treated group also improved the neovascularization at the injection site, confirmed by CD31 positive staining compared to bulks made of Permacol^TM only. The results of this study encourage us to further develop this injectable, bioactive bulking material towards a future therapeutic approach for a minimal invasive and long-lasting treatment of SUI.

Agreement between simple catheter method and 3D transperineal ultrasound for assessing urethral length measurement before stress urinary incontinence treatment

AIMS

Optimal placement of periurethral material has an important role in treatment efficacy with stress urinary incontinence (SUI). The validity of methods for determining urethral length and the precise location of the mid-urethral complex for SUI treatment have been sparsely studied. The aim of this study was to investigate the agreement between urethral lengths measured with a catheter and by transperineal ultrasound.

METHODS

Fifty-seven women with SUI or mixed urinary incontinence (MUI) with predominant stress symptoms were recruited. The urethral length was assessed with 3D transperineal ultrasound and measurements were taken offline from the postero-inferior margin of the pubic symphysis to the bladder neck. Then, it was measured with a foley catheter by another evaluator, blinded to the ultrasound data. The distance between the inflated balloon and the urethral meatus was considered.

RESULTS

Thirty-three women (58%) had SUI and 24 (42%) had MUI. The mean urethral length evaluated with ultrasound and the catheter were 3.03 ± 0.34 cm and 3.02 ± 0.41 cm (P = 0.857), respectively. Agreement between the two methods as assessed by the intra-class correlation coefficient was 0.90 (CI0.82-0.94, P ≤ 0.001). Limits of agreement (Bland-Altman) were +0.46 to -0.45 cm, with a mean difference of -0.01 ± 0.23 cm.

CONCLUSIONS

Findings of this study, reveal an excellent agreement between a simple catheter technique and ultrasound assessment for measuring urethral length, with a small mean bias and clinically acceptable limits of agreement. This provides relevant information in clinical practice for determining optimal placement of periurethral material or mid-urethral tape for SUI treatment.

Urolastic for the treatment of women with stress urinary incontinence: 24-month follow-up

Introduction

To evaluate the efficacy and durability of Urolastic, a new urethral bulking agent in women with stress urinary incontinence (SUI), after a follow-up of 24-months.

Material and methods

A follow-up study of women with SUI who received a Urolastic injection and successfully passed the 12-month follow-up. Assessment included the Stamey Grade, 1-h Pad weight test, and the International quality of life (I-QoL) score.

Results

Nineteen women who completed the 12-month follow-up were invited for the 24-month follow-up study. One patient did not respond to the correspondence. Four of the 18 patients who responded to the correspondence reported removal of the Urolastic implant at another facility, based on their desire. The explanation for this removal was painful intercourse (n = 1) or less than optimal dryness (n = 3). The overall objective improvement in continence status at 24-months was 66% compared to the 89% at the 12-month follow-up, while in addition the 1-h pad weight test showed >50% reduction in pad weight in 66% of patients compared to 84% at the 12-month follow-up. Adverse events reported were urinary tract infection (n = 1), local genital infection with erosion into the vagina (n = 1), painful intercourse (n = 2), and urgency (n = 4).

Conclusions

Urolastic is comparable to other bulking agents in terms of durability, efficacy, and complications.

Urethral bulking agents versus other surgical procedures for the treatment of female stress urinary incontinence: a systematic review and meta-analysis

Bulking agents provide an alternative option in the management of women with stress urinary incontinence and they seem to have an important role in the management flow chart of SUI. However, evidence on this issue is scanty. The most important aspect is to understand whether bulking agents are comparable with the other first-line anti-incontinence surgical procedure (MUS, Burch colposuspension and pubovaginal slings). Hence, the primary aim of the current review was to assess the objective and subjective outcomes of bulking agents in comparison with the other surgical procedures for the treatment of SUI. PubMed and Medline were systematically searched and we included studies evaluating the use of bulking agents in comparison with other surgical approaches for either primary or recurrent treatment of female SUI. Three studies meeting the inclusion criteria were identified. Two of these studies were RCTs evaluating the use of bulking agents versus other surgical procedures for the treatment of primary female SUI; the remnant article was a retrospective cohort study that compared the effectiveness and safety of repeat midurethral sling with urethral bulking after failed midurethral sling. The combined results of all analyses showed that the objective recurrence rate of peri- or trans-urethral injections is significantly higher in comparison with the other surgical procedures. Similar findings were observed when considering separately the treatment for primary or recurrent SUI. Furthermore, lower subjective recurrence rate was observed among patients undergoing other surgical treatment in comparison with those undergoing bulking agents; however, this trend was not statistically significant. Moreover, patients undergoing injection of bulking agents experienced a lower rate of voiding dysfunctions in comparison to the control group. According to current evidence, bulking agents should not be proposed as first-line treatment in those women seeking permanent cure for both primary and recurrent SUI. However, the effectiveness of a procedure should be balanced with its invasiveness and patients' expectations. Bulking agents are a minimally invasive approach to treat SUI and their use should be considered as an alternative strategy particularly in special conditions: patients who are fragile, in those who do not wish to have surgery, or in whom surgical options are restricted (postoperatively, after irradiation).

Managing urinary incontinence: what works?

Urinary incontinence is a common condition, which, although not life-threatening, impairs the health-related quality of life of affected individuals. All women complaining of incontinence require a basic assessment and those with complex or refractory symptoms may benefit from urodynamic studies. Initial treatment includes lifestyle advice, behavioral modifications, bladder retraining and pelvic floor muscle training. For those women with persistent stress urinary incontinence following conservative therapy, surgical management might be considered. The development of the minimally invasive, retropubic, synthetic, mid-urethral sling procedures has revolutionized stress incontinence surgery and reduced the popularity of 'traditional' procedures, such as colposuspension and autologous fascial sling. In an attempt to reduce further the morbidity, transobturator and single-incision slings have been introduced. While antimuscarinic agents are the mainstay of the current medical management of urgency urinary incontinence, a recently developed selective β3-adrenergic receptor agonist (mirabegron) offers an alternative pharmacological option. Modalities such as intravesical botulinum toxin and neuromodulation (peripheral or sacral) are available to women with refractory urgency incontinence. Finally, when all other options have been explored and proven unsuccessful, inappropriate or not feasible, reconstructive surgery or catheter insertion might be considered as a last resort. The aim of this paper is to review conservative, medical and surgical management for urinary incontinence by using the best available evidence in the literature.

Autologous adipose stem cells in treatment of female stress urinary incontinence: results of a pilot study

The purpose of our study was to find out whether transurethral injections of autologous adipose stem cells (ASCs) are an effective and a safe treatment for female stress urinary incontinence (SUI). We treated five SUI patients with ASCs combined with bovine collagen gel and saline. Prior to the treatment, the ASCs were isolated from subcutaneous fat and expanded for 3 weeks in a good manufacturing practice-level laboratory. The mixture of ASCs and collagen was injected transurethrally via cystoscope. Additionally, viability, multipotency, and surface marker profile of ASCs were analyzed in vitro. We followed up with patients 3, 6, and 12 months after the injections. The primary endpoint was a cough test to measure objectively the effect of the treatment. Validated questionnaires were used to determine the subjective cure rate. After 6 months, 1 of 5 patients displayed a negative cough test with full bladder filled with 500 ml of saline. At 1 year, the cough test was negative with three patients; two of them were satisfied with the treatment and did not wish further treatment for SUI. Validated questionnaires showed some subjective improvement in all five patients. This is the first study describing the use of autologous ASCs in combination with collagen gel for female SUI treatments. Thus far, the treatment with autologous ASCs has proven safe and well tolerated. However, the feasibility and efficacy of the treatment were not optimal; therefore, additional research is needed to develop SUI injection therapies.

Efficacy and safety of polyacrylamide hydrogel for the treatment of female stress incontinence: a randomized, prospective, multicenter North American study

PURPOSE

Bulkamid® is a new polyacrylamide hydrogel bulking agent for stress urinary incontinence that is injected in the urethral submucosa using a specifically designed device. We evaluated the safety and efficacy of Bulkamid vs Contigen® collagen gel for stress urinary incontinence or stress predominant mixed urinary incontinence.

MATERIALS AND METHODS

This was a single-blind, randomized, prospective, 33-center, 2-arm parallel study of hydrogel vs collagen gel with followup to 1 year. At baseline patients underwent physical examination and bladder testing, and completed quality of life questionnaires and bladder diaries. After randomization patients could receive up to 3 injections at 1-month intervals. Patients were assessed 3, 6, 9 and 12 months after bulking. They completed bladder diaries and quality of life questionnaires, and pad weight was tested. At the last visit Valsalva leak point pressure was measured. Subjective and objective incontinence outcomes and adverse events were compared.

RESULTS

Of the 345 women 229 were randomized to hydrogel and 116 were randomized to collagen gel. At 12 months a 50% or greater decrease in leakage and incontinence episodes was seen in 53.2% and 55.4% of patients who received hydrogel and collagen gel, respectively. At 12 months 47.2% of patients with hydrogel and 50% with collagen gel reported zero stress incontinence episodes, and 77.1% and 70%, respectively, considered themselves cured or improved. Major adverse events were rare in each group.

CONCLUSIONS

Bulkamid is not inferior to Contigen. It has a favorable, persistent effect on stress urinary incontinence with a low risk of serious adverse events. Bulkamid is a new, simple, office based bulking system that shows promise as a treatment in women with stress urinary incontinence, particularly since Contigen is no longer commercially available.

Urolastic-a new bulking agent for the treatment of women with stress urinary incontinence: outcome of 12 months follow up

Objective. To evaluate the efficacy and safety of the new injectable implant, Urolastic, in women with stress urinary incontinence (SUI) after 12-month followup. Materials and Methods. A prospective, cohort study included adult women with SUI. Patients were treated with Urolastic periurethral injections under local anaesthesia. The injection procedure was repeated after 6 weeks when indicated. Patients were evaluated for efficacy and safety parameters 6 weeks, 3 months, and 12 months after therapy. Results. Twenty women 56 (33-71) years old were included. Thirteen patients (65%) received one injection each (overall average of 2,1 mL); 7 patients (35%) received a second injection. Nineteen patients complete the 12-month followup. The mean Stamey incontinence grade significantly decreased from 1.9 at baseline to 0.4 at 12 months (visit IV) (P < 0.001). None of the patients were dry at baseline; 68% of them were dry at 12 months. The mean number of incontinence episodes significantly decreased from 6/day at baseline to 1.6/day at visit IV (P < 0.001). Reduction in pad weight went from 20.2 to 7.8 g at one year. The mean I-QoL score significantly increased from 51 at baseline to 76 at visit IV (P < 0.001). Six patients (30%) developed minor complications related to the injection procedure. Conclusions. Urolastic is effective and long-standing urethral bulking agent with moderate adverse events.

Persistent and recurrent stress urinary incontinence following mid-urethral tape surgery in women: a UK perspective

Stress urinary incontinence is a common health problem that affects a large proportion of women in Britain. It poses physical and psychological implications for the affected women and is a frequent indication for referral to tertiary urology centres. Midurethral tape surgery (MUTS) has established itself as the standard first-line surgical treatment as a result of its low morbidity, short hospital stay and high long-term success. Failure of the initial surgery can present as persistent or recurrent symptoms. This is a major challenge to the treating urologists as a result of the complicated nature of the condition and the lack of strong evidence supporting individual treatment modalities. In this article we discuss the factors associated with MUTS failure and the surgical options for its treatment.

Urethral bulking: a urology perspective

Urethral bulking therapy (UBT) is a minimally invasive procedure for stress urinary incontinence that is beneficial for properly selected patients. Many different materials are available for UBT, although none fulfill all the qualities of an ideal agent. In general, short-term clinical results are encouraging; however, over longer follow-up, results are disappointing and retreatment is often necessary. Proper patient selection and management of patient expectations are paramount to successful application of UBT.

Transplantation of muscle-derived stem cells plus biodegradable fibrin glue restores the urethral sphincter in a pudendal nerve-transected rat model

We investigated whether fibrin glue (FG) could promote urethral sphincter restoration in muscle-derived stem cell (MDSC)-based injection therapies in a pudendal nerve-transected (PNT) rat, which was used as a stress urinary incontinence (SUI) model. MDSCs were purified from the gastrocnemius muscles of 4-week-old inbred female SPF Wistar rats and labeled with green fluorescent protein. Animals were divided into five groups (N = 15): sham (S), PNT (D), PNT+FG injection (F), PNT+MDSC injection (M), and PNT+MDSC+FG injection (FM). Each group was subdivided into 1- and 4-week groups. One and 4 weeks after injection into the proximal urethra, leak point pressure (LPP) was measured to assess urethral resistance function. Histology and immunohistochemistry were performed 4 weeks after injection. LPP was increased significantly in FM and M animals after implantation compared to group D (P < 0.01), but was not different from group S. LPP was slightly higher in the FM group than in the M group but there was no significant difference between them at different times. Histological and immunohistochemical examination demonstrated increased numbers of surviving MDSCs (109 ± 19 vs 82 ± 11/hpf, P = 0.026), increased muscle/collagen ratio (0.40 ± 0.02 vs 0.34 ± 0.02, P = 0.044), as well as increased microvessel density (16.9 ± 0.6 vs 14.1 ± 0.4/hpf, P = 0.001) at the injection sites in FM compared to M animals. Fibrin glue may potentially improve the action of transplanted MDSCs to restore the histology and function of the urethral sphincter in a SUI rat model. Injection of MDSCs with fibrin glue may provide a novel cellular therapy method for SUI.

An open multicenter study of polyacrylamide hydrogel (Bulkamid®) for female stress and mixed urinary incontinence

Introduction

Polyacrylamide hydrogel (PAHG, Bulkamid®) is a promising urethral bulking agent. This multicenter study was carried out to evaluate safety and efficacy of Bulkamid® for female stress and mixed urinary incontinence.

Methods

Submucosal injection of Bulkamid® was performed in 135 women with urinary incontinence (stress, 67; mixed, 68) followed for 12 months. Forty-seven had a reinjection (35%).

Results

At 12 months, the subjective response rate was 66%. Incontinence episodes/24 h and urine leakage g/24 h decreased significantly (from 3.0 to 0.7 and 29 g to 4 g, respectively). Additionally, the median International Consultation on Incontinence Questionnaire score was reduced to approximately 50%, and the overall quality of life visual analogue scale score was decreased significantly (from 72 to 20). Efficacy was very similar between patients with stress and mixed incontinence. Thirty treatment-related adverse events were registered. The most frequent was urinary tract infection (n = 10). No polyacrylamide hydrogel-specific adverse events were seen.

Conclusions

Bulkamid® is an effective and safe bulking agent in women with stress or mixed incontinence.

The surgical treatment of female stress urinary incontinence

Urinary incontinence is a common symptom experienced by significant numbers of adult women. Stress urinary incontinence (SUI) is the most frequently encountered type and affects around 50% of incontinent females. Many affected women do not consult their doctors about this troublesome symptom perhaps based on a belief that they cannot be helped. Recent years have seen the development of several new and popular techniques for the surgical treatment of this condition and many of the "gold standard" procedures for stress incontinence have been challenged. Currently, evidence in favor of the use of sub-urethral tapes especially tension-free vaginal tapes suggests that a new standard of low morbidity and high efficacy surgical treatment for SUI has been set. This review is intended to examine all of the surgical options for the treatment of SUI and provide health care professionals with an overview of the vast array of currently available procedures.

Effects of Macroplastique Implantation System for stress urinary incontinence and urethral hypermobility in women

A study was carried out to evaluate efficacy of Macroplastique(R) (MPQ) Implantation System (MIS) in women with urodynamic stress urinary incontinence (SUI) and urethral hypermobility after an unsuccessful conservative treatment. This is a prospective randomized controlled trial in women without previous incontinence surgery. Twenty-four women received MPQ. Twenty-one controls underwent a pelvic floor muscle exercises home program. Follow-up was at 3 months and the MPQ group also at 12 months. At 3 months, pad usage decreased significantly more in the MPQ group than in the control group (p = 0.015). According to physician and patient self-assessment, respectively, 71% and 63% women in the MPQ group were considered cured or markedly improved. This was significantly higher compared to controls. There was a significant higher increase of Incontinence Quality-of-Life questionnaire score in the MPQ group compared to controls (p = 0.017). Improvements in MPQ group at 3 months are sustained to 12 months. Adverse events were mild and transient. MIS is an acceptable option for women with SUI and urethral hypermobility.

Functional and Histological Changes after Myoblast Injections in the Porcine Rhabdosphincter

OBJECTIVE

Transurethral ultrasound-guided injection of autologous myoblasts has recently been shown to cure urinary stress incontinence. In the present study, the dose-dependent changes in maximal urethral closure pressures after application of myoblasts were investigated in a porcine animal model.

METHODS

Myoblast cultures were grown from a porcine muscle biopsy. The biopsy was enzymatically dissociated by using a modified cell dispersion technique. Single myoblasts in suspension were manually collected with a micropipette under microscopic control. Next a clonal myoblast culture was prepared. Before the cells were applied, fluorescence labelling (PKH) was used to assess integration of the injected myoblasts into the rhabdosphincter. With the help of a transurethral ultrasound probe (23 F, 11 MHz) and a special injection system, the myoblasts were injected into the rhabdosphincter of five pigs under direct sonographic control. Into two different areas of the rhabdosphincter, increasing different cell counts were injected (total volume 1.5 ml). At each area, 10 depots of 150 microl volume were injected all along the rhabdosphincter. The following cell counts were used: 1.5 x 10(6), 2.1 x 10(6), 4.2 x 10(6) (low range) 5.69 x 10(6), 8.1 x 10(6), 1.13 x 10(7), 1.6 x 10(7) (mid range) 2.26 x 10(7), 4.4 x 10(7), and 7.8 x 10(7) (high range). To avoid possible cell rejection, we immunosuppressed the pigs with daily cortisone (1g Solu Dacortin) because allogenic myoblasts were used. Urethral pressure profiles (UPPs) were measured before and 3 wk postoperatively before the pigs were put to sleep. The lower urinary tract was removed in all pigs for histological analysis.

RESULTS

Histological examination of the specimens revealed that the injected cells had survived at the injection site and had formed new myofibres. Overall the UPP curves revealed dose-dependent changes. Statistically significant increased pressure values of up to more than 300% could be observed in all cases in which higher concentrations of cells had been applied. Increases were also noted in mid range concentrations although not to such a high extent (approximately 150%). Pressure values had even diminished (approximately 50%) after injecting the three lowest concentrations (1.5 x 10(6), 2.1 x 10(6), 4.2 x 10(6)).

CONCLUSIONS

The present results show that the effects after application of myoblasts into the rhabdosphincter are dose-dependent.

Autologous myoblasts and fibroblasts for female stress incontinence: a 1-year follow-up in 123 patients

OBJECTIVE

To assess the efficacy and safety of the application of autologous myoblasts and fibroblasts for treating female stress urinary incontinence (SUI) after a follow-up of >/=1 year.

PATIENTS AND METHODS

In all, 123 women with SUI (aged 36-84 years) were treated with transurethral ultrasonography-guided injections with autologous myoblasts and fibroblasts obtained from skeletal muscle biopsies. The fibroblasts were suspended in a small amount of collagen as carrier material and injected into the urethral submucosa, while the myoblasts were implanted into the rhabdosphincter. All patients were evaluated before and 12 months after the injection using the Incontinence and Quality of Life Instrument (I-QOL) scores, urodynamic variables, and morphology and function of the urethra and rhabdosphincter.

RESULTS

At 1 year after implanting the cells, 94 of the 119 women (79%) were completely continent, 16 (13%) had a substantial improvement and nine (8%) a slight improvement. Four patients were lost to follow-up. The incontinence and I-QOL scores, and the thickness, contractility and electromyographic activity of the rhabdosphincter were significantly improved after treatment.

CONCLUSIONS

These results show the efficacy and safety of transferring autologous myoblasts and fibroblasts in the treatment of female SUI, after a follow-up of 1 year.

Injectables for the treatment of stress urinary incontinence: current use and future perspectives

Stress urinary incontinence is a prevalent symptom among women. It also affects men, primarily those operated on for prostate disease. Even though it is not life threatening, it seriously impacts quality of life. Bulking agents have been used in the treatment of incontinence for many decades, offering a treatment option for both women and men. Their short-term efficacy is satisfactory, but there is concern regarding durability of effect. Despite concerns regarding efficacy, the minimally invasive nature of the technique, with uncommon and self-limited complications, has made injectables quite popular among both physicians and patients. In light of recent developments in the surgical treatment of incontinence, resulting in highly efficacious, but also easy and safe-to-perform, procedures, the role of injectables must be re-evaluated. In these cost-conscious times, health economics is also an important issue, and comparative cost-effectiveness assessment of available treatment options is becoming imperative.

Current trends in the evaluation and management of female urinary incontinence

Despite its common occurrence and often seemingly obvious causes, female urinary incontinence requires a thorough and thoughtful evaluation for its proper diagnosis and treatment. With rare exceptions, urinary incontinence is the result of failure of the sphincter mechanism to resist bladder pressures encountered during daily activities. This may be the result of sphincter failure, overactivity of the bladder detrusor muscle or both. In uncomplicated cases, the diagnosis is usually based on an evaluation in the office. Urodynamic and cystoscopic study may be helpful in complex, resistant and recurring cases of urinary incontinence of any cause. Most cases of incontinence may be classified as stress, urge or mixed urinary incontinence. Treatment of stress urinary incontinence focuses on supplementing the urethral continence mechanisms, particularly the urethral supports and periurethral striated muscle function. The current paradigm for the treatment of urge incontinence centres on pharmacologic therapy, primarily by correcting detrusor overactivity with antimuscarinic drugs. Other therapies aimed at altering sensorimotor function may be used in resistant cases. The treatment of mixed urinary incontinence requires consideration of the contribution of each of its components. With proper diagnosis, effective treatment is possible for most patients.

Patient-perceived outcomes in the treatment of stress urinary incontinence: focus on urethral injection therapy

Intervention for stress urinary incontinence (SUI) is generally focused on minimizing urinary leakage. However, the overall impact of SUI therapy on patients' quality of life is, arguably, more important than leakage outcomes. We performed a literature search to investigate the effect of urethral injection therapy on quality of life. Significant quality-of-life improvements have been observed with a number of injectable agents, while there is a distinct lack of correlation between subjective and objective outcomes. Two studies comparing urethral injection therapy with surgical intervention found superior objective efficacy with surgery, but no significant differences in quality-of-life improvements. Personal goals of patients undergoing urethral injection are yet to be explored, but there may be willingness to trade a lower success rate in favor of a more minor treatment procedure. In conclusion, quality-of-life improvements after urethral injection appear significant and comparable to those obtained with surgery. Further study of patients' own perceptions, pre- and posttreatment, would be valuable.