Injection of Urethral Bulking Agents

Analysis of Predictive Factors for Return to Sports in Female Athletes With Stress Urinary Incontinence

Introduction This study aimed to identify predictive factors for successful return to sports among elite female athletes (EFAs) experiencing stress urinary incontinence (SUI). We used machine learning to analyze these predictors. Methods This study was conducted at Yokosuka Urogynecology and Urology Clinic, located in Yokosuka City, Kanagawa, Japan. A total of 153 EFAs with postpartum SUI were included in this retrospective cohort study. Information regarding the frequency of pelvic floor muscle training (PFMT), treatment approaches, rates of return to sports after one year, and one-hour pad test (1HrPadtest) at three months were collected. Results At three months, 26.8% of the EFAs improved in SUI; after one year, 28.1% returned to their respective sports successfully. The equation for predicting return to sports (logit(p)) involved several factors: (a) serum total testosterone, (b) PFMT frequency per week, (c) 1HrPadtest at three months, and (d) vaginal erbium-doped yttrium aluminum garnet laser (VEL) + urethral EL (UEL) treatment. The equation was as follows: -126 - 0.07276a + 25.98b - 1.947c - 25.32d, with a logit(p) cutoff point at 0.5. The optimal cutoff values and the four influential factors were determined through a receiver operating characteristic (ROC) analysis and the random forest model, respectively. Conclusions For EFAs with severe SUI to successfully return to their sports activities, the PFMT frequency was paramount. Patients who exhibited unsatisfactory results in the 1HrPadtest at the three-month mark benefited from the VEL+UEL treatment. Serum total testosterone proved to be an effective discerning criterion.

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.

Long-Term Surveillance and Management of Urological Complications in Chronic Spinal Cord-Injured Patients

Bladder dysfunction is a common complication after chronic spinal cord injury (SCI). Patients may experience renal function loss, urinary tract infection (UTI), urolithiasis, bladder cancer, and even life-threatening events such as severe sepsis or renal failure. Suitable patient care may prevent UTI and urinary incontinence, decrease medication use, and preserve renal function. As the primary goal is to preserve renal function, management should be focused on facilitating bladder drainage, the avoidance of UTI, and the maintenance of a low intravesical pressure for continence and complete bladder emptying. Currently, several bladder management options are available to SCI patients: (1) reflex voiding; (2) clean intermittent catheterization; (3) indwelling catheterization. The target organ may be the bladder or the bladder outlet. The purposes of intervention include the following: (1) increasing bladder capacity and/or decreasing intravesical pressure; (2) increasing bladder outlet resistance; (3) decreasing bladder outlet resistance; (4) producing detrusor contractility; (5) urinary diversion. Different bladder management methods and interventions may have different results depending on the patient's lower urinary tract dysfunction. This review aims to report the current management options for long-term bladder dysfunction in chronic SCI patients. Furthermore, we summarize the most suitable care plans for improving the clinical outcome of SCI patients.

Stress Urinary Incontinence: Slings, Single-Incision Slings, and Nonmesh Approaches

Synthetic midurethral slings offer optimal cure rates for the minimally invasive treatment of stress urinary incontinence in women. Performed via a retropubic or transobturator technique, midurethral sling approaches demonstrate comparable efficacy, with unique adverse event profiles. Single incision slings were introduced to minimize the complication of groin pain with full-length transobturator slings and enhance operative recovery. The earliest therapies for stress urinary incontinence including urethral bulking, retropubic colposuspension, and autologous sling offer alternative methods of surgical management without using synthetic mesh. These methods boast satisfactory efficacy with low rates of complications, and may be ideal for appropriately selected patients.

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.

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.