Three-dimensional ultrasonography: an objective outcome tool to assess collagen distribution in women with stress urinary incontinence

Imaging findings of vinyl dimethyl polydimethylsiloxane used as a paraurethral injectable for female stress urinary incontinence

Objectives:

Vinyl dimethyl polydimethylsiloxane (VDPDMS) is a urethral bulking agent used for female stress urinary incontinence (SUI), that is clearly visible on computed tomography (CT). Clinical effects are promising, but it remains difficult to identify factors predicting clinical success. Clinical outcome might depend on the shape and position of the implants after injection. Objective of this study is to analyze the appearance and position of bulk material on CT scans and to see whether it is delivered the intended circumferential and mid-urethral position.

Methods:

A single-center retrospective study was performed in 20 women, treated with VDPDMS for SUI. A senior radiologist analyzed all CTs, using an assessment scheme. This scheme describes whether the bulk is scattered, mid-urethral, and/or circumferentially distributed. The imaging findings were subsequently correlated to the patient global impression of improvement (PGI-I) and the percentage of subjective improvement experienced 6 weeks post-operatively.

Results:

The patient’s mean age was 61 years, and they underwent median 2.0 previous surgical treatments for SUI. Three patients reported no improvement, 9 patients had 20–90% improvement and 8 reported >90% improvement of their SUI. In 17/74 (24%) positions, the implant was scattered rather than spherical. In 9/20 (45%), the implants were not located in the intended mid-urethral position. In 8/20 patients (40%), the material was distributed circumferentially.

Conclusion:

This is the first study describing the position and shape of VDPDMS in patients after treatment. The appearance and position of the implants appears to be variable, but optimal positioning or shape seems to be no absolute requisite for success.

Durability of Macroplastique volume and configuration in women with stress urinary incontinence secondary to intrinsic sphincter deficiency: A retrospective review

OBJECTIVES

To evaluate the durability of Macroplastique® (MPQ) volume and configuration in women with stress urinary incontinence (SUI) secondary to intrinsic sphincter deficiency (ISD) using serial three-dimensional ultrasound (3DUS) measurements.

METHODS

Following Institutional Review Board approval, charts of women with SUI and ISD (defined based on leak point pressure; lateral imaging of urethral support without hypermobility) who underwent MPQ were reviewed from a prospectively maintained database. All had at least two serial transperineal 3DUS measurements with no MPQ or other bulking agent injection between measurements. 3DUS was performed using the Philips IU22 ultrasound system with endovaginal 3D 9-3V end-fire probe typically at 6-8 weeks post-injection and yearly thereafter. The same imaging team blinded to clinical outcomes evaluated volume and configuration (circumferential/symmetric or asymmetric) at each 3DUS.

RESULTS

Between 2011 and 2019, 62 of 174 women met study criteria. Those with prior other bulking agent injection or having ≤1 3DUS follow-up were excluded. Seventy-one percent of patients had one injection, while the remainder had two or more (29%). Median time between first and second 3DUS was 12 months. The mean change in MPQ volume between the first and last 3DUS measurement was -0.2 cc (95% CI: -0.5 to 0.004; P = .054). A median of 5.0 cc were injected in each patient. Forty-seven women had symmetric MPQ at first 3DUS, of whom only five (11%) had a follow-up 3DUS showing asymmetric MPQ distribution.

CONCLUSIONS

At mid-term follow-up, repeat transperineal 3DUS after MPQ injection revealed minimal change in volume and configuration in the urethral wall.

Materials Selection for the Injection into Vaginal Wall for Treatment of Vaginal Atrophy

Vaginal atrophy caused by the aging process and perineal trauma has a negative impact on women. A new vaginal atrophy treatment is injection of materials into the vaginal wall, including platelet-rich plasma (PRP), autogenous fat graft (AFG), hyaluronic acid (HA), botulinum toxin (BTX), and collagen, but to date their efficacy has not been reviewed. Vaginal wall injection is available only for mild cases of vaginal atrophy or as an adjunct to vaginal surgery. PRP is used mainly to restore vaginal function, and multiple injections are needed to achieve good results in vaginal atrophy. HA, AFG, and collagen are used mainly to augment the vaginal wall. BTX injection can inhibit vaginal muscle spasm and reduce pain during sexual intercourse in patients with vaginismus. Injection of most of these materials into vaginal wall is effective and relatively safe. Vascular embolisms are the most serious complication of vaginal injection and should be prevented. In addition, there has been no randomized double-blind placebo-controlled trial or discussion of methods to avoid serious complications resulting from vaginal injection. Therefore, further studies of the injection of materials into the vaginal wall to treat vaginal atrophy are required, and the procedures should be standardized to benefit more patients.Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Macroplastique for women with stress urinary incontinence secondary to intrinsic sphincter deficiency

Objective

To evaluate the subjective and objective outcomes of Macroplastique® (MPQ) in women with stress urinary incontinence (SUI) secondary to intrinsic sphincter deficiency (ISD).

Materials and Methods

Following Institutional Review Board (IRB) approval, charts of non-neurogenic women with SUI secondary to ISD who underwent MPQ injection and had 6 months minimum follow-up were reviewed from a prospectively maintained database. Patients were divided into 3 groups: Naïve (Group I), Prior Anti-Incontinence Surgery (Group II), and combined Prior Bulking Agent and Anti-Incontinence Surgery (Group III). Data collected included SUI self-report, Urogenital Distress Inventory (UDI-6) Question 3, and VAS Quality of Life (QoL) Questionnaire scores at baseline and in follow-up. Three-dimensional ultrasound (3DUS) evaluated volume/configuration of MPQ. Success was defined after the last MPQ injection as a UDI-6 Question 3 score of 0 (dry) or 1, and no reoperation for SUI.

Results

From 2011-2017, 106 of 142 women met study criteria. At a median follow-up of 20 months (mean=26 months; range: 6-71), success rate was 41% for Group I, 40% for Group II, and 65% for Group III (p = 0.22). QoL scores were significantly improved over baseline in all groups. There was no significant difference in clinical outcome between the asymmetrical and symmetrical group on 3DUS. The completely dry rate was highest in Group III at 29%, compared to 4% for Group I and 15% for Group II (p = 0.05).

Conclusion

Macroplastique® improved subjective and objective outcome measures for SUI secondary to ISD as both a primary and secondary treatment option in women.

Pelvic floor imaging

Pelvic floor ultrasound is a valuable adjunct in elucidation of cause, diagnosis, and treatment of pelvic floor disorders. Three-dimensional ultrasound specifically has been shown to have many advantages over conventional imaging modalities. Proper evaluation of pelvic floor muscle function, strength, and integrity is an important component of diagnosis and treatment of pelvic floor disorders. The pelvic floor muscle training used to change the structural support and strength of muscle contraction requires clinicians to be able to conduct high-quality measurements of pelvic floor muscle function and strength. Ultrasound is a useful modality to assess the pelvic floor and its function. As practitioners become more familiar with the advantages and capabilities of ultrasound, this tool should become part of routine clinical practice in evaluation and management of pelvic floor disorders.

Ultrasound imaging of the pelvic floor: where are we going?

We produced a non systematic review of ultrasound imaging of the pelvic floor in women with urinary incontinence (UI) and/or pelvic organ prolapse (POP). We have searched the PubMed and Embase databases for the following PICO question: women; imaging; urinary incontinence, pelvic organ prolapse, pelvic floor, pelvic floor muscle, pelvic floor muscle training; physical examination, no imaging; diagnosis, prognosis, outcome. The production of a systematic review was deemed impossible based on the type and quality of the published evidence. Clinical research focused on the pathophysiology of the UI and POP looking relation between anatomic abnormalities, childbirth, the risk of UI or POP, the outcome of conservative treatment and reconstructive surgery. Published papers fall into the remits of diagnostic studies but often fail to comply with the recommendations of the STARD initiative. Most published evidence remains the product of a single institution effort and confirmatory studies are rarely found. Imaging studies in patients with UI did not provide evidence of any clinical benefit in the management of patients. In patients with POP, interesting correlations have been identified such as between childbirth, dimension of levator hiatus, avulsion of levator ani and risk of prolapse, but the non clinical benefit of pelvic floor imaging could still not be identified. Research on pelvic floor imaging requires a coordinated, international, multicentre effort to improve internal and external validity of imaging techniques, confirm observations published by single institutions and provide health technology assessment of imaging in the management of UI or POP patients.

Three-dimensional transperineal ultrasonography of the pelvic floor: improving visualization for new clinical applications and better functional assessment

OBJECTIVE

With increasing awareness of the scope of pelvic floor disorders has come development and introduction into clinical practice of new imaging techniques, with increasing importance of ultrasonography. Complex pelvic floor anatomy, the conceptual difficulty in the basics of some pelvic floor disorders, and the uneven standardization of ultrasonographic techniques were the impetuses of this review. The purpose of this study was to review the basic anatomy of the pelvic floor and the transperineal ultrasonographic evaluation technique and to provide an overview of the current clinical use of 3-dimensional transperineal ultrasonography in the evaluation of the anterior and posterior pelvic floor compartments.

METHODS

A literature review illustrated with index cases from our center was conducted.

RESULTS

Ultrasonography has been widely applied to evaluation of the anterior and posterior compartments of the pelvic floor. Three-dimensional ultrasonography has a role in improving pelvic floor assessment.

CONCLUSIONS

Three-dimensional transperineal ultrasonography has been applied to evaluation of normal and pathologic pelvic floor anatomy. Practical application, through well-designed and sufficiently powered clinical studies, will establish the association between the clinical presentations of dysfunction with ultrasonographic findings.

Volume changes and histological response to injected dextranomer/hyaluronic acid copolymer (Zuidex) and collagen (Contigen) in rats

The objective of this study was to investigate the stability in terms of volume changes and local tissue reactions of dextranomer (Dx)/hyaluronic acid (HA) and collagen implants. A total of 57 rats were included in this study: the control group (nine rats), collagen-injected group (24 rats), and Dx/HA copolymer-injected group (24 rats). Under anesthesia, 0.35 ml of bulking agents was injected subcutaneously in the abdominal area. At 1, 6, and12 months, eight animals of the two implant groups and three animals of the control group were killed. The area of the injected material and surrounding tissue were carefully resected for histopathological examination. Mean volume changes in the Dx/HA copolymer group were 0.56 +/- 0.12, 0.43 +/- 0.08, and 0.28 +/- 0.02 ml at 1, 6, and 12 months, respectively. Mean volume changes in the collagen group were 0.25 +/- 0.03, 0.21 +/- 0.08, and 0.21 +/- 0.01 at 1, 6, and 12 months, respectively. The degree of tissue reaction and fibrosis are more pronounced in the Dx/HA copolymer group at each measurement period after injection.

Is there a role for periurethral collagen injection in the management of urodynamically proven mixed urinary incontinence?

OBJECTIVES

To investigate the effectiveness of periurethral collagen injection (PCI) in patients presenting with symptoms of mixed urinary incontinence (MUI) and urodynamically demonstrated sphincter deficiency and detrusor overactivity.

METHODS

A retrospective review was performed on all patients undergoing PCI from February 1999 to February 2003, during which those with MUI were treated with PCI as first-line therapy. The inclusion criteria were MUI symptoms, detrusor overactivity on urodynamic study, stress urinary incontinence due to sphincter deficiency (determined from physical examination, stress test, urodynamic study with Valsalva leak point pressure, and cystography findings, without urethral hypermobility). The primary outcome measures were the Urogenital Distress Inventory (UDI), Incontinence Impact Questionnaire, and quality-of-life score and the need for anticholinergic medications or additional surgery. Comparisons were performed using the Wilcoxon signed ranks test and paired t test.

RESULTS

Of the 56 patients who underwent PCI, 43 presented with symptoms of MUI, and 16 of these (29%) had both detrusor overactivity and stress urinary incontinence on urodynamic study. The mean follow-up after PCI (without additional PCI) was 18 months (range 6 to 39). The mean age was 65 years (range 40 to 84). The mean Valsalva leak point pressure was 54 +/- 40 cm H2O (range 18 to 146). Ten patients had undergone previous anti-incontinence procedures, and anticholinergic medications had failed in six. The questionnaire scores, indicating severe MUI/poor quality of life before PCI, improved after PCI: UDI question 1, 2.3 +/- 0.8 versus 1.3 +/- 1.0 (P = 0.021); UDI question 2, 2.1 +/- 1.2 versus 1.4 +/- 1.0 (P = 0.068); UDI question 3, 2.9 +/- 0.4 versus 1.8 +/- 1.2 (P = 0.010); and quality-of-life question, 8.6 +/- 2.1 versus 5.2 +/- 3.5 (P = 0.026). The mean injected volume/patient was 8.5 cm3 (range 5 to 17) within a mean of 1.9 treatments (range 1 to 3). Four patients continued taking anticholinergic medications and one proceeded to sling placement.

CONCLUSIONS

The use of PCI as the primary/initial intervention in patients with MUI may be the preferred approach, particularly in patients with an elevated risk of anticholinergic medication side effects or when voiding dynamics preclude sling placement.

Three-dimensional ultrasonography to assess long-term durability of periurethral collagen in women with stress urinary incontinence due to intrinsic sphincter deficiency

OBJECTIVES

To investigate the natural history of periurethral collagen injection (PCI) over time using serial three-dimensional ultrasonography (3DUS) of the urethra as an objective measure.

METHODS

Retrospective chart review was performed for all patients who underwent PCI between February 1999 and February 2003. All had been diagnosed with stress urinary incontinence due to intrinsic sphincter deficiency without urethral hypermobility, had follow-up data including two or more 3DUS scans within 1 year or more, and had undergone no additional PCIs (ie, remained clinically improved). The follow-up examinations included serial history, symptom and quality-of-life (QOL) questionnaires (Urogenital Distress Inventory, global QOL visual analog scale [scale of 0 to 10, with 0 = best]), physical examination, and 3DUS scans. The primary subjective and objective outcomes were the Urogenital Distress Inventory and QOL scores and the 3DUS-determined periurethral collagen volume and configuration, respectively.

RESULTS

Of the 54 patients undergoing PCI during the accrual period, 20 had follow-up of 1 year or longer (mean 2.0, range 1 to 3.8). The mean 3DUS collagen volumes were not statistically different at baseline at a mean of 4 months after PCI (2.9 +/- 1.9 cm3) compared with at the last follow-up visit (2.7 +/- 1.9 cm3; P = 0.34). The volume retention rate was 97% +/- 33% of the baseline volume. The periurethral configuration was circumferential in 80% and asymmetric in 20%, and was maintained over time. The postinjection Urogenital Distress Inventory question 3 (stress urinary incontinence) and QOL scores were significantly improved compared with the pre-PCI evaluations with a mean of 2.4 +/- 0.8 versus 1.4 +/- 0.7 (P = 0.013) and 7.3 +/- 2.6 versus 3.5 +/- 2.5 (P = 0.001), respectively.

CONCLUSIONS

This is the first study to demonstrate the long-term durability of PCI on serial 3DUS in association with improved continence and QOL using questionnaire analysis. This new knowledge provides a technical and therapeutic endpoint for PCI.

Role of three-dimensional ultrasound in assessment of women undergoing urethral bulking agent therapy

PURPOSE OF REVIEW

The technique of three-dimensional ultrasound imaging has been developed over the past 15 years, and has been particularly embraced by the field of obstetrics. More recently, advances have been made in gynecological applications, with promise demonstrated in pelvic floor and lower urinary tract imaging. A clinically useful extension of three-dimensional ultrasound imaging of the lower urinary tract is the assessment of urethral bulking agent therapy, as three-dimensional ultrasound imaging provides an objective means of assessing technical outcomes (i.e. periurethral position, configuration and volume of bulking agent). Our aim is to review recent developments in the use of three-dimensional ultrasound imaging in female incontinence, focusing on its role in the assessment of women undergoing urethral bulking agent therapy for stress urinary incontinence.

RECENT FINDINGS

Three-dimensional ultrasound imaging provides reproducible, affordable and clinically relevant information in the assessment of urethral bulking agent therapy with collagen. Serial, long-term three-dimensional ultrasound imaging assessment has enabled a definition of the technical outcome associated with a durable improvement in continence. The optimal volume varies widely between patients, but a circumferential or horseshoe-shaped periurethral configuration of collagen is strongly correlated with a durable improvement in continence. This finding is in agreement with limited data from a two-dimensional ultrasound assessment of Macroplastique.

SUMMARY

Three-dimensional ultrasound imaging provides an objective means of assessing technical outcomes from urethral bulking agent therapy not available previously. The volume and configuration information obtained allows for rational therapeutic decision-making, particularly with regard to determining the need for re-injection and recognizing the failure of an adequate therapeutic trial.