Review of the available urethral bulking agents

Efficacy and safety of Hyadex for treatment of vesicoureteral reflux: a multicenter experience

OBJECTIVE

This study was performed to evaluate the efficacy and safety of dextranomer/cross-linked hyaluronic acid (Hyadex) in patients with a clinical diagnosis of vesicoureteral reflux (VUR).

METHODS

In this cross-sectional multicenter observational study, Hyadex was used in four different centers for the endoscopic treatment of VUR from 2020 to 2022. The study involved 74 patients (93 renal units) who were diagnosed with VUR according to voiding cystourethrography (VCUG) findings and were considered suitable for subureteric endoscopic treatment. The follow-up time (control VCUG time) was 3 months.

RESULTS

In the VCUG evaluation, grade I VUR was found in 13 renal units, grade II in 23 renal units, grade III in 42 renal units, and grade IV in 12 renal units. The success rates of Hyadex treatment according to the degree of VUR were as follows: 84.6% for grade I, 82.6% for grade II, 71.4% for grade III, and 66.0% for grade IV. No major complications were observed.

CONCLUSION

Endoscopic subureteric Hyadex injection had high success rates in appropriately selected patients with VUR and may be used as the first-line treatment for children with VUR.

Prevalence of stress urinary incontinence and intrinsic sphincter deficiency in patients with stage IV pelvic organ prolapse

AIM

To determine the prevalence of stress urinary incontinence (SUI) and intrinsic sphincter deficiency (ISD) in women with stage IV pelvic organ prolapse.

METHODS

Retrospective analysis of women with stage IV prolapse who underwent multichannel urodynamic testing. Abdominal leak point pressures (ALPP) and maximum urethral closure pressures (MUCP) were recorded. ISD was defined as ALPP ≤60 cm of water and/or MUCP ≤20 cm of water. Percentages were used to present the proportion of subjects diagnosed with SUI and ISD.

RESULTS

A total of 145 patients met inclusion criteria. Mean age was 69 years; most patients were Caucasian (56%). Eighty-two (56%) patients were found to have SUI on urodynamic testing. Thirty-six (44%) of these were asymptomatic and identified as having occult SUI. Sixteen (19.5%) patients were diagnosed with ISD using ALPP and/or MUCP. Six (37%) of the ISD patients had at least one MUCP value ≤20 cm of water and 12 (75%) had observed leakage with at least one ALPP value ≤60 cm of water. The number of patients with leakage at ALPP ≤60 cm of water increased with increasing bladder volumes. Five ISD patients (31%) had ALPP ≤60 cm of water at 200 mL, six (37.5%) had ALPP ≤60 cm of water at 300 mL and seven (43.8%) had ALPP ≤60 cm of water at 400 mL.

CONCLUSION

Greater than 50% of patients with stage IV pelvic organ prolapse had SUI on urodynamic testing, and 20% were found to have ISD. Of the patients diagnosed with SUI, 40% were asymptomatic. These findings may assist in counseling and preoperative planning for women with stage IV prolapse.

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.

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.

Contemporary diagnostics and treatment options for female stress urinary incontinence

Stress urinary incontinence is not a deadly disease, but for the large population of women suffering from it, it is a very important issue. Especially in the continuously aging population all over the world, there is more and more need for treatment of this serious medical condition. Treatment of female stress urinary incontinence exists already for ages. In the 20th century invasive treatments like Burch colposuspension and pubovaginal slings were the mainstay of surgical treatments. The introduction of the midurethral sling made the procedure less invasive and accessible for more caregivers. Luckily there are many options available and the field is developing quickly. In recent years many new medical devices have been developed, that increase the number of treatment options available and make it possible to find a suitable solution for the individual patient based on subjective and objective results and the chances of complications. This manuscript provides an introduction to the therapeutical options that are available nowadays for female stress urinary incontinence.

Urethral injection therapy for urinary incontinence in women

BACKGROUND

Urinary incontinence imposes a significant health and economic burden to society. Periurethral or transurethral injection of bulking agents is a minimally invasive surgical procedure used as one the surgical treatments of stress urinary incontinence (SUI) in adult women.

OBJECTIVES

To assess the effects of periurethral or transurethral injection therapy on the cure or improvement of urinary incontinence in women.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Trials Register (searched 8 November 2010) and the reference lists of relevant articles.

SELECTION CRITERIA

All randomised or quasi-randomised controlled trials of treatment for urinary incontinence in which at least one management arm involved periurethral or transurethral injection therapy.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed methodological quality of each study using explicit criteria. Data extraction was undertaken independently and clarification concerning possible unreported data sought directly from the investigators.

MAIN RESULTS

Excluding duplicate reports, we identified 14 trials (excluding one that was subsequently withdrawn from publication and not included in this analysis) including 2004 women that met the inclusion criteria. The limited data available were not suitable for meta-analysis because they all came from separate trials. Trials were small and generally of moderate quality.One trial of 45 women that compared injection therapy with conservative treatment showed early benefit for the injectable therapy with respect to continence grade (risk ratio (RR) 0.70, 95% confidence interval (CI) 0.52 to 0.94) and quality of life (mean difference (MD) 0.54, 95% CI 0.16 to 0.92). Another trial, comparing Injection of autologous fat with placebo, terminated early because of safety concerns. Two trials that compared injection with surgical management found significantly better objective cure in the surgical group (RR 4.77, 95% CI 1.96 to 11.64; and RR 1.69, 95% CI 1.02 to 2.79), although the latter trial data did not reach statistical significance if an intention-to-treat analysis was used.Eight trials compared different agents and all results had wide confidence intervals. Silicone particles, calcium hydroxylapatite, ethylene vinyl alcohol, carbon spheres and dextranomer hyaluronic acid combination gave improvements which were not shown to be more or less efficacious than collagen. Dextranomer hyaluronic acid compound treated patients appeared to have significantly higher rates of injection site complications (16% with the hyaluronic acid compound versus none with collagen; RR 37.78, 95% CI 2.34 to 610.12) and this product has now been withdrawn from the market.A comparison of periurethral and transurethral methods of injection found similar outcomes but a higher (though not statistically significant) rate of early complications in the periurethral group. One trial of 30 women showed a weak (but not clinically significant) advantage for patient satisfaction (data not suitable for analysis in RevMan) after mid-urethral injection in comparison to bladder neck injection but with no demonstrable difference in continence levels.

AUTHORS' CONCLUSIONS

The available evidence base remains insufficient to guide practice. In addition, the finding that placebo saline injection was followed by a similar symptomatic improvement to bulking agent injection raises questions about the mechanism of any beneficial effects. One small trial comparing silicone particles with pelvic floor muscle training was suggestive of benefit at three months but it is not known if this was sustained, and the treatment was associated with high levels of postoperative retention and dysuria. Greater symptomatic improvement was observed with surgical treatments, though the advantages need to be set against likely higher risks. No clear-cut conclusions could be drawn from trials comparing alternative agents, although dextranomer hyaluronic acid was associated with more local side effects and is no longer commercially available for this indication. There is insufficient evidence to show superiority of mid-urethral or bladder neck injection. The single trial of autologous fat provides a reminder that periurethral injections can occasionally cause serious side effects. Also, a Brief Economic Commentary (BEC) identified three studies suggesting that urethral bulking agent might be more cost-effective compared with retropubic mid-urethral slings, transobturator or traditional sling procedure when used as an initial treatment in women without hypermobility or as a follow-up to surgery failure provided injection is kept minimal. However, urethral bulking agent might not be cost-effective when compared with traditional sling as an initial treatment of SUI when a patient is followed up for a longer period (15 months post-surgery).

Novel minimally invasive laser treatment of urinary incontinence in women

BACKGROUND AND OBJECTIVE

Urinary incontinence (UI) is a common disorder that affects women of various ages and impacts all aspects of life. Our aim was to evaluate the non-invasive erbium:yttrium-aluminum-garnet (Er:YAG) laser that exploits its thermal effect and has been used in reconstructive and rejuvenation surgery as a potential treatment strategy for stress UI (SUI) and mixed UI (MUI).

STUDY DESIGN/MATERIALS AND METHODS

We included 175 women (aged 49.7 ± 10 years) with newly diagnosed SUI (66% of women) and MUI (34%), respectively. Patients were clinically examined and classified by incontinence types (SUI and MUI) and grades (mild, moderate, severe, and very severe) using International Consultation on Incontinence Modular Questionnaire (ICIQ) and assessing Incontinence Severity Index (ISI). Using Er:YAG laser, we performed on average 2.5 ± 0.5 procedures in each woman separated by a 2 month period. At each session, clinical examination was performed, ICIQ and ISI assessed and treatment discomfort measured with visual analog system (VAS) pain scale, and adverse effects and patients' satisfaction were followed. Follow-ups were performed at 2, 6, and 12 months after the treatment.

RESULTS

After the treatment, ISI decreased for 2.6 ± 1.0 points in patients diagnosed with mild UI before the treatment, for 3.6 ± 1.4 points in those with moderate UI, for 5.7 ± 1.8 points in those with severe UI and for 8.4 ± 2.6 in those with very severe UI (P < 0.001, paired samples t-test). Altogether, in 77% patients diagnosed with SUI, a significant improvement was found after treatment, while only 34% of women with MUI exhibited no UI at one year follow-up. Age did not affect the outcome. No major adverse effects were noticed in either group.

CONCLUSION

The results of our study, have shown that new non-invasive Er:YAG laser could be regarded as a promising additional treatment strategy for SUI with at least one year lasting positive effects. On the other hand, it does not seem appropriate for treating MUI.

Internal anal sphincter augmentation and substitution

There is an increasing recognition of the importance of internal anal sphincter (IAS) dysfunction presenting as passive faecal incontinence. This problem may manifest after anal sphincterotomy or following the more minimally invasive operations for haemorrhoids, as well as with advancing age. Because of the poor results of IAS plication and the beneficial outcomes with peri-urethral bulking agents in urology, these materials have been developed for use in IAS dysfunction. This review outlines the basic purported mechanisms of action, defining the materials in clinical use, their methods of deployment, complications and reported outcomes. There is still much that is unknown concerning the ideal agent or the volume and the technique of deployment, which will only be answered by powerful, prospective, randomized, controlled trials. The specific role of autologous stem cells designed to regenerate the sphincters in cases of functional impairment or muscle loss is yet to be seen.

Laparoscopic surgery of vesicoureteral reflux: an experience in 42 patients with the Lich-Gregoir extravesical technique

INTRODUCTION

Vesico-ureteral reflux (VUR) is a common congenital anomaly of the urinary tract in the pediatric population, existing controversy regarding its management. Patients selected for treatment options are offered, from endoscopic injection of substances sub-ureteral to ureteral reimplantation surgery.

OBJECTIVE

To evaluate the use of the laparoscopic surgical technique for the treatment of vesico-ureteral reflux, with an analysis of the procedure, results and complications.

MATERIAL AND METHODS

We evaluated a series of 50 ureteral units in 42 patients, who undergoing laparoscopic transperitoneal ureteral reimplant, using the classic technique of Lich-Gregoir detrusorrafia.

RESULTS

The mean operative time was 74 min. There were no intraoperative nor immediate postoperative. At longer follow-up VUR was cured in all cases.

CONCLUSIONS

Laparoscopic surgery is an effective alternative in the surgical treatment of vesico-ureteral reflux, with results comparable to open surgery techniques and over sub-ureteral injection techniques.

Endoscopic treatment of vesicoureteral reflux in children with posterior urethral valves

PURPOSE

We reviewed the clinical outcome of endoscopic injection therapy in children with vesicoureteral reflux persisting after posterior urethral valve ablation.

METHODS

We retrospectively reviewed the charts of 16 patients with posterior urethral valves who have undergone endoscopic injection to correct persistent reflux after successful relief of urethral obstruction. Breakthrough urinary tract infections, persistent high-grade reflux and failed ureteroneocystostomy were the indications of endoscopic antireflux surgery.

RESULTS

Reflux was grade I in 1, grade II in 3, grade III in 11 and grade IV in 4 ureters. Mean age at injection was 6.9 ± 3.8 years and the mean interval from initial intervention to injection was 4.3 ± 2.4 years. Injected material was dextranomer/hyaluronic acid in the majority (87.5 %) of cases. Reflux was resolved or downgraded in 12 ureters (63.1 %) after a single injection. All failed cases had urodynamically documented bladder dysfunction.

CONCLUSION

More than half of the patients with vesicoureteral reflux, persisting after initial valve ablation, showed complete resolution or significant downgrading in their reflux grade after endoscopic injection. Given the technical difficulties and potential complications of open surgical reimplantation in valve patients, endoscopic subureteral injection can be considered as an effective alternative to cure persistent vesicoureteral reflux.

Periurethral abscess following polyacrylamide hydrogel (Bulkamid) for stress urinary incontinence

Bulkamid is a periurethral bulking agent used to treat stress urinary incontinence (SUI). Manufacturers describe it as nontoxic, nonbiodegradable and biocompatible. Periurethral abscesses are one of the known complications of bulking agents. We present the first reported case of periurethral abscess following Bulkamid injection. The woman had previously had a transobturator tape (TOT) and total vaginal mesh repair. At 6 weeks after injection of the bulking agent, she reported 100 % cure of her SUI. Transperineal ultrasound was used to diagnose and monitor an abscess that developed anterior and lateral to the urethra and separate from the TOT. Magnetic resonance imaging was helpful in delineating the extent of the abscess into the retropubic space but was not able to identify the urethra or the TOT. Surgical drainage of the abscess was performed vaginally, resulting in successful resolution of pain but recurrence of incontinence.

Autologous Bone Marrow-Derived Cells Regenerate Urethral Sphincters

Regenerative medicine based on tissue engineering and/or stem cell therapy techniques has the potential to improve irreversibly damaged tissues. Surgical injury to the lower urinary tract can occur as a result of radical prostatectomy or bladder neck surgery. Regeneration of urethral sphincters could be an effective treatment for post-surgical intrinsic sphincter deficiency (ISD)-related urinary incontinence. The replacement, enhancement, and/or recovery the urethral sphincter striated and smooth muscles could increase urethral closure pressure to help patients regain continence. Stem cells from muscle-derived satellite or adipose-derived mesenchymal cells provide temporary improvement in urethral closure pressure but do not reconstruct the muscle layer structures. Our strategy to accomplish regeneration of urethral sphincters is the utilization of autologous bone marrow-derived cells. We have developed a freeze injury model of ISD in rabbits. Freezing of the urinary sphincter causes loss of the majority of striated and smooth muscle cells, and causes a significant decrease in leak point pressure. In this review, we show that the autologous bone marrow-derived cells implanted within the freeze-injured sphincters differentiate into striated or smooth muscle cells. These cells then develop to reconstitute muscle layer structures within the sphincter. Furthermore, the leak point pressure of cell-implanted rabbits is significantly higher than that of cell-free injected controls. We conclude that implantation of autologous bone marrow-derived cells could be an effective treatment for human post-surgical ISD-related urinary incontinence.

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

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

Urethral injection therapy for urinary incontinence in women

BACKGROUND

Periurethral or transurethral injection of bulking agents is a minimally invasive surgical procedure used for the treatment of stress urinary incontinence in adult women.

OBJECTIVES

To assess the effects of periurethral or transurethral injection therapy on the cure or improvement of urinary incontinence in women.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Trials Register (searched 8 November 2010) and the reference lists of relevant articles.

SELECTION CRITERIA

All randomised or quasi-randomised controlled trials of treatment for urinary incontinence in which at least one management arm involved periurethral or transurethral injection therapy.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed methodological quality of each study using explicit criteria. Data extraction was undertaken independently and clarification concerning possible unreported data sought directly from the investigators.

MAIN RESULTS

Excluding duplicate reports, we identified 14 trials (excluding one that was subsequently withdrawn from publication and not included in this analysis) including 2004 women that met the inclusion criteria. The limited data available were not suitable for meta-analysis because they all came from separate trials. Trials were small and generally of moderate quality.One trial of 45 women that compared injection therapy with conservative treatment showed early benefit for the injectable with respect to continence grade (risk ratio (RR) 0.7, 95% confidence interval (CI) 0.52 to 0.94) and quality of life (RR 0.54, 95% CI 0.16 to 0.92). Another, comparing Injection of autologous fat with placebo, terminated early because of safety concerns. Two trials that compared injection with surgical management found significantly better objective cure in the surgical group (RR 4.77, 95% CI 1.96 to 11.64; and RR 1.69, 95% CI 1.02 to 2.79), although the latter trial data did not reach statistical significance if an intention-to-treat analysis was used.Eight trials compared different agents and all results had wide confidence intervals. Silicone particles, calcium hydroxylapatite, ethylene vinyl alcohol, carbon spheres and dextranomer hyaluronic acid combination gave improvements which were not shown to be more or less efficacious than collagen. Dextranomer hyaluronic acid compound treated patients appeared to have significantly higher rates of injection site complications (16% with the hyaluronic acid compound versus none with collagen; RR 37.78, 95% CI 2.34 to 610) and this product has now been withdrawn from the market.A comparison of periurethral and transurethral methods of injection found similar outcomes but a higher (though not statistically significant) rate of early complications in the periurethral group. One trial of 30 women showed a weak (but not clinically significant) advantage for patient satisfaction (data not suitable for analysis in Revman) after mid-urethral injection in comparison to bladder neck injection but with no demonstrable difference in continence levels.

AUTHORS' CONCLUSIONS

The available evidence base remains insufficient to guide practice. In addition, the finding that placebo saline injection was followed by a similar symptomatic improvement to bulking agent injection raises questions about the mechanism of any beneficial effects. One small trial comparing silicone particles with pelvic floor muscle training was suggestive of benefit at three months but it is not known if this was sustained, and the treatment was associated with high levels of postoperative retention and dysuria. Greater symptomatic improvement was observed with surgical treatments, though the advantages need to be set against likely higher risks. No clear-cut conclusions could be drawn from trials comparing alternative agents, although dextranomer hyaluronic acid was associated with more local side effects and is no longer commercially available for this indication. There is insufficient evidence to show superiority of mid-urethral or bladder neck injection. The single trial of autologous fat provides a reminder that periurethral injections can occasionally cause serious side effects.

A prospective non-randomized two-centre study of patients with passive faecal incontinence after birth trauma and patients with soiling after anal surgery, treated by elastomer implants versus rectal irrigation

AIM

This study is a prospective evaluation of patients with passive faecal incontinence and patients with soiling treated by elastomer implants and rectal irrigation.

PATIENTS AND METHODS

Patients with passive faecal incontinence after birth trauma resulting from a defect of the internal sphincter and patients with soiling after previous anal surgery were included. All patients underwent endo-anal ultrasound, magnetic resonance imaging, and anal manometry. The patients with passive faecal incontinence were initially treated by anal sphincter exercises and biofeedback therapy during half a year. The patients completed incontinence scores, a quality of life questionnaire, and a 2-week diary card.

RESULTS

The elastomer group consisted of 30 males and 45 females with a mean age of 53 years (25-77). The rectal irrigation group consisted of 32 males and 43 females with a mean age of 50 years (25-74). At 6 months follow-up, 30 patients with soiling of the rectal irrigation group and only nine patients of the elastomer group were completely cured (p = 0.02). Only three patients with passive faecal incontinence were cured in the rectal irrigation group and none in the elastomer group. Three distal migrations of elastomer implants required removal at follow-up.

CONCLUSIONS

After patients had performed anal sphincter exercises, no clear improvement of passive faecal incontinence was obtained by elastomer implants or rectal irrigation. However, rectal irrigation is far more effective than elastomer implants in patients with soiling.

Local giant cell foreign body reaction after silicone injection for fecal incontinence in humans: two case reports

Since the 1990s, one of the methods used for treating fecal incontinence due to internal anal sphincter defects has been the injection of bulking agents. The aim of this paper is to report two cases of local giant cell foreign body reaction after injection of PTQ(TM) in humans. To the best of the authors' knowledge, this is the first report of an adverse immune response to silicone injection in humans.

Endoscopic sealing of bronchopleural fistulas with submucosal injection of a tissue expander: a novel technique

The occurrence of a bronchopleural fistula (BPF) continues to represent a challenging management problem, and is associated with high morbidity and mortality. A novel and successful technique that uses submucosal injection of a tissue expander for bronchoscopic occlusion of BPFs has been designed. This method may be used either alone or in combination with bronchoscopic instillation of n-butyl-cyanoacrylate glue. The occlusion technique is described, with a presentation of two patients who were successfully treated with this method. The submucosal injection of a tissue expander is an effective, economical and minimally invasive technique for managing BPFs.

Effect of the Macroplastique Implantation System for stress urinary incontinence in women with or without a history of an anti-incontinence operation

INTRODUCTION AND HYPOTHESIS

We evaluated the outcomes and the effect of the Macroplastique Implantation System on the quality of life in women with stress incontinence with or without a history of an anti-incontinence operation during 12 to 62 months follow-up.

METHODS

Thirty-five women with urodynamically proven stress incontinence with intrinsic sphincter deficiency were included in this study. Macroplastique injection was performed in all patients. Quality of life was evaluated prior to therapy, in early postoperative time (at the sixth weeks) and in late postoperative time (12 to 62 months follow-up) with the use of three different questionnaires: Incontinence Quality-of-Life Questionnaire (I-QOL), Incontinence Impact Questionnaire-7 (IIQ-7), and Urogenital Distress Inventory-6 (UDI-6). Questionnaires were also compared with those previous to the anti-incontinence operation and to the primary procedure groups.

RESULTS

The median age of the women was 50.00 (interquartile range = 17.00) years. There were 24 primary procedures and 11 had undergone previous anti-incontinence surgery. Maximum follow-up time was 62 months, minimum follow-up time was 12 months, and the median follow-up time of the study was 58 (interquartile range = 44-60) months. When preoperative and postoperative median of the I-QOL, IIQ-7, and UDI-6 scores were compared, the differences between scores were found to be statistically significant. I-QOL, IIQ-7, and UDI-6 scores were related to the previous surgery. The overall I-QOL, IIQ-7, and UDI-6 summary scores showed high internal consistency.

CONCLUSIONS

The Macroplastique injection system is an effective, safe, and acceptable option for stress urinary incontinence in women with or without a history of an anti-incontinence operation. Moreover, it can be performed under local anesthesia without cystoscopic guidance; moreover, side effects are rare.

Implantation of autologous bone-marrow-derived cells reconstructs functional urethral sphincters in rabbits

The purpose of this study was to determine if implantation of autologous bone-marrow-derived cells has the potential to treat stress urinary incontinence caused by intrinsic sphincter deficiency. Bone marrow cells harvested from femurs of New Zealand White rabbits were cultured for 10 days. Seven days before implantation, the urethral sphincters located at the internal urethral orifice were cryo-injured by spraying liquid nitrogen for 15 s. The cultured autologous bone-marrow-derived cells were implanted 7 days after cryo-injury. For controls, cell-free solutions were injected. At 7 and 14 days after implantation, leak point pressures were determined and the urethral sphincters were examined by immunohistochemistry. At 7 and 14 days, the cell-implanted regions contained numerous striated and smooth muscle-like cells expressing myoglobin and smooth muscle actin, respectively. The proportions of myoglobin- and smooth muscle actin-expressing areas in both the 7- and 14-day cell-implanted regions were significantly higher than in controls. By 14 days, these differentiated cells formed contacts with similar cells, creating layered muscle structures. At that time, the leak point pressure of the cell-implanted rabbits was significantly higher than that of the controls. In conclusion, autologous bone-marrow-derived cells can reconstruct functional urethral sphincters.

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

INTRODUCTION AND HYPOTHESIS

To investigate the long-term safety and efficacy of transurethral injection of NASHA/Dx gel in women suffering from stress urinary incontinence (SUI).

METHODS

Women with SUI treated with NASHA/Dx gel via the transurethral Implacer device at Mayday University Hospital between November 2002 and December 2003 had long-term outcomes of therapy evaluated.

RESULTS

Eighteen of 21 were followed-up at mean 6.7 years (±SD 0.15). One year after the injection, 11/21 (52.3%) reported improvement. Of the women, 6/21 (28.5%) had a repeat injection and seven (33.3%) women experienced adverse events in the form of periurethral swellings. At 6.7 years, only one of seven women was continent of urine without requiring any further continence procedure, 44.4% were still experiencing SUI symptoms. Nine of 18 (42.8%) had undergone other continence procedures.

CONCLUSION

Transurethral injection of NASHA/Dx gel in women with SUI is associated with complications and not effective in the long term.

Tissue integration of polyacrylamide hydrogel: an experimental study of periurethral, perivesical, and mammary gland tissue in the pig

BACKGROUND Polyacrylamide hydrogel (PAAG) is a nondegradable water-based polymer with high viscoelasticity. The gel is used as a tissue filler, the only risk being prolonged infection with anaerobic, contaminating microorganisms if not treated early with broad-spectrum antibiotics. OBJECTIVE With silicone gel as reference, PAAG tissue integration and migration was studied in a longitudinal study of the pig. MATERIALS AND METHODS Forty-one pigs were used. PAAG and silicone gel were injected into mammary tissue, and PAAG was injected into urethral or bladder wall or the anal canal. Tissues and regional lymph nodes were examined at 1, 1(1/2), 3, 3(1/2), 6, 12, and 14 months, and other lymph nodes and organs were examined at 1, 6, 12, and 14 months. RESULTS PAAG was invaded by macrophages and giant cells that were gradually replaced by a network of fibrous tissue. Silicone gel was seen inside these cells or as large vacuoles, surrounded by a fibrous capsule. Regional lymph nodes contained PAAG only at 1 1/2 months and silicone gel at 12 months. CONCLUSION PAAG is a stable, viscoelastic bulking agent, which unlike silicone gel is slowly integrated within its host tissue via a thin fibrous network. Long-term risk of fibrosis and migration is minimal.

Extravesical seromuscular ureteroneocystostomy: an effective and simple operation for treatment of vesicoureteral reflux

PURPOSE

To evaluate the success rate of extravesical seromuscular ureteroneocystostomy in the treatment of children with vesicoureteral reflux (VUR).

PATIENTS AND METHODS

In a prospective study from August 2005 to January of 2006, 15 patients (11 girls, 4 boys), median age of 9.5 years (range: 1-24 years), with high-grade VUR underwent operation. Urinary tract ultrasonography and voiding cystoureterography (VCUG) were the main diagnostic tools to detect VUR before the operation and at 3 months after the operation.

RESULTS

No VUR was detected at evaluation of 3-month postoperative VCUGs (14 cases, 93%). However, one child (7%) still had persistent VUR. This patient underwent reoperation and the length of the seromuscular tunnel was increased more with a favorable result. The overall success rate of this technique was about 93%.

CONCLUSION

Extravesical seromuscular ureteroneocystostomy is simple and effective method for the treatment of VUR in children.

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.

An overview of stress urinary incontinence treatment in women

Stress urinary incontinence (SUI) is common in women, but it is under-reported and under-treated. We review here the management of SUI in women. Pelvic floor muscle training treats SUI in the majority of female patients, whereas anti-SUI devices are not widely accepted. Duloxetine has been approved for treating SUI. Suburethral slings have revolutionized the surgical management of SUI with durable efficacy, in contrast with injectable bulking agents.

Periurethral injection therapy for urinary incontinence in women

BACKGROUND

Periurethral or transurethral injection of bulking agents is a surgical procedure most often used for the treatment of stress urinary incontinence a common, troublesome symptom amongst adult women.

OBJECTIVES

To assess the effects of periurethral/transurethral injection therapy in the treatment of urinary incontinence in women.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group Specialised Trials Register (28 February 2007), MEDLINE (January 1996 to March 2007, PREMEDLINE (7 February 2007) and the reference lists of relevant articles.

SELECTION CRITERIA

All randomised or quasi-randomised controlled trials of treatment for urinary incontinence, in which at least one management arm involved periurethral/transurethral injection therapy.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed methodological quality of each study using explicit criteria. Data extraction was undertaken independently using a standard form and clarification concerning possible unreported data sought directly from the investigators.

MAIN RESULTS

We identified twelve trials including 1318 women that met the inclusion criteria. The limited data available were not suitable for meta-analysis. Injection of autologous fat was compared to placebo in a study of 68 women which was terminated early because of safety concerns. No differences in subjective or objective outcome were found in the two groups. No studies were found comparing injection therapy with conservative treatment. Two studies that compared injection with surgical management found significantly better objective outcome in the surgical group. Eight studies compared different agents - all results had wide confidence intervals. Silicone particles, calcium hydroxylapatite, ethylene vinyl alcohol and carbon spheres gave improvements equivalent to collagen. Porcine dermal implant gave improvements comparable to silicone at six months. A comparison of periurethral and transurethral methods of delivery of the bulking agent found similar outcome but a higher rate of early complications in the periurethral group.

AUTHORS' CONCLUSIONS

Despite five additional trials, this updated review is still an unsatisfactory basis for practice. The trials were small and generally of moderate quality. The only evidence of benefit comes for within-group short-term changes following injection. The finding that placebo saline injection was followed by a similar symptomatic improvement questions the mechanism of any effects. There were no trials in comparison with pelvic floor muscle training -the obvious non-surgical comparator. Greater symptomatic improvement was observed after surgery, although these advantages need to be set against likely higher risks. No clear-cut conclusions could be drawn from trials comparing alternative agents; one small trial suggests that periurethral injection may carry more risks than transurethral injection. The single trial of autologous fat provides a reminder that periurethral injections can occasionally cause serious side-effects. Pending further evidence, injection therapy may represent a useful option for short-term symptomatic relief amongst selected women with co-morbidity that precludes anaesthesia - two or three injections are likely to be required to achieve a satisfactory result.

Office Management of Stress Incontinence: Current and Future Role

Approximately 11 million women in the United States may be regularly incontinent. More than 80% of women decline any treatment and less than 1% undergoes surgical management. It is clear that there is a clinically unmet need and a mandate for effective, lower cost, noninvasive treatment. These demands will be met by an array of new technologies.

An exploration into patient preference for injectable therapy over surgery in the treatment of female urinary incontinence

OBJECTIVE

To explore patient preference for injectable therapy over open surgery in the treatment of urinary incontinence.

MATERIAL AND METHODS

Fifty-eight female patients presented for treatment of urinary incontinence. During the initial interview process, they were asked to quantify their preference for injectable therapy over surgery by specifying the lowest success rate they would accept and still try injectable therapy. The results were summarized and assessed in relation to patient age and history of previous urogynecologic surgery.

RESULTS

The mean lowest acceptable success rate for all 58 surveyed patients was 34%, with 23 (40%) accepting a success rate of only 10%. Although not statistically significant, the data suggested that older patients may tend to accept lower success rates than younger patients (mean of 39% for patients aged less than 60 years compared to 22% for those aged 80 years or older). There was no difference in response based on history of previous urogynecologic surgery.

CONCLUSION

Patients appear willing to accept a relatively low success rate for injectable therapy compared to open surgery.

PTQ™ Implants in the treatment of faecal soiling

Effective in the short term

Emerging periurethral bulking agents for female stress urinary incontinence: is new necessarily better?

Bulking therapy for stress urinary incontinence in women continues to evolve from the standpoint of material science. Several new materials have recently been subjected to clinical trials with the aim of assessing efficacy and safety of these agents for possible device registration. These new additions run the gamut of biologic to synthetic materials, including re-engineered carbon-coated zirconium beads, ethylene vinyl copolymer, calcium hydroxylapatite, silicone, and hyaluronic acid. Trial design and results reporting for bulking agents has also evolved, with the addition of quality-of-life and patient approbation assessments now being included with outcomes for incontinence reduction and adverse events recording. The new agents and recent studies are reviewed within a context of the prior evidence that has supported the use of the bulking strategy for management of symptomatic stress incontinence. Several recent trials have also compared bulking agents with surgical interventions from effectiveness, approbation, and cost vantage points so as to better determine the reasonability of bulking agent use in an era of minimally invasive incontinence surgery.

Magnetic resonance imaging to evaluate NASHA/Dx gel (Zuidex) for stress urinary incontinence

The Zuidex system for the treatment of stress urinary incontinence consists of non-animal stabilised hyaluronic acid/dextranomer (NASHA/Dx) gel and a precision guide, the Implacer. Whether the Implacer accurately deposits NASHA/Dx gel in the desired location within the urethral wall was investigated by magnetic resonance imaging (MRI), performed at a mean of 35 days post-treatment. Three or more deposits were observed in 11 of 16 patients (68.8%), with 39 of the 50 deposits clearly located within the urethral wall, as intended. Fourteen of 16 patients (87.5%) demonstrated improvement in their incontinence at 3 months, sustained at 12 months in 13 patients. No significant correlations between total implant volume and improvements in incontinence were observed at 3 months (p > or = 0.16) and 12 months (p > or = 0.30). In conclusion, accurate placement of NASHA/Dx gel into the desired location within the urethral wall was achieved in the majority of cases using the Implacer device, without endoscopic guidance.

Injectable biomaterials for incontinence and vesico-ureteral reflux: current status and future promise

Many injectable biomaterials have been produced as bulking agents for compression of urethral sphincter or ureteral orifice for treating adult stress incontinence or vesico-ureteral reflux in pediatrics. The agents being developed include glutaraldehyde crosslinked collagen, dextranomer/hyaluronic acid copolymer, pyrolytic carbon-coated zirconium oxide beads, polydimethyl-siloxane microparticles, polytetrafluoroethylene paste, autologous fats, autologous chondrocytes, and others. Though less invasive nature of these agents has gained their popularity as a quick solution of the disease symptoms, most of such treatments fail to produce good long-term efficacy. The failure is likely caused by the rapid degradation of material implants and the lack of tissue regeneration/integration properties. We thus believe that a good injectable biomaterial for incontinence should possess the following two properties: (1) to resist degradation and to reside in the implantation sites for a long period of time or (2) to enhance tissue regeneration and to establish permanent periurethral or subureteric tissue. Here we report some recent results for supporting this hypothesis.

Periurethral cellular injection: comparison of muscle-derived progenitor cells and fibroblasts with regard to efficacy and tissue contractility in an animal model of stress urinary incontinence

OBJECTIVES

To compare muscle-derived cells (MDCs) and fibroblasts with regard to their potential for restoration of urethral function on injection in a previously established animal model of stress urinary incontinence.

METHODS

The animals were divided into four (dosage) or five (cell concentration) experimental groups: normal, nontreated controls (normal group) or bilateral sciatic nerve transection with either periurethral injection of saline (saline group), MDCs (MDC group), fibroblasts (fibroblast group), or MDC/fibroblast mixture (mixed group). At 4 weeks after injection, the leak point pressure (LPP) was measured and contractility testing and histologic analysis were performed.

RESULTS

The histologic examination demonstrated muscular atrophy in the saline group and new striated muscle fibers at the sites of MDC injection in the MDC group, but not in the fibroblast group. Denervation of the urethra resulted in a significant decrease of maximal fast-twitch muscle contraction amplitude to only 9% of normal. MDC injection into the denervated urethra significantly improved the fast-twitch muscle contraction amplitude to 73% of normal. The LPP of the normal, saline, MDC, fibroblast, and mixed groups at 4 weeks after treatment was 43.3 +/- 2.5, 25.8 +/- 1.4, 38.2 +/- 4.2, 38.3 +/- 1.2, and 34.5 +/- 3.3 cm H2O, respectively. In the cell dosage experiment, the LPP increased with increases in the injected cell number. Evidence of obstruction was observed in the high-dose (1 x 10(7) cells) fibroblast group.

CONCLUSIONS

Although both MDCs and fibroblast injection increased the LPP in a stress urinary incontinence rat model, only MDCs significantly improved urethral muscle strip contractility. Moreover, urinary retention developed with high-dose fibroblast injection, but not with MDC injection.

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

OBJECTIVE

Urethral injection (periurethral/intraurethral bulking) is an established, minimally invasive therapy for stress urinary incontinence (SUI). This review aims to determine which women should potentially benefit from, and be considered as candidates for, injection therapy and to elucidate what we are trying to achieve.

METHODS

Based on MEDLINE database searches, all aspects of urethral injection were examined, including patient selection, safety, injection technique, efficacy, quality of life, goals and cost.

RESULTS

Such therapy has a low complication rate, improves or cures about 3 out of 4 women, as shown in mainly short-term studies, and improves patients' quality of life. It can be used in the majority of patients with uncomplicated SUI. Therefore, injection therapy may be considered as a first-line treatment option for patients who have failed conservative therapy such as pelvic floor exercises and who decline or have a contraindication for pharmacological treatment. However, the decision of whether to use this type of treatment must be based on an informed discussion between the physician and patient--this dialogue should incorporate questions about patients' own treatment goals. Injection therapy appears to have the profile required to meet patients' goals, based on the findings that a procedure with an improvement in incontinence, minimal short-term risk, no long-term risk, and performed in a clinic, would be acceptable.

CONCLUSION

Investigating and trying to achieve patients' own treatment goals will ultimately enable us to do what is best for our patients, but current evidence suggests that injection therapy is a valid option worth discussing with many patients.

The etiology, assessment, and treatment of fecal incontinence

Fecal incontinence is a common symptom that often impairs quality of life. It is generally caused by a variety of conditions that are associated with anorectal sensorimotor dysfunction and/or diarrhea. Assessment should be tailored to age and symptom severity. Modulation of disordered bowel habits is the key to management; biofeedback and surgery might also be beneficial.

Urinary incontinence in women

Urinary incontinence is common in women, but is under-reported and under-treated. Urine storage and emptying is a complex coordination between the bladder and urethra, and disturbances in the system due to childbirth, aging, or other medical conditions can lead to urinary incontinence. The two main types of incontinence in women, stress urinary incontinence and urge urinary incontinence, can be evaluated by history and simple clinical assessment available to most primary care physicians. There is a wide range of therapeutic options, but the recent proliferation of new drug treatments and surgical devices for urinary incontinence have had mixed results; direct-to-consumer advertising has increased public awareness of the problem of urinary incontinence, but many new products are being introduced without long-term assessment of their safety and efficacy.

Injection therapy for stress urinary incontinence in adult women

Stress urinary incontinence (SUI) is prevalent in adult women and has a considerable impact on quality of life. However, it often remains undiagnosed and therefore untreated. Noninvasive treatment is likely to be offered in mild cases and may entail pelvic floor muscle re-education, minimally invasive devices or pharmacotherapy. Surgical intervention is widely considered as the only effective option for more severe SUI, although it is not suitable for all patients. Injection therapy with urethral bulking agents represents an alternative minimally invasive procedure and can be used for all types of SUI. Many bulking agents have been developed, although the ideal remains to be discovered. The safety and durability of agents remain a concern. No differences in agents from an efficacy point of view have been found. For many years urethral injection could only be administered endoscopically. The recent development of devices for blind injection has increased the speed and convenience of urethral injection, removing the need for surgical facilities. The subjective cure rate after injection therapy is higher than the objective one. A focus on the patient's wishes and expectations with respect to success and risks of a treatment for SUI is required. In addition, randomized clinical trials are mandatory to establish the place and efficacy of urethral bulking agents compared with conservative therapy (pelvic floor muscle re-education) in treating SUI in adult women.

An open, multicentre study of NASHA/Dx Gel (Zuidex) for the treatment of stress urinary incontinence

OBJECTIVE

The Zuidex system facilitates non-endoscopic urethral injection for stress urinary incontinence (SUI). It comprises four pre-filled syringes of non-animal stabilised hyaluronic acid/dextranomer (NASHA/Dx) gel and an Implacer device. This open, 12-month study was performed to evaluate the safety and efficacy of this system in women with SUI.

METHODS

Patients were aged > or =18 years with a history of SUI for > or =12 months (hypermobility and/or intrinsic sphincter deficiency), had failed prior non-invasive therapy and were invasive-therapy naïve. Up to two treatments with NASHA/Dx gel were permissible (re-treatment was offered at week 8). Positive response to treatment was defined as a reduction in provocation test leakage of > or =50% compared with baseline. Efficacy was also measured by 24-hour pad weight test leakage, and number of incontinence episodes/24 hours.

RESULTS

A total of 142 patients were enrolled, with a mean age of 55.7 years. The response rate was 78% at week 12, and 77% at month 12. Significant reductions in median provocation test leakage, 24-hour pad-weight test leakage and number of incontinence episodes/24 hours were observed at all time-points. At month 12, the median decreases from baseline in these three variables were 93%, 89% and 67%, respectively. Treatment-related adverse events were of a nature expected with urethral injection - most were transient, and of mild or moderate intensity.

CONCLUSIONS

Treatment with NASHA/Dx gel produced large, statistically significant reductions in urinary leakage sustained over 12 months and was well tolerated. These findings suggest that NASHA/Dx gel could be considered as an early intervention in treatment-naïve cases of SUI.

Treatment of incontinence after prostatectomy using a new minimally invasive device: adjustable continence therapy

OBJECTIVE

To evaluate the safety and efficacy of a new minimally invasive urological implant for incontinence after prostatectomy.

PATIENTS AND METHODS

The adjustable continence therapy device (ProACT, Uromedica, Plymouth, MN, USA) consists of two balloons placed via a perineal approach bilaterally at the bladder neck in patients after prostatectomy. Titanium ports, attached via discrete tubing to each balloon, are placed in the scrotum, allowing for separate volume adjustments of the balloons at any time during and after surgery. Changes in a quality-of-life questionnaire (I-QoL), pad usage and a subjective continence grading score were assessed in 117 consecutive men after implanting the Pro-ACT, at baseline and at 1, 3, 6, 12 and 24 months.

RESULTS

After a mean (range) follow-up of 13 (3-54) months and with a mean of 3 (0-15) adjustments, 67% of men were dry, using at most one 'security' pad daily; 92% were significantly improved, and 8% showed no improvement. The I-QoL score improved from a median of 34.7 to 66.3 after 2 years (42 men; P < 0.001), the daily pad count decreased from a mean of 6 (1-24)/day to 1 (0-6)/day at 2 years (P < 0.001). Continence achieved at < or = 6 months after implantation through incremental adjustment remained durable at > or = 2 years in most patients. There were complications during and after surgery in 54 patients, mostly minor and decreasing with increasing expertise, primarily reflecting the development and refinement of the new surgical technique and its instrumentation. Re-implantation for complications was required in 32 patients, with a 75% success rate.

CONCLUSIONS

The ProACT peri-urethral prosthesis produces durable outcomes equivalent or better than other minimally invasive treatments for incontinence after prostatectomy. Its unique design allows for easy adjustment after surgery to achieve the desired urethral resistance, with no further surgical intervention, thus allowing for an optimum balance between voiding pressures and continence. The promising results reported here suggest that this may be an appropriate, effective and durable first-line treatment to offer men with stress urinary incontinence after prostatectomy.

Urethral Bulking Agents: Imaging Review

OBJECTIVE

At imaging, injectable bulking materials used for urinary incontinence have the potential to mimic urethral and periurethral pathology. This article elucidates the appearance of the most commonly used agents in multiple techniques and helps the practicing radiologist avoid potential diagnostic pitfalls.

CONCLUSION

Carbon-coated microbeads (Durasphere) and cross-linked bovine collagen (Contigen) have fairly characteristic imaging appearances and can in most cases be differentiated from true pathology.