GAX collagen in the treatment of urinary incontinence in elderly women: a two year follow up

Stress urinary incontinence in females. Diagnosis and treatment modalities – past, present and the future

Introduction:

Stress urinary incontinence (SUI) can be defined as involuntary and unintentional loss of urine through the urethra when vesical pressure exceeds the urethral sphincter pressure during instances of coughing, sneezing or physical exercise. Stress urinary incontinence is the most common form of incontinence in females with an estimated prevalence of 4.5–53% in adult women with urinary incontinence. Yet despite its distressing nature and a negative impact on quality of life, very few women present with their symptoms to a urologist.

Materials and methods:

A literature search of the MEDLINE, Cochrane Library, Embase, NLH, ClinicalTrials.gov and Google Scholar databases was done up to November 2020, using terms related to SUI, medical therapy, surgical therapy and treatment options. The search terms included female stress urinary incontinence, mid-urethral sling, tension-free vaginal tape and trans obturator tape. The search included original articles, reviews and meta-analyses.

Conclusion:

Current guidelines for the management of stress urinary incontinence propose a step-ladder pattern, based on treatment invasiveness starting from conservative therapies, then drugs followed by minimally invasive procedures and culminating in invasive surgeries. The surgical approach is to be considered only after conservative therapies fail. The recent advances in the treatment of stress urinary incontinence have brought to light newer modalities and newer technologies that can be utilized which include laser therapy, stem cell therapy, intravesical balloon and others that show a lot of promise. This paper provides an in-depth analysis and reviews the literature on the current modalities and the future prospects of female stress urinary incontinence.

Level of evidence:

Not applicable for this review article.

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.

Stress urinary incontinence and overactive bladder syndrome: current options and new targets for management

In the United States, office visits for women seeking treatment for urinary incontinence more than doubled between 1994 and 2000, from 1845 per 100 000 women. This review article addresses treatment options for 2 common types of incontinence in women: stress urinary incontinence (SUI) and detrusor overactivity (DO), commonly referred to as urge urinary incontinence (UUI). In the past, those with SUI typically faced limited treatment options, such as Kegel exercises, pessaries, or major surgery (Burch or Marshall-Marchetti-Krantz operations). However, treatment options for women also included anticholinergic medications, behavioral therapy, and implantable neuromodulation. In recent years, more options have become available. For women with SUI, a variety of minimally invasive synthetic midurethral sling approaches (eg, retropubic, transobturator, and single incision) and office-based procedures (eg, periurethral injection of bulking agents and radiofrequency collagen denaturation [Renessa®; Novasys Medical]) are now offered. More outpatient options will hopefully be available soon, including an inflatable, free-floating balloon to act as a shock absorber, and injection of muscle-derived stem cells into the periurethral tissue. Women with UUI now have targeted options, such as posterior tibial nerve stimulation (PTNS) and intravesical injections of onabotulinumtoxinA (Botox®; Allergan, Inc.), in addition to nonoral systemic medications.

Nonsurgical transurethral radiofrequency collagen denaturation: results at three years after treatment

Objective. To assess treatment efficacy and quality of life in women with stress urinary incontinence 3 years after treatment with nonsurgical transurethral radiofrequency collagen denaturation. Methods. This prospective study included 139 women with stress urinary incontinence due to bladder outlet hypermobility. Radiofrequency collagen denaturation was performed using local anesthesia in an office setting. Assessments included incontinence quality of life (I-QOL) and urogenital distress inventory (UDI-6) instruments. Results. In total, 139 women were enrolled and 136 women were treated (mean age, 47 years). At 36 months, intent-to-treat analysis (n = 139) revealed significant improvements in quality of life. Mean I-QOL score improved 17 points from baseline (P = .0004), while mean UDI-6 score improved (decreased) 19 points (P = .0005). Conclusions. Transurethral collagen denaturation is a low-risk, office-based procedure that results in durable quality-of-life improvements in a significant proportion of women for as long as 3 years.

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.

Urethral injection therapy: what is the mechanism of action?

AIMS

The mechanism of action of injection therapy is virtually unknown. Urethral Pressure Reflectometry (UPR) is a novel technique for measuring pressure and cross-sectional area in the urethra. UPR which provides reliable physiological meaningful parameters was used to study the mechanism of urethral injection therapy.

MATERIALS AND METHODS

Fifteen patients with stress urinary incontinence (nine women) and mixed incontinence (six women) were investigated with UPR before and 101 days after urethral injection therapy. The patients subjectively judged if their stress and urge symptoms were cured/improved almost unchanged or worsened.

RESULTS

Ten women were cured/improved after the injection therapy. None became worse. Six patients had urge symptoms before injection therapy which did not change after the procedure. The patients were divided into two groups based on their subjective assessments of effect. One group with effect (10 women) and 1 group without effect (5 women). The patients had significantly higher squeezing opening pressure after the treatment. The other parameters were unchanged. The mean squeezing opening pressure increased significantly (P < 0.01) more in the group of patients with effect (10.6 cmH(2)O) than in the group without effect (-1.6 cmH(2)O).

CONCLUSION

Injection therapy may work by increasing the power of the urethral sphincter. The bulking material may function as additional central filler volume which increase the length of the muscle fiber and thereby the power of the sphincter.

Nonsurgical transurethral collagen denaturation for stress urinary incontinence in women: 12-month results from a prospective long-term study

STUDY OBJECTIVE

To assess efficacy of nonsurgical transurethral collagen denaturation (Renessa) in women with stress urinary incontinence (SUI) caused by bladder outlet hypermobility.

DESIGN

Continuing, prospective, 36-month, open-label, single-arm clinical trial. Twelve-month results from intent-to-treat (ITT) analysis are reported. Canadian Task Force classification II-2.

SETTING

Thirteen physician offices or ambulatory treatment centers.

PATIENTS

Women with SUI secondary to bladder outlet hypermobility for 12 months or longer who failed earlier conservative treatment and had not received earlier surgical or bulking agent therapy.

INTERVENTIONS

Women were treated as outpatients and received an oral antibiotic and local periurethral anesthesia before undergoing treatment with transurethral radiofrequency collagen denaturation.

MEASUREMENTS AND MAIN RESULTS

Voiding diaries and in-office stress pad weight tests yield objective assessments. Subjective measures include the Incontinence Quality of Life (I-QOL), Urogenital Distress Inventory (UDI-6), and Patient Global Impression of Improvement (PGI-I) instruments. In total, 136 women received treatment (ITT population). Patients experienced significant reductions versus baseline in median number of leaks caused by activity/day and activity/week (p <.0026 for both), with 50% of patients reporting 50% or more reduction. Pad weight tests revealed that 69% of women had 50% or more reduction in leakage (median reduction 15.2 g; p <.0001); 45% were dry (29% no leaks; 16% < 1-g leakage). Significant improvements occurred in median scores on the I-QOL (+9.5 [range -66.0 to 91.0]; p <.0001) and mean scores on the UDI-6 (-14.1 +/- 24.7; p <.0001). Furthermore, 71.2% showed I-QOL score improvement, including 50.3% with 10-point or greater improvement, and 49.6% reported on the PGI-I that they were "a little," "much," or "very much" better.

CONCLUSION

At 12 months, treatment of SUI with nonsurgical transurethral collagen denaturation resulted in significant improvements in activity-related leaks and quality of life.

Laparoscopic Burch colposuspension after failed sub-urethral tape procedures: a retrospective audit

Our objective was to evaluate the outcome of laparoscopic Burch colposuspension in women with recurrent stress urinary incontinence after failed primary sub-urethral tape procedures. A total of 16 patients were identified, and their data from symptom-specific questionnaires, urodynamic studies and urogynaecological assessment were collected. At a median follow-up of 24.5 months, objective and subjective cure rates were 54.5% and 92.9%, respectively. Average satisfaction score regarding outcome after surgery was 9.3 on a rating scale from 0 to 10. All but one patient had symptoms of urge incontinence pre-operatively with 64.3% experiencing cure or improvement post-operatively. Voiding difficulties were observed in one patient, and post-operative urodynamics revealed a significant decrease in urinary flow rate (p < 0.05) but with no difference in urinary residuals or maximum urethral closure pressure. Severe peri-urethral fibrosis was identified in 62.5% of the patients. Laparoscopic Burch colposuspension is an effective and safe surgical option.

Stress urinary incontinence in women: what options lie between traditional therapies and surgery?

Stress urinary incontinence affects women of all ages, becoming more prevalent with increasing age. While many nonsurgical therapies are available for the treatment of stress urinary incontinence, options are limited for women who fail to respond to these therapies yet may not be candidates for, or wish to avoid, surgery. This limitation prompted efforts to develop less-invasive procedures for treating stress urinary incontinence patients, including bulking-agent injections and a new transurethral, radiofrequency collagen-denaturation system. This new treatment (Renessa((R))) reduces tissue compliance without necrosis or stricture, thus differentiating it from a surgical radiofrequency treatment, transvaginal radiofrequency tissue ablation. The advent of new treatment options for stress urinary incontinence allows physicians to offer their patients a broader choice of treatment options, underscoring the importance of educating patients regarding all available therapies, including success rates and risk for complications. This is particularly important for women who have not responded to prior treatment strategies.

Comparison of the precision of transurethral endoscopic versus ultrasound-guided application of injectables

OBJECTIVE

To compare the precision of transurethral endoscopic- vs ultrasound (US)-guided injections, as transurethral application of various injectables under endoscopic view are widely used to treat urinary incontinence.

MATERIAL AND METHODS

Bovine collagen was injected into the lower urinary tract in 20 dead female pigs. In each pig five depots of collagen were injected and there were five pigs in each group. In group I collagen was injected into the urethral wall under endoscopic control. In group II collagen depots were injected periurethrally under endosocopic guidance. In group III collagen was injected into the urethral wall under US control. In group IV collagen depots were injected periurethrally under US guidance. A transurethral US probe (6 F, 15 MHz) and injection device were used for transurethral US-guided injections. In all pigs the urethra and the periurethral tissue were removed after injection and investigated using anatomical preparations and histological sections.

RESULTS

In group I only two collagen depots were actually located in the urethral wall in two pigs (two of 25 depots, 8%). In group II five depots in two pigs were located in the urethral wall (five of 25 depots, 20%). The periurethral collagen depots were found to spread out in the loose connective and fat tissue around the urethra. In group III all US-guided injections of collagen were situated in the urethral wall and in group IV they were all located periurethrally.

CONCLUSIONS

The present study shows that endoscopic application of injectables is an inaccurate technique, while US-guided injections are precise. US-guided injection enables excellent control of the therapeutic procedure.

Treatment options for patients with suboptimal response to surgery for stress urinary incontinence

BACKGROUND

Many women with stress urinary incontinence (SUI) undergo surgery to relieve their symptoms. Currently, tension-free vaginal tape or transobturator tape sling procedures are the surgical treatments of choice. Although these procedures are often successful, a growing number of women experience suboptimal results ranging from improvement without cure to postoperative failure. Follow-up surgery often improves residual or recurrent symptoms but generally carries lower success rates and higher complication risks. Additionally, many women with suboptimal results are reluctant to undergo further surgery.

SCOPE

A PubMed literature search for studies of SUI treatment options published from 1986 to 2006 was performed.

FINDINGS

The literature revealed a gap in published studies addressing non-surgical options for patients with failed SUI surgeries. Studies of non-surgical treatments for SUI often exclude women who have had prior surgeries, or do not analyze this subgroup. It is, therefore, difficult to assess non-surgical treatment options for women with failed surgeries. Women whose residual or recurring SUI is attributable to intrinsic sphincter deficiency may instead elect the injection of a bulking agent. Bulking agents are associated with a low rate of complications but frequently require several injections to be successful. Women experiencing suboptimal surgical results whose SUI is attributable to hypermobility may select a new non-surgical treatment, radiofrequency collagen denaturation. This non-invasive procedure has also demonstrated a low rate of complications.

CONCLUSIONS

Considering the effect of SUI symptoms on women's quality of life, and with more women experiencing suboptimal results after surgery for SUI, it is important to assess alternatives to further surgery.

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.

Outcome measures and surgery for stress urinary incontinence

A large number of surgical procedures to correct urinary stress incontinence in the female have been described. There has been wide variablility in reported success rates. This variablility is due to a number of factors. Papers published in 1997 that assess outcomes in the treatment of female stress urinary incontinence illustrate many of the current problems that exist with examining outcomes, including patient selection, modifications in technique, the definition of success, how success is measured and when the outcome is assessed.

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.

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.

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.

Urological surgical techniques

Urinary tract injuries during gynaecological surgery are increasing with the advent of more complex and laparoscopic techniques; ureteric and bladder injuries are the most common. Adequate knowledge of the anatomy will help avoid some problems, but prompt recognition during surgery offers the best chance of treatment without long-term compromise. When the problems are not recognised during surgery, various techniques can be used to effect repair. Surgery for stress incontinence has undergone many changes in technique in recent years. Any procedure needs to combine a low morbidity with high long-term success rates. Colposuspension has been the 'gold standard' for many years, against which other techniques are judged. A laparoscopic approach has reduced hospital stay, although with increased morbidity. The tension-free vaginal tape technique is now widely employed as the first-line procedure. It is a relatively easy technique to learn, with a good success rate and low morbidity; long-term results are still awaited. This chapter deals with two aspects of urogynaecological surgery. The first section reviews urinary tract injuries occurring during gynaecological surgery. In the second section we look at recent developments in surgery for urinary stress incontinence.

Systematic review: efficacy of silicone microimplants (Macroplastique) therapy for stress urinary incontinence in adult women

OBJECTIVE

To assess the efficacy of silicone microimplants (Macroplastique; polydimethylsiloxane) therapy for stress urinary incontinence in adult women, using a systematic review of identified studies.

MATERIALS AND METHODS

A computer-aided and manual search for published studies investigating silicone microimplants therapy for stress urinary incontinence in adult women. The methodological quality of the included studies was assessed using criteria based on generally accepted principles of interventional research.

RESULTS

Only two RCTs, only published as an abstract, were found. Eleven pre-experimental or observational studies were identified. Overall, the methodological quality was low. The main methodological shortcomings of the studies were: no random allocation procedure, lack of prestratification on prognostic determinants, no blinding, small sample sizes, and lack of proper analysis and presentation of results. There was variability in the indication for implantation, implantation procedure, rate and volume of silicone microimplants. The use of different outcome measures in most of the trials made comparison between studies difficult.

CONCLUSIONS

Because of the low methodological quality of included studies, results should be interpreted with caution and no firm conclusions about the efficacy of silicone microimplants were possible. Randomized clinical trials, using valid and reliable subjective and objective measurements, are necessary to establish the efficacy of silicone microimplants therapy in treating stress urinary incontinence in adult women.

Trends toward less invasive treatment of female stress urinary incontinence

Recent improvements in our understanding of the underlying pathophysiologic mechanisms responsible for stress urinary incontinence (SUI) in women have led to the development of innovative new surgical methods. Many are less invasive than previous techniques and appear to offer improved safety and shorter hospital stays, while maintaining the efficacy of traditional open incontinence surgery. Procedures using injectable periurethral bulking agents, laparoscopic colposuspension, and insertion of tension-free vaginal tape characterize this current trend toward less invasive surgical treatments. The increasing range of available procedures allows surgical treatment of SUI to be individualized for the patient. Women of diverse ages and levels of medical fitness can increasingly be offered a choice of safe, effective treatment for SUI.

Beyond collagen: injectable therapies for the treatment of female stress urinary incontinence in the new millennium

Previous experience with GAX-collagen has shown that the endoscopic correction of female SUI is both possible and effective. It is clear, however, that durability remains a primary concern when implementing this approach to treatment. The availability of recently developed and newly emerging materials, carefully designed using the tenets and techniques of biotechnology and materials science, may provide solutions to some of the difficulties beleaguering this treatment option. Results with currently available injectables are summarized in Table 1. Careful review and critical analysis of new bulking agents will soon reveal which materials approach the therapeutic ideal. It is likely that the ultimate choice of a particular substance, synthetic or biologic, may best be determined by the clinical circumstances involving the individual patient.

Outcome results of transurethral collagen injection for female stress incontinence: assessment by urinary incontinence score

PURPOSE

We assessed the results of collagen injection for female sphincteric incontinence using strict subjective and objective criteria.

MATERIALS AND METHODS

We evaluated 63 consecutive women with sphincteric incontinence who underwent a total of 131 transurethral collagen injections. Sphincteric incontinence was confirmed by urodynamics. All patients were treated with 1 to 5 transurethral collagen injections and treatment outcome was classified according to a new outcome score. Cure was defined as no urinary loss due to urge or stress incontinence documented by a 24-hour diary and pad test, and patient assessment that cure was achieved. Failure was defined as poor objective results and patient assessment that treatment failed. Cases that did not fulfill these cure and failure criteria were considered improved and further classified as a good, fair or poor response.

RESULTS

Mean patient age plus or minus standard deviation was 67.7 +/- 12.8 years. All women had a long history of severe stress urinary incontinence, 18 (29%) underwent previous anti-incontinence surgery, and 41% had combined stress and urge incontinence. Preoperatively diary and pad tests revealed a mean of 7.5 +/- 4.6 incontinence episodes and 152 +/- 172 gm. of urine lost per 24 hours. Overall 1 to 5 injections were given in 26, 17, 13, 3 and 4 patients, respectively. Mean interval between injections was 4.4 +/- 5.7 months, mean followup was 12 +/- 9.6 months, and mean interval between the final injection and outcome assessment was 6.4 +/- 4.9 months. There was a statistically significant decrease in the total number of incontinence episodes per 24-hour voiding diary after each injection session. Although there was a clear trend toward decreased urinary loss per 24-hour pad test, statistical significance was not established. Using the strict criteria of our outcome score overall 13% of procedures were classified as cure, 10%, 17% and 42% as good, fair and poor, respectively, and 18% as failure.

CONCLUSIONS

As defined by strict subjective and objective criteria, we noted a low short-term cure rate after collagen injection in women with severe sphincteric incontinence. It remains to be determined how patients with less severe incontinence would fare using our outcome assessment instruments.

Injectable agents in the treatment of stress urinary incontinence in women: where are we now?

Periurethral bulking agents have been used for decades. The only currently available agents (in the United States) include glutaraldehyde cross-linked collagen, autologous fat, and carbon bead technology. Initial subjective cure rates with collagen are acceptable, but with the majority of women requiring reinjection. The risk of allergic phenomena complicates collagen use. Autologous fat injection is initially effective in >50% of women, but resorption and fibrous replacement hamper the stability of the transplanted graft. Polytetrafluoroethylene and silicone are not currently approved by the US Food and Drug Administration because of particle migration. Materials in development include biologic agents such as allogeneic human collagen and autologous cartilage. Developmental synthetic agents include microballoon technology, hyaluronic acid with or without microsphere technology, hydroxylapatite, and a variety of polymeric technologies. Patient selection and material characteristics influence the optimal choice for injectable agent.

Use of collagen for the treatment of stress urinary incontinence: an update

This article provides a comprehensive and updated overview of the current role of collagen injections in the management of genuine stress incontinence. The clinical indications for collagen injection are described, and relevant technical advances are discussed. Finally, we review the latest outcome data on the use of collagen injection, as well as the factors that affect outcome.

A multicentre evaluation of a new surgical technique for urethral bulking in the treatment of genuine stress incontinence

This prospective study assesses the surgeon and patient acceptability of a new implantation device for transurethral Macroplastique injection, as well as the safety and effectiveness of the technique. Ten women with genuine stress incontinence were recruited at each of four participating urogynaecological centres. Treatment was performed in an outpatient or day case setting and follow up took place at six weeks and three months after treatment. Those in whom treatment had failed were offered re-treatment. The operator acceptance of the device was rated as excellent or acceptable in 95% after the first treatment and 100% after re-treatment. Urethral insertions were rated acceptable in 92.5%. Pain was scored as mild to moderate in 89% of all insertions. The overall success rate was 74.3% at three months with an implantation rate of 1.35 which appears to be comparable to published endoscopic data. We have concluded from this study that the Macroplastique implantation device is safe to use and provides simplified, yet effective alternative to the endoscopic implantation of urethral bulking agents.

Collagen injection therapy in elderly women: long-term results and patient satisfaction

OBJECTIVES

To evaluate long-term results and patient satisfaction using collagen injection therapy in elderly women.

METHODS

Periurethral injection of collagen using local anesthesia was performed on 58 women 65 years old or older (range 65 to 86, mean 73. 2) to treat stress urinary incontinence. All patients underwent urodynamic evaluation. Forty-nine patients (84.5%) had intrinsic sphincteric deficiency; 9 patients (15.5%) had genuine stress urinary incontinence. Twenty-one patients (36.2%) had no urethral hypermobility using Q-tip testing, and 37 (63.8%) had urethral hypermobility.

RESULTS

At 2 months after injection, the initial response was assessed: 28 patients (48.3%) were totally dry and 18 (31.0%) were socially continent. Therapy was unsuccessful in 12 (20. 7%). To achieve continence, 1 to 4 injections (mean 1.9) were required. The average total volume to achieve success was 14.6 mL. No significant differences were observed in outcome, volume injected, or number of injections in patients with versus without urethral hypermobility. At a mean follow-up of 24.4 months (range 8 to 43), of the 46 patients who achieved continence, 19 (41.3%) developed recurrent leakage and required reinjection. The average interval to recurrence was 7.9 months (range 2 to 16). Of the 19 patients reinjected, only 8 (42.1%) regained continence. The long-term success rate after repeated injections was 35 (60.3%) of 58. An independent examiner contacted 40 patients for telephone interview. To date, 25 of the patients contacted noted a moderate or maximal level of symptom improvement, and 18 reported continued improvement in quality of life. Thirty-six patients noted minimal difficulty with the procedure, and 34 would recommend the treatment.

CONCLUSIONS

Collagen is a safe, moderately effective alternative to manage stress urinary incontinence in elderly women. Elderly patients should be counseled that approximately 40% will experience recurrent leakage, which may not resolve with reinjection.

Periurethral collagen injection: a long-term follow-up study

OBJECTIVE

To determine the long-term success of the periurethral injection of collagen (Contigen(R), Bard UK) in women with genuine stress incontinence.

PATIENTS AND METHODS

Sixty-one women with genuine stress incontinence were enrolled in a trial of periurethral collagen injections between 1 September 1990 and 31 August 1992. They were assessed at 1, 3, 6, 12 and 24 months after the last collagen injection. In 1998, their notes were reviewed, and a standardized questionnaire was sent to 46 women who were still alive and had undergone no further anti-incontinence surgery.

RESULTS

Of the 53 women who were either known failures or who had follow-up information beyond 5 years, 26% were subjectively improved. Women who had a maximum urethral closure pressure of >20 cmH2O and those who had urinary incontinence for <10 years before their first injection were more likely to have had long-term success. There was no correlation between long-term success and the number of previous operations, body mass index, age or preoperative pad loss. Neither the number of injection sessions, total volume of collagen injected nor perceived bulking at the time of surgery affected long-term success rates. Of the 14 women who considered themselves subjectively improved, seven had daily incontinence and only one was completely dry. Urinary retention and urinary tract infection were the most common complications. In addition, one woman reported a flare-up of her skin test and transient 'flu-like symptoms 2 weeks after the injection, and one woman developed a right upper lobe pneumonia 2 weeks after the collagen injection.

CONCLUSION

The long-term results of periurethral collagen injections are disappointing. We found no evidence to support the use of periurethral collagen injections in women with intrinsic sphincter deficiency, who had a higher failure rate than those with hypermobility. Further research is essential to develop agents that are not immunogenic, produce minimal inflammatory response and yet are durable.

Collagen injections for urinary stress incontinence in a small urban urology practice: time to failure analysis of 99 cases

PURPOSE

We examined the durability of collagen injection response for female incontinence using Kaplan-Meier survival statistics and the log rank test.

MATERIALS AND METHODS

A total of 99 women 26 to 84 years old (mean age 60) underwent collagen injections for urethral incompetence. In this retrospective chart audit treatment failures were analyzed using survival statistics. In addition, we conducted a sensitivity analysis of the data using a worst and best case model to account for variability of the data due to the high amount of censored observations.

RESULTS

Mean incidence of success was 56% with a mean followup of 9.5 months (95% confidence interval 0.17 to 24.6). Median duration of success was 4.7 months (95% confidence interval 3.4 to 5.9). Of the 10 time to failure function comparisons only cystometric incontinence classification had a statistically significant predictive value for treatment failures (p = 0.003). The survival analysis curve provided a 13% success probability at 18 months and was close to the worst case time to failure function.

CONCLUSIONS

Collagen injection has minimal morbidity and a low median success rate. Bladder instability, as determined by cystometrogram, is an important determinant of success. Survival statistics methods should be used more widely to describe urological outcomes because they provide dynamic and, thus, more meaningful information to urologists and patients than summary statistics.

Colposuspension after previous failed incontinence surgery: a prospective observational study

OBJECTIVE

To evaluate the outcome of colposuspension for genuine stress incontinence in women who had previously undergone bladder neck surgery.

DESIGN

Prospective observational study.

SETTING

Tertiary referral urogynaecology unit.

PARTICIPANTS

Fifty-two consecutive women with recurrent genuine stress incontinence operated on by one surgeon.

MAIN OUTCOME MEASURES

Subjective and objective cure of stress incontinence. Complications of surgery.

RESULTS

The mean age of the women was 51 years (range 28-72) and weight 72.7 kg (range 53-112). Sixty-five continence procedures had been performed previously, with 13 women (25%) having had more than one operation. Nine months post-operatively the subjective cure rate was 80% and objective cure rate 78%. Intraoperative complications were few but included two bladder injuries and one rectus muscle tear which required repair. Seven women (13%) developed voiding difficulties which required clean intermittent self-catheterisation, but only one needed to continue this for six months. None of the women developed detrusor instability.

CONCLUSIONS

In this setting colposuspension after previous bladder neck surgery offers a high rate of success. However, long term follow up is needed to see if this effect is maintained.

Incontinence in the elderly

This year has seen many advances in the treatment of incontinence in the elderly, particularly the use of devices to control genuine stress incontinence and new drug treatments for detrusor instability to reduce side-effects and improve compliance. The results of existing surgical treatments for genuine stress incontinence have been evaluated more closely and newer techniques, which are less invasive and produce less morbidity, have been applied and evaluated in the elderly.

Periurethral injection for the treatment of urinary incontinence

Periurethral injection of substrates that compress, support, or narrow the bladder neck for the treatment of stress incontinence is not new. Several injectable compounds have been used in a small number of patients during the 1940s and through the 1960s; however, the results were not very successful and often led to significant complications. More recently, two major materials have been developed that seem to be useful in treating stress incontinence by periurethral injection: Polytef paste and GAX collagen. Other injectables include autologous fat tissue and silicone microimplants. The most suitable patients for periurethral injection are elderly women, patients who constitute high operative risk, and those with stress incontinence due to intrinsic sphincter failure. Patients with stress incontinence due to a combination of urethral hypermobility and intrinsic sphincter deficiency with failure of suspension procedure may also benefit from the procedure. The reported long-term (more than 24 months) success rates according to the various substances are as follows: Teflon (Polytef) (E.I.du Pont de Nemours and Co, Wilmington, DE): 30 to 38 percent cured or improved; repeated injections usually do not improve the outcome; mostly minor complications with case reports of more serious side effects such as periurethral granuloma formation and bladder outlet obstruction. GAX collagen: 69 to 77 percent subjectively cured or improved after 24 months; 54 to 57 percent objectively cured or improved, the reported morbidity in these procedures is minimal; repeated injections can improve the outcome. The experience with autologous fat and silicone microimplants is insufficient, with an overall success rate of 70 percent (1-40 months follow-up; mean 12 months) and 58 to 70 percent (17-36 months), respectively. Most of the procedures are performed as outpatient cases, and some under local anesthesia. These procedures are minimally invasive, usually safe and well tolerated, require shorter hospitalization, and are cost effective. In conclusion, in carefully selected patients, periurethral injection seems to be a reasonable option in the modern treatment of female stress incontinence.