An Open Multicenter Study of Clinical Efficacy and Safety of Urolastic, an Injectable Implant for the Treatment of Stress Urinary Incontinence: One-Year Observation

Cost-effectiveness of urethral bulking polydimethylsiloxane-Urolastic® compared with mid-urethral sling surgery for stress urinary incontinence: A two-arm cohort study

OBJECTIVE

To investigate the cost-effectiveness of urethral bulking polydimethylsiloxane-Urolastic® (PDMS-U) compared with mid-urethral sling (MUS) surgery for stress urinary incontinence (SUI) at 1-year follow-up.

DESIGN

Prospective, two-arm cohort study with 2-year follow-up.

SETTING

International multicentre.

POPULATION

Women with moderate to severe SUI.

MAIN OUTCOME MEASURES

Primary outcome was subjective cure (Patient Global Impression of Improvement).

SECONDARY OUTCOMES

objective cure (negative cough stress test), Urogenital Distress Inventory (UDI-6), complications and re-interventions. Cost-effectiveness outcomes: total costs, quality-adjusted life year (QALY) using IIQ7-scores (Incontinence Impact Questionnaire) and EQ-5D-5L, incremental cost-effectiveness ratio (ICER) and monetary benefit (adjusted for baseline confounders).

RESULTS

In all, 131 PDMS-U and 153 MUS surgery patients were treated. Subjective cure rates for MUS surgery and PDMS-U were, respectively: 101/112 (90%) versus 40/87 (46%), adjusted odds ratio (aOR; for age, body mass index [BMI], severity, type of urinary incontinence and previous SUI procedure) was 4.9. Objective cure rates for MUS surgery and PDMS-U were respectively: 98/109 (90%) versus 58/92 (63%), aOR 5.4. Average total costs for PDMS-U and MUS surgery were €3567 and €6688. ICER for MUS surgery cost €15 598 per IIQ QALY and €37 408 per EQ-5D-5L QALY. With a willingness to pay (WTP) of €25 000, MUS has a 84% chance of being cost-effective using IIQ, whereas PDMS-U has a 99% chance of being cost-effective using EQ-5D-5L.

CONCLUSION

MUS surgery is more cost-effective in realising improved disease-specific quality of life (QoL), while PDMS-U is more cost-effective in realising improved generic QoL.

Update on Urethral Bulking for Stress Urinary Incontinence in Women

PURPOSE OF REVIEW

Urethral bulking agents are an effective treatment for stress urinary incontinence in select females. The material and techniques used for urethral bulking are constantly evolving. With the introduction of several new agents, there is an ongoing debate over which agent is the most effective, durable, and safe.

RECENT FINDINGS

Current available bulking agents include Bulkamid®, Macroplastiue®, Durasphere®, Coaptite®, or Urolastic®. Each of these agents has its own biophysical properties that affect its efficacy and safety. Evidence evaluating bulking agents has increased over time but there is no definitive data that suggest superiority of one agent over another. The ideal urethral bulking agent for female stress incontinence has yet been identified. Currently available agents have acceptable short-term and medium-term efficacy with few adverse events.

Sexual Function Following Treatment for Stress Urinary Incontinence With Bulk Injection Therapy and Mid-Urethral Sling Surgery

BACKGROUND

Peri-urethral bulking injections (PBI) gain popularity for the treatment of stress urinary incontinence (SUI), but - in contrast to mid-urethral sling (MUS) surgery - little is known about its impact on sexual function.

METHODS

This was a secondary analysis of a prospective cohort study that included patients with moderate to severe SUI undergoing either MUS surgery or PBI with polydimethylsiloxane Urolastic (PDMS-U). The validated Dutch and English version of the 'Pelvic Organ Prolapse and/or Urinary Incontinence Sexual Function Questionnaire - IUGA Revised' (PISQ-IR) was used to assess sexual function at baseline, at 6 and 12 months of follow-up. For between-group analysis, differences in baseline characteristics were corrected using multivariate analysis of covariance.

OUTCOMES

The primary outcome was the PISQ-IR single summary score of sexually active (SA) women following both procedures, calculated by mean calculation. Secondary outcomes were the PISQ-IR subscale scores of SA and non-sexually active (NSA) women, the proportions of sexual activity and subjective improvement ('Patient Global Impression of Improvement' (PGI-I)).

RESULTS

A total of 259 women (MUS: n = 146, PBI: n = 113) were included in this study. The PISQ-IR single summary score of SA women improved following both interventions (in the MUS group from 3.2 to 3.4 and in the PBI group from 3.0 to 3.3 after 12 months). After correcting for differences in baseline characteristics, the PISQ-IR summary score at 6 and 12 months was similar for both treatment groups. For SA women, condition-specific and condition-impact subscale scores significantly improved following both procedures.

CLINICAL IMPLICATIONS

In treating SUI, PBI is inferior to MUS surgery. However, there is a need for less invasive strategies, especially for women who are unfit for surgery or have contraindications. Sexual function improves after PBI using PDMS-U, which is relevant for the counselling of women with SUI about available treatment options.

STRENGTHS & LIMITATIONS

Strength: until this study, there was a lack of knowledge about the effects of PBI on sexual function.

LIMITATION

there may be indication bias as we did not perform a randomized controlled trial.

CONCLUSION

PBI using PMDS-U and MUS surgery for the treatment of SUI improve sexual function equally in SA women, mainly by decreasing the condition's impact on sexual activity and quality. Latul YP, Casteleijn FM, Zwolsman SE, et al. Sexual Function Following Treatment for Stress Urinary Incontinence With Bulk Injection Therapy and Mid-Urethral Sling Surgery. J Sex Med 2022;19:1116-1123.

Up-to-Date Procedures in Female Stress Urinary Incontinence Surgery: A Concise Review on Bulking Agents Procedures

To avoid complications related to mid-urethral slings (MUS), alternative procedures to treat stress urinary incontinence (SUI), such as urethral bulking agents (UBAs) have been adopted. The aim of this review is to narratively report the efficacy and safety of UBAs for SUI treatment. For this review, research from PubMed and EMBASE was performed to evaluate relevant studies that were undertaken from January 2012 to January 2022. Nineteen prospective studies were included. Several definitions of subjective and objective success were adopted. At a follow-up of <24 months, significant improvement was widely observed, even if with a heterogeneous rate of success between 32.7−90%, and a reinjection rate of 8.3−77.3%. Compared with other procedures, MUS resulted as significantly superior to UBAs but was balanced by a higher complication rate. Acute urinary retention, urinary tract infection and de novo urgency, and other complications, such as injection site rupture, urethral erosion and particle migration have been described after UBAs. SUI after UBAs treatment resulted in improvements in all studies and can be considered a safe and effective option to treat SUI. However, homogenous and longer-term data lack, limiting general recommendations. Thus, larger RCTs evaluating long-term effects are required.

Urethral bulking agents for the treatment of stress urinary incontinence in women: A systematic review

AIMS

To perform a systematic review to assess and compare the efficacy and safety of all urethral bulking agents (UBAs) available for the treatment of stress urinary incontinence (SUI) in women.

METHODS

This systematic review was conducted in accordance with the PRISMA guideline. A systematic search was conducted using the Ovid Medline, Embase and PubMed databases. Studies were included if they involved women who underwent either Bulkamid®, Macroplastique®, Durasphere®, Coaptite®, or Urolastic® injections for the treatment of SUI. A total of 583 articles were screened with 56 articles included. A qualitative analysis was performed.

RESULTS

The newer synthetic UBAs are not inferior to Contigen®, with variable mean success rates of 30%-80% in the short-term. Better long-term success rates were found with Bulkamid® (42%-70%), Coaptite® (60%-75%), and Macroplastique® (21%-80%) on qualitative review. Urinary tract infection rates were similar between bulking agents (4%-10.6%) although temporary acute urinary retention was more commonly associated with Coaptite® (mean: 34.2%), and de novo urgency in Durasphere® (mean: 24.7%). Significant complications such as migration into lymph nodes was reported with Durasphere®. Erosion was reported with Macroplastique®, Coaptite®, and Urolastic®, with a rate as high as 24.6% in one study of Urolastic®.

CONCLUSION

Available data support the use of Bulkamid® and Macroplastique®, which has shown a short-term efficacy of 30%-90% and 40%-85% respectively, and long-term efficacy of 42%-70%, and 21%-80%, respectively. Bulkamid® appears to have a more favorable safety profile, with no cases of erosion or migration of product associated with its use. Direct comparisons of UBAs have not been performed.

Patients' satisfaction and safety of bulk injection therapy Urolastic for treatment of stress urinary incontinence: A cross-sectional study

Aims

Primary outcome was to evaluate patients' satisfaction after being treated with bulk injection therapy polydimethylsiloxane Urolastic (PDMS‐U) for stress urinary incontinence (SUI). Secondary outcomes were: subjective cure, objective cure, severity of SUI symptoms, complications, reintervention rate, and disease‐specific quality of life. Furthermore, to determine if outcomes worsened during time‐after‐treatment (time‐frames: 0‐12, 13‐24, and ≥25 months).

Methods

In a cross‐sectional design, patients treated with PDMS‐U were recruited for hospital revisit. The primary outcome, patients' satisfaction, was assessed by the surgical satisfaction questionnaire. Subjective cure, objective cure, and severity of symptoms were assessed by the patients global impression of improvement, standardized cough stress test, and Sandvik severity scale, respectively. Medical charts and face‐to‐face interviews were used to determine complications and reinterventions.

Results

About 110 patients participated, 87 revisited the hospital. Median follow‐up was 25 months (interquartile range: 14;35 months). Patients' satisfaction rate was 51%. Subjective and objective cure were respectively 46% and 47%. Most prevalent complications were: urinary retention (22%), pain (15%), and dyspareunia (15%). Exposure and erosion occurred in 7% and 5%, respectively. Reintervention rate of reinjection and excision of bulk material was 6% and 18.0%, respectively. Objective cure significantly worsened during time‐after‐treatment (P = < .05).

Conclusions

About half of the patients being treated with PDMS‐U were satisfied and subjectively cured 2 years after treatment, although the majority still experienced symptoms of SUI. Most complications were mild and transient, however, in 18% excision of bulk material was indicated for severe or persistent complications such as pain, exposure, or erosion.

Adverse Events Associated with Nonsurgical Treatments for Urinary Incontinence in Women: a Systematic Review

BACKGROUND

Urinary incontinence (UI) is a common malady in women. Numerous nonsurgical treatments are available, each associated with risk of adverse events (AEs).

METHODS

We systematically reviewed nonsurgical interventions for urgency, stress, or mixed UI in women, focusing on AEs. We searched MEDLINE®, Cochrane Central Trials Registry, Cochrane Database of Systematic Reviews, and Embase® through December 4, 2017. We included comparative studies and single-group studies with at least 50 women. Abstracts were screened independently in duplicate. One researcher extracted study characteristics and results with verification by another independent researcher. When at least four studies of a given intervention reported the same AE, we conducted random effects model meta-analyses of proportions. We also assessed the strength of evidence.

RESULTS

There is low strength of evidence that AEs are rare with behavioral therapies and neuromodulation, and that periurethral bulking agents may result in erosion and increase the risk of voiding dysfunction. High strength of evidence finds that anticholinergics and alpha agonists are associated with high rates of dry mouth and constitutional effects such as fatigue and gastrointestinal complaints. Onabotulinum toxin A (BTX) is also associated with increased risk of urinary tract infections (UTIs) and voiding dysfunction (moderate strength of evidence).

DISCUSSION

Behavioral therapies and neuromodulation have low risk of AEs. Anticholinergics and alpha agonists have high rates of dry mouth and constitutional effects. BTX is associated with UTIs and voiding dysfunction. Periurethral bulking agents are associated with erosion and voiding dysfunction. These AEs should be considered when selecting appropriate UI treatment options. AE reporting is inconsistent and AE rates across studies tended to vary widely. Trials should report AEs more consistently.

How cure rates drive patients' preference for urethral bulking agent or mid-urethral sling surgery as therapy for stress urinary incontinence

AIMS

To assess the patients' median-accepted threshold of cure rate for urethral bulking agent (UBA) treatment compared to mid-urethral sling (MUS) surgery for treatment of female stress urinary incontinence (SUI). Secondly, to determine the correlation between treatment trade-off point and patient characteristics.

METHODS

Women older than 18 years, with predominant SUI, seeking treatment, underwent a structured interview. The treatment trade-off point was determined in scenario one: UBA vs transobturator standard MUS surgery (SMUS) performed under general/spinal anesthesia with one-night hospital stay, and scenario 2: UBA compared to single-incision MUS surgery (SIMS) performed under local analgesia (with sedation) in a daycare setting. The treatment trade-off point was assessed by decreasing the cure rate of UBA from 85% to 10% with steps of 2% until the patient's treatment preference switched to SMUS/SIMS.

RESULTS

One hundred and five patients were interviewed. Mean age was 52 years (SD, ±13.4). The median trade-off point for scenarios 1 and 2 was 79% (interquartile range [IQR]: 69, 85) and 85% (IQR: 71, 85), respectively. Patients with longer duration of SUI symptoms were willing to trade more efficacy to prefer UBA treatment.

CONCLUSIONS

Patients with SUI are willing to trade a lower cure rate to prefer UBA over SMUS to avoid hospitalization and general anesthesia. When SIMS is performed in a daycare setting under local analgesia, the majority of patients with SUI are of the opinion that cure rates of UBA should be at least as high as SIMS to be worth considering. The treatment preference is not strongly correlated with the patients' characteristics.

Patients' perspectives on urethral bulk injection therapy and mid-urethral sling surgery for stress urinary incontinence

INTRODUCTION AND HYPOTHESIS

The aim of this study was to identify all treatment decision factors that determined the preference for peri-urethral bulk injection therapy (PBI) or mid-urethral sling (MUS) surgery in patients with primary stress urinary incontinence (SUI). Second, we explored what patients expect from treatment for SUI and whether patients would consider PBI as a primary treatment option.

METHODS

In a qualitative design, 20 semi-structured, face-to-face interviews were conducted in women with primary SUI. Exclusion criteria were: previous PBI or MUS surgery; predominating urgency. Interviews were guided by three open-ended questions and a topic list. PBI treatment and MUS surgery were described in detail, and the efficacy was stated as 70% and 90%, respectively. Data saturation was reached when no new treatment decision factors were identified in three consecutive interviews. Interviews were audiotaped and fully transcribed. Thematic analysis by a coding process was done independently by two researchers.

RESULTS

Sixteen procedural, personal, professional, social and external treatment decision factors were identified. Regarding expectations about treatment for SUI, women believed 'becoming dry' was wishful thinking. The majority of patients accepted a small degree of persistent urinary incontinence after treatment. Regardless of their treatment preference, patients indicated that women should be informed about PBI as a primary treatment option.

CONCLUSION

Patients with primary SUI are open to PBI as an alternative treatment option even with lower cure rates compared with MUS surgery performed under general or spinal anesthesia. Patients indicated that women with primary SUI seeking treatment should be informed about PBI as a treatment option.

Results of an innovative bulking agent in patients with stress urinary incontinence who are not optimal candidates for mid-urethral sling surgery

AIMS

To assess the efficacy and safety of peri-urethral bulking injections (PBI) with an innovative bulking material (PDMS-U) in women with stress-urinary incontinence (SUI) who are not optimal candidates for mid-urethral sling surgery.

METHODS

A prospective study was performed in women with SUI who, for several reasons, have a relative contraindication for a mid-urethral sling procedure. These reasons include: (i) recurrent SUI after a prior SUI surgical procedure; (ii) a history of oncologic gynaecological surgery; (iii) a history of neurologic disease resulting in voiding problems; (iv) a maximal flow rate of less than 15 mL per second or; (v) women with a contraindication for surgery with general or regional anaesthesia. All women were treated with PBI consisting of PDMS-U, a bulking agent that polymerizes in situ. The primary outcome was subjective improvement, defined as "a little better" to "very much better" on the PGI-I. Secondary outcomes included objective cure, disease specific quality of life and adverse events.

RESULTS

Subjective improvement was reported by 18 (90%) of the 20 included patients. The subjective cure rate was 56% and the objective cure rate was 65%. There was a statistically significant improvement of all domain scores of the UDI-6, IIQ-7, and PISQ-12 at 6 months follow up. Abnormal post voiding residual volume (>150 mL) was the most common adverse event (40%), but persisted in only one patient, based on the patient's preference for a catheter.

CONCLUSIONS

PBI with PDMS-U is a viable treatment option in women with a relative contra-indication for mid-urethral sling surgery.

Para-Urethral Injections with Urolastic® for Treatment of Female Stress Urinary Incontinence: Subjective Improvement and Safety

INTRODUCTION

Female stress urinary incontinence (SUI) is often treated surgically. Urethral bulking agents are a minimally invasive alternative, especially in patients suffering from intrinsic sphincter deficiency, but often with limited long-term efficacy. Urolastic® is a non-deformable, non-resorbable silicone elastomer that is used as an injectable. Its properties might result in a more durable response after injection. If this durability factor can be combined with a low complication rate, this can become a useful treatment option. We therefore assessed the subjective improvement and safety after treatment with Urolastic®.

MATERIALS AND METHODS

In 2 Dutch hospitals, 65 patients were treated with Urolastic®. The subjective improvement was assessed and the medical charts were reviewed for complications that appeared during the follow-up period. The complications were classified using the Clavien-Dindo classification.

RESULTS

We found that 76-88% of the patients showed subjective improvement at 12-25 months follow-up. The rate of improvement experienced was 50-70%. The rate of complications classified as Clavien-Dindo >II was 24-33%. The 12 patients with 75-100% subjective improvement after 2 months, showed 85% improvement after a median of 25 months.

CONCLUSIONS

With careful patient selection, Urolastic® seems to be a safe, durable and effective treatment option for female SUI.

Translational approaches to the treatment of benign urologic conditions in elderly women

PURPOSE OF REVIEW

Stress urinary incontinence, overactive bladder, interstitial cystitis/painful bladder syndrome, and underactive bladder are highly prevalent among elderly women, and have significant impact on quality of life; however, existing treatments are limited and are not always successful for all patients. Researchers are investigating a multitude of new therapies to treat these conditions. This review will summarize the recent literature on investigative therapies for these conditions.

RECENT FINDINGS

Multiple new treatments are being developed for lower urinary tract dysfunction. Some of these treatments, including balloon therapy and muscle-derived stem cells for stress urinary incontinence, could provide alternatives to existing therapies. Others require further research before being used in patients, such as pudendal nerve stimulation for overactive bladder and intravesical liposomes for drug delivery in interstitial cystitis/painful bladder syndrome.

SUMMARY

Multiple new therapies are being investigated that could provide clinicians with additional tools to treat lower urinary tract disorders in millions of elderly women.