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Ashton L, Nataksuka H, Johnson CM, Kenne K, Kreder KJ, Kruse R, Wendt L, Takacs EB, Vollstedt AJ. A Single Injection of Platelet-Rich Plasma Injection for the Treatment of Stress Urinary Incontinence in Females: A Randomized Placebo-Controlled Trial. Urology 2024:S0090-4295(24)00499-0. [PMID: 38942391 DOI: 10.1016/j.urology.2024.06.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 05/22/2024] [Accepted: 06/21/2024] [Indexed: 06/30/2024]
Abstract
OBJECTIVE To determine the efficacy of a single injection of platelet-rich plasma into the anterior vaginal wall at the mid-urethra compared to placebo, as there is emerging evidence that platelet-rich plasma may help treat female stress urinary incontinence. METHODS This was a single-blind, randomized, placebo-controlled clinical trial at a single institution. Females with bothersome, demonstrable stress-predominant urinary incontinence were enrolled. Participants were randomized to either injection of 5 mL autologous platelet-rich plasma or saline at the anterior vaginal wall at the mid-urethra. The primary outcome was composite treatment success at six months, defined as a negative cough stress test and an answer of "much better" or "very much better" on the Patient's Global Impression of Improvement. RESULTS Fifty patients were enrolled in the study and randomized to the platelet-rich plasma group (n = 25) or the saline placebo group (n = 25). There was no statistically significant difference in the primary outcome between the two groups. Adverse events were minor, and the rate of adverse events was similar between both groups. CONCLUSIONS In this randomized placebo-controlled study, we were unable to demonstrate a difference in stress urinary incontinence treatment success between platelet-rich plasma and saline injections. At this time, there is insufficient evidence to offer a one-time platelet-rich plasma injection into the anterior vaginal wall for treatment of female stress urinary incontinence.
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Affiliation(s)
| | | | | | | | | | | | - Linder Wendt
- Institute for Clinical and Translational Science, University of Iowa.
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Lin L, Sun Y. Injection therapy for urinary incontinence: An innovation under the minimally invasive pinhole. Neurourol Urodyn 2024; 43:1238-1241. [PMID: 38530001 DOI: 10.1002/nau.25454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 03/15/2024] [Indexed: 03/27/2024]
Affiliation(s)
- Lusha Lin
- West China Tianfu Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yao Sun
- Department of Critical Care Medicine, Peking University People's Hospital, Beijing, China
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Saraluck A, Chinthakanan O, Kijmanawat A, Aimjirakul K, Wattanayingcharoenchai R, Manonai J. Autologous platelet rich plasma (A-PRP) combined with pelvic floor muscle training for the treatment of female stress urinary incontinence (SUI): A randomized control clinical trial. Neurourol Urodyn 2024; 43:342-353. [PMID: 38108468 DOI: 10.1002/nau.25365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 11/26/2023] [Accepted: 12/01/2023] [Indexed: 12/19/2023]
Abstract
IMPORTANCE Autologous platelet-rich plasma (A-PRP) injection is a novel intervention for stress urinary incontinence (SUI) in women. However, no Phase II clinical trial has compared the outcomes of A-PRP injection combined with pelvic floor muscle training (PFMT) with those of PFMT alone in these women. OBJECTIVE The primary aim was to compare the efficacy of A-PRP + PFMT versus PFMT alone in women with SUI. The secondary aim was to determine any adverse effects of A-PRP injection. DESIGN Randomized clinical trial, single-blind assessment. SETTING Urogynecology clinic at a tertiary medical center. PARTICIPANTS Women with previously untreated SUI. Women in whom there was any suspicion of urgency, those with an Overactive Bladder Symptoms Score of ≥1, and those with obesity, pelvic organ prolapse, thrombocytopenia, or coagulopathy were excluded. INTERVENTIONS Two injections of A-PRP were administered with a 1-month interval between injections in the A-PRP injection + PFMT group. Both groups received PFMT. MAIN OUTCOMES AND MEASURES The primary outcome was determined using the 1-h pad weight test (PWT). Secondary outcomes were measured using the Incontinence Quality of Life Questionnaire, item 11 on the International Consultation on Incontinence Questionnaire-Female Lower Urinary Tract Symptoms questionnaire, Patient Global Impression of Improvement, and the percentage subjective improvement score. RESULTS Data for 60 study participants were available for analysis (A-PRP + PFMT group, n = 31; PFMT group, n = 29). The 1-h PWT decreased significantly in the A-PRP + PFMT group but only slightly in the PFMT group at the 5-month follow-up. There was a statistically significant between-group difference in the 1-h pad weight of about 8 g in favor of the A-PRP + PFMT group. A statistically significant difference in symptoms of SUI measured by the questionnaires was found between the A-PRP + PFMT group and the PFMT group at the 2- and 5-month follow-up assessments. There were no reports of adverse events following injection of A-PRP. CONCLUSIONS AND RELEVANCE A-PRP + PFMT could be a treatment option for women with SUI. Large Phase III randomized controlled trials are required to confirm our findings.
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Affiliation(s)
- Apisith Saraluck
- Department of Obstetrics & Gynaecology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Orawee Chinthakanan
- Department of Obstetrics & Gynaecology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Athasit Kijmanawat
- Department of Obstetrics & Gynaecology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Komkrit Aimjirakul
- Department of Obstetrics & Gynaecology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Rujira Wattanayingcharoenchai
- Department of Obstetrics & Gynaecology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Jittima Manonai
- Department of Obstetrics & Gynaecology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Mardiyan Kurniawati E, Anisah Rahmawati N, Hardianto G, Paraton H, Hastono Setyo Hadi T. Role of platelet-rich plasma in pelvic floor disorders: A systematic review. Int J Reprod Biomed 2023; 21:957-974. [PMID: 38370486 PMCID: PMC10869963 DOI: 10.18502/ijrm.v21i12.15034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 08/16/2023] [Accepted: 10/18/2023] [Indexed: 02/20/2024] Open
Abstract
Background Management for pelvic floor disorders needs to be improved. Platelet-rich plasma (PRP) offers an innovative treatment in general medical care to promote cell regeneration. Objective This review aims to investigate the role of PRP in pelvic floor disorders. Materials and Methods 6 international databases were accessed using several keywords namely PubMed, Science Direct, Cochrane Library, ProQuest, Google Scholar, and Scopus. The inclusion criteria were articles written in English, published in 10-yr period from 2012 until 2022, and investigated the relevant topic. This systematic review followed PRISMA guideline. Results 644 articles were found in several databases and 15 articles met the criteria. Management for pelvic floor disorders needs to be improved, but there are still many challenges, such as less effective treatments, risk of recurrence, and postoperative wound healing. PRP offers an innovative treatment in general medical care to promote cell regeneration. A total of 644 articles from the database were found, but 15 studies met the criteria. A total of 600 women with various pelvic floor disorders treated with PRP were analyzed. PRP positively impacts female sexual dysfunction, perineal trauma, vulvovaginal atrophy, stress urinary incontinence, vesicovaginal fistula, perineal rupture, and pelvic organ prolapse. Dosages, preparation techniques, injection techniques, and additive materials are varied. Most studies do not report side effects from the therapy, but the urinary disorder complaints must be paid attention to. Conclusion PRP can be used to manage pelvic floor disorders. Future studies should clarify and standardize the dose in each case and how to make PRP produce the best results.
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Affiliation(s)
- Eighty Mardiyan Kurniawati
- Department of Obstetrics and Gynecology, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia
| | | | - Gatut Hardianto
- Department of Obstetrics and Gynecology, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia
| | - Hari Paraton
- Department of Obstetrics and Gynecology, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia
| | - Tri Hastono Setyo Hadi
- Department of Obstetrics and Gynecology, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia
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Dankova I, Pyrgidis N, Tishukov M, Georgiadou E, Nigdelis MP, Solomayer EF, Marcon J, Stief CG, Hatzichristou D. Efficacy and Safety of Platelet-Rich Plasma Injections for the Treatment of Female Sexual Dysfunction and Stress Urinary Incontinence: A Systematic Review. Biomedicines 2023; 11:2919. [PMID: 38001920 PMCID: PMC10669888 DOI: 10.3390/biomedicines11112919] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 10/17/2023] [Accepted: 10/26/2023] [Indexed: 11/26/2023] Open
Abstract
Introduction: There is no clear evidence in the literature that platelet-rich plasma (PRP) injections improve female sexual dysfunction (FSD) and female stress urinary incontinence (SUI). Objectives: A systematic review was performed to study the efficacy and safety of PRP injections in women with the above pathologies, as well as to explore the optimal dosing, frequency and area of injections, and duration of treatment. Methods: A systematic search on PubMed, Embase and the Cochrane Library database was performed, as well as sources of grey literature from the date of database or source creation to January 2023. After title/abstract and full-text screening, clinical studies on humans evaluating the efficacy of PRP in gynecological disorders using standardized tools were included. Risk of bias was undertaken with RoB-2 for randomized-controlled trials (RCT) and the Newcastle-Ottawa Scale (NOS) for observational studies. Results: Four prospective and one retrospective study explored FSD, while six prospective and one RCT evaluated female SUI. A total of 327 women with a mean age of 51 ± 12 years were included. For FSD, PRP significantly improved the Female Sexual Function Index (FSFI), the Vaginal Health Index (VHI) and the Female Sexual Distress score (FSDS). For SUI, PRP led to a significant improvement in the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) and the Urogenital Distress Inventory (UDI-6). The identified RCT reported a significantly higher mean score of ICIQ-SF (p < 0.05) and UDI-6 (p < 0.01) in the midurethral sling group compared to the PRP injections group. Regarding the risk of bias, the RCT was characterized by high risk, whereas the observational studies were of moderate risk. The protocol for PRP injections for FSD is the injection of 2 mL of PRP into the distal anterior vaginal wall once a month for 3 months. For female SUI, 5-6 mL of PRP should be injected into the periurethral area once a month for 3 months. Conclusions: Despite the promising initial results of PRP injections, the level of current evidence is low due to methodological issues in the available studies. It becomes clear that there is an emerging need for high-quality research examining PRP injections for the treatment of FSD and female SUI.
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Affiliation(s)
- Irina Dankova
- School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece (M.T.)
| | - Nikolaos Pyrgidis
- Department of Urology, University Hospital, LMU Munich, 81377 Munich, Germany; (J.M.); (C.G.S.)
| | - Maksim Tishukov
- School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece (M.T.)
| | - Efstratia Georgiadou
- Department of Gynecology & Obstetrics, Buelach Hospital, 8180 Bülach, Switzerland;
| | - Meletios P. Nigdelis
- Department of Gynecology, Obstetrics and Reproductive Medicine, Saarland University Hospital, 66421 Homburg, Germany; (M.P.N.); (E.-F.S.)
| | - Erich-Franz Solomayer
- Department of Gynecology, Obstetrics and Reproductive Medicine, Saarland University Hospital, 66421 Homburg, Germany; (M.P.N.); (E.-F.S.)
| | - Julian Marcon
- Department of Urology, University Hospital, LMU Munich, 81377 Munich, Germany; (J.M.); (C.G.S.)
| | - Christian G. Stief
- Department of Urology, University Hospital, LMU Munich, 81377 Munich, Germany; (J.M.); (C.G.S.)
| | - Dimitrios Hatzichristou
- First Department of Urology, G. Gennimatas Hospital, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece;
- Institute for the Study of Urological Diseases, 54622 Thessaloniki, Greece
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Transurethral Incision of the Bladder Neck with or without Additional Procedure Resumes Spontaneous Voiding in Female Voiding Dysfunction-A Long-Term Retrospective Follow-Up. J Clin Med 2023; 12:jcm12041514. [PMID: 36836048 PMCID: PMC9964962 DOI: 10.3390/jcm12041514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Revised: 02/10/2023] [Accepted: 02/13/2023] [Indexed: 02/17/2023] Open
Abstract
AIM This study evaluated the long-term effectiveness of transurethral incision of the bladder neck (TUI-BN) with or without an additional procedure for female voiding dysfunction. METHODS Women with voiding difficulty who underwent TUI-BN in the last 12 years were included. All patients underwent a videourodynamics study (VUDS) at baseline and after TUI-BN. A successful outcome was defined as having a voiding efficiency (VE) increase by ≥50% after treatment. Patients with insufficient improvement were chosen for repeated TUI-BN, urethral onabotulinumtoxinA injection, or transurethral external sphincter incision (TUI-ES). The current voiding status, surgical complications, and additional surgeries were evaluated. RESULTS A total of 102 women with VUDS evidence of a narrow bladder neck during voiding were enrolled. The long-term success rate of the first TUI-BN was 29.4% (30/102) and increased to 66.7% (34/51) after combining TUI-BN and an additional procedure. The overall long-term success rates were 74.6% in women with detrusor underactivity (DU), 52.0% in detrusor overactivity and low contractility, 50.0% in bladder neck obstruction, 20.0% in hypersensitive bladder, and 75% in stable bladder (p = 0.022). Patients with a lower maximum flow rate (Qmax), (p = 0.002), lower voided volume (p < 0.001), lower corrected Qmax (p < 0.001), lower ladder contractility index (p = 0.003), lower voiding efficiency (p < 0.001), but larger post-void residual volume (p < 0.001) had a satisfactory surgical outcome. Spontaneous voiding was achieved in 66 (64.7%) patients, de novo urinary incontinence in 21 (20.6%), and vesicovaginal fistula in 4 (3.9%), all were repaired. CONCLUSIONS TUI-BN alone or in combination with an additional procedure was safe, effective, and durable in patients with DU to resume spontaneous voiding.
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Liu Z, Tang Y, Liu J, Shi R, Houston M, Munoz A, Zhang Y, Li X. Platelet-rich Plasma Promotes Restoration of the Anterior Vaginal Wall for the Treatment of Pelvic Floor Dysfunction in Rats. J Minim Invasive Gynecol 2023; 30:45-51. [PMID: 36265834 DOI: 10.1016/j.jmig.2022.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Revised: 10/11/2022] [Accepted: 10/11/2022] [Indexed: 11/18/2022]
Abstract
STUDY OBJECTIVE To determine the efficacy of using platelet-rich plasma (PRP) for vaginal wall repair in rats with vaginal wall impairment induced by vaginal distension (VD). DESIGN A single-blind, randomized study. SETTING A certified animal research facility. ANIMALS Twenty-four female Sprague Dawley rats. INTERVENTIONS Female Sprague Dawley rats were divided into sham (n = 8), VD (n = 8), and VD + PRP (n = 8) groups. Vaginal tissues from the VD group were dissected at 28-day post injury. VD + PRP rats received vaginal PRP injections on the 1st, 7th, 14th, and 21st day after VD and sacrificed on the 28th day. MEASUREMENTS AND MAIN RESULTS Urodynamic tests were performed in all rats. Immunohistochemistry was used to evaluate matrix metalloprotease-2 (MMP-2) and matrix metalloprotease-9 (MMP-9). Masson's staining was used to evaluate collagen fibers and calculate collagen volume fraction. Collagen fiber damage was confirmed in the VD group, evidenced by thinner and sparse distribution of collagen fibers, with significantly higher MMP-2 and MMP-9 expression than the sham group (p <.05). The collagen fiber damage in the vaginal wall likely led to pelvic floor dysfunction (PFD), evidenced by significantly decreased bladder leak-point pressure (p <.01) and abdominal leak-point pressure (p <.01) in the VD group compared with the sham group. After completion of the PRP treatment, a significantly higher collagen volume fraction (p <.01) and significantly increased bladder leak-point pressure (p <.05) and abdominal leak-point pressure (p <.01) were achieved in the VD + PRP compared with the VD group, thus indicating repair of the vaginal wall and improvement of PFD. CONCLUSION PRP injections facilitate the regeneration of vaginal wall tissue, particularly collagen fiber, after VD, leading to functional improvement of PFD. Findings support the feasibility of using PRP as a novel treatment for PFD.
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Affiliation(s)
- Zhaoxue Liu
- Department of Rehabilitation Medicine, The Third Xiangya Hospital, Central South University (MM. Liu, Drs. Tang, Liu, Shi, and Li), Changsha
| | - Yuan Tang
- Department of Rehabilitation Medicine, The Third Xiangya Hospital, Central South University (MM. Liu, Drs. Tang, Liu, Shi, and Li), Changsha; Department of Rehabilitation Medicine, The First People's Hospital of Changde City, Changde (Dr. Tang), China
| | - Jiaojiao Liu
- Department of Rehabilitation Medicine, The Third Xiangya Hospital, Central South University (MM. Liu, Drs. Tang, Liu, Shi, and Li), Changsha; Pelvic Floor and Postpartum Rehabilitation Center, Hospital for Maternal and Child Health Care (Dr. Liu), Changsha
| | - Ruting Shi
- Department of Rehabilitation Medicine, The Third Xiangya Hospital, Central South University (MM. Liu, Drs. Tang, Liu, Shi, and Li), Changsha
| | - Michael Houston
- Department of Biomedical Engineering, University of Houston, Houston, (MS. Houston and Dr. Zhang), Texas
| | - Alvaro Munoz
- Centro Universitario del Norte, Universidad de Guadalajara, Colotlán, (Dr. Munoz), Jalisco, Mexico
| | - Yingchun Zhang
- Department of Biomedical Engineering, University of Houston, Houston, (MS. Houston and Dr. Zhang), Texas
| | - Xuhong Li
- Department of Rehabilitation Medicine, The Third Xiangya Hospital, Central South University (MM. Liu, Drs. Tang, Liu, Shi, and Li), Changsha.
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Therapeutic Efficacy and Mid-Term Durability of Urethral Sphincter Platelet-Rich Plasma Injections to Treat Postprostatectomy Stress Urinary Incontinence. Biomedicines 2022; 10:biomedicines10092235. [PMID: 36140336 PMCID: PMC9496362 DOI: 10.3390/biomedicines10092235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 09/05/2022] [Accepted: 09/06/2022] [Indexed: 11/20/2022] Open
Abstract
Platelet-rich plasma (PRP) is used for tissue repair and regeneration. Herein, we investigated the therapeutic efficacy and mid-term durability of injections of PRP into the urethral sphincter for the management of postprostatectomy incontinence (PPI). Thirty-nine patients with PPI that were refractory to conservative treatments were prospectively enrolled. They received repeated PRP urethral sphincter injections monthly for a total of four months. The primary endpoint was the Global Response Assessment (GRA) score after treatment. The secondary endpoints included changes in the stress urinary incontinence (SUI) visual analog scale (VAS) from baseline to the end of follow-up and urodynamic parameters from baseline to 3 months. The mean follow-up period after the entire treatment course was 21.0 ± 11.3 (range: 1.6−36.3) months. After PRP injections, the median GRA score with quartiles was 2.0 (1.0, 2.0). The SUI VAS and abdominal leak point pressure significantly improved from 6.9 ± 1.8 to 4.4 ± 2.3, p < 0.001, and from 74.8 ± 37.0 to 115.5 ± 57.9 cmH2O, p = 0.004, respectively, after the fourth PRP urethral sphincter injection. Following PRP urethral sphincter injections, the severity of SUI significantly reduced, indicating efficacy and mid-term durability as a novel treatment for PPI.
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Chiang CH, Kuo HC. The Efficacy and Mid-term Durability of Urethral Sphincter Injections of Platelet-Rich Plasma in Treatment of Female Stress Urinary Incontinence. Front Pharmacol 2022; 13:847520. [PMID: 35211026 PMCID: PMC8861290 DOI: 10.3389/fphar.2022.847520] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Accepted: 01/19/2022] [Indexed: 11/25/2022] Open
Abstract
Aims: This study investigated the therapeutic effect of repeated urethral sphincter injections of autologous platelet-rich plasma (PRP) in treatment of stress urinary incontinence (SUI) in women due to intrinsic sphincter deficiency (ISD) refractory to medical treatment or after the first anti-incontinence surgery. Methods: Twenty-six women with SUI due to urodynamically proven ISD were prospectively enrolled. Five milliliters of PRP (2.5–5 times of the platelet concentrations in peripheral blood) were injected into the external sphincter at 5 sites, with 4 treatments at monthly interval. The primary end-point was post-treatment Global Response Assessment (GRA, scored 0–3) score after four PRP treatments. A GRA ≥ 2 was considered as a successful result. The secondary endpoints included changes in visual analog scale (VAS) of SUI and urodynamic parameters. The follow-up date was 12 months after the fourth PRP treatment. Results: The mean age was 61.7 ± 15.3 years. The overall success rate was 50% with the post-treatment mean GRA of 1.5 ± 1.1. Complete dryness was achieved in 12 patients (46.2%) after the PRP treatment, and 7 (26.9%) kept total continence at 12 months. The mean VAS of SUI score decreased significantly from 6.4 ± 2.3 to 3.9 ± 2.3 after treatment (p < 0.001). The abdominal leak point pressure increased significantly from 117.5 ± 63.8 to 133.6 ± 61.7 cmH2O (p = 0.045). No perioperative adverse events or severe complications occurred, except 1 (3.8%) patient reported straining to void which was self-limited. Conclusion: Repeated urethral sphincter injections of autologous PRP are a safe procedure that provides significant reduction in the severity of female SUI and a mid-term durability, suggesting PRP treatment is effective to increase urethral sphincter resistance for female SUI.
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Affiliation(s)
- Ching-Hsiang Chiang
- Department of Urology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - Hann-Chorng Kuo
- Department of Urology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
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