Bulking agents for minimally invasive correction of stress urinary incontinence in women

BACKGROUND:The study is relevant due to the widespread prevalence of stress urinary incontinence in women and the search for minimally invasive and safe treatment methods. AIM:The aim of this study was to present data based on modern evidence-based information on the effectiveness of urethral bulking agents and their safety in stress urinary incontinence treatment in women. MATERIALS AND METHODS:A review of the literature (original articles, systematic reviews) on the use of urethral bulking agents for stress urinary incontinence treatment in women was carried out. RESULTS:Urethral bulking agents for stress urinary incontinence treatment are effective due to the creation of additional bulk in the paraurethral area without fibrosis or because of inflammation followed by fibrous tissue formation. The efficacy and complications depend on the properties of the used urethral bulking agents. Since the performed studies are heterogeneous and the methods for evaluating the use of bulking fillers in stress urinary incontinence treatment vary, it is difficult to comparatively characterize urethral bulking agents to determine the most effective one. The search is being conducted for an ideal proper filler, which should be biocompatible and non-immunogenic and maintain a long-term therapeutic effect. CONCLUSIONS:Urethral bulking injections are an alternative therapy for women with stress urinary incontinence who are informed about its short-term effect and are expecting to avoid the risk of possible complications after surgery. Promising is to be regarded as the use of new urethral bulking agents based on hyaluronic acid with an optimal choice of concentration, degree of crosslinking and type of crosslinking agent to ensure maximum duration of action and minimum side effects.

Pathophysiology and Management of Long-term Complications After Transvaginal Urethral Diverticulectomy

Female urethral diverticulum (UD) is a rare and benign condition that presents as an epithelium-lined outpouching of the urethra. It has various symptoms, of which incontinence in the form of postmicturition dribble is the most common. The gold standard for the diagnosis of UD is magnetic resonance imaging, and the treatment of choice is transvaginal diverticulectomy. Despite the high success rate of transvaginal diverticulectomy, postoperative complications such as de novo stress urinary incontinence (SUI), recurrence, urethrovaginal fistula, recurrent urinary tract infections, newly-onset urgency, and urethral stricture can occur. De novo SUI is thought to result from weakening of the anatomical support of the urethra and bladder neck or damage to the urethral sphincter mechanism during diverticulectomy. It can be managed conservatively or may require surgical treatment such as a pubovaginal sling, Burch colposuspension, or urethral bulking agent injection. Concomitant SUI can be managed by concurrent or staged anti-incontinence surgery. Recurrent UD may be a newly formed diverticulum or the result of a remnant diverticulum from the previous diverticulectomy. In cases of recurrent UD requiring surgical repair, placing a rectus fascia pubovaginal sling may be an effective method to improve the surgical outcome. Urethrovaginal fistula is a rare, but devastating complication after urethral diverticulectomy; applying a Martius flap during fistula repair may improve the likelihood of a successful result. Malignancies in UD are rarely reported, and anterior pelvic exenteration is the recommended management in such cases.

A novel Levator Ani Midurethral Support Via Single Vaginal Incision to Treat Stress Urinary Incontinence: Case Report

IntroductionA novel native tissue midurethral support procedure, Levator Ani Midurethral Support via single vaginal incision, to treat patients with stress urinary incontinence is introduced in this case report. After mesh controversy, there is a need for a minimal invasive native tissue surgical procedure to treat stress urinary incontinence with minimal complication.Case PresentationA 51-year-old female with stress urinary incontinence had three mesh midurethral slings and one autologous fascia sling with severe infection that failed. She developed recurrent stress urinary incontinence and coital incontinence. After she was referred to our care, she was initially treated with urethral bulking injections which also failed. There were few alternatives left after failure of three mesh midurethral slings, one autologous fascia sling with severe infection and urethral bulking injections. The patient was successful treated with our novel native tissue midurethral support procedure, Levator Ani Midurethral Support via single vaginal incision. She remains continent 23 months after the Levator Ani Midurethral Support via single vaginal incision and her coital incontinence has also resolved. She reported she has no pelvic pain or dyspareunia. ConclusionsAfter further study, this novel native tissue midurethral support procedure, Levator Ani Midurethral Support via single vaginal incision may meet the need for a minimal invasive native tissue surgical procedure for the treatment of stress urinary incontinence with minimal complication.

Contemporary trends for urological training and management of stress urinary incontinence in Ireland

Introduction and hypothesis The aim of this study is to evaluate the trends in stress urinary incontinence (SUI) surgery since the 2018 pause on use of the polypropylene (PP) mid-urethral sling (MUS) and to quantify the effect this has had on surgical training. Methods Two anonymous surveys were sent to all current urology trainees and to all consultant surgeons who specialise in stress urinary incontinence surgery. Results Prior to the pause, 86% (6 out of 7) of consultant urologists and 73% (11 out of 15) of consultant gynaecologists would “always”/“often” perform MUS for SUI. After that, 100% (22 out of 22) of consultants reported that they “never” perform MUS. There has been a modest increase in the use of urethral bulking agent (UBA) procedures among urologists, with 43% (3 out of 7) now “often” performing this, compared with 71% (5 out of 7) “never” performing it pre-2018. Trainee exposure to SUI surgery reduced by 75% between 2016 and 2020. Despite a ten-fold increase in UBA procedures logged by trainees, the decline in MUS has resulted in a major reduction in total SUI surgeries. Coinciding with this decrease in surgeries, there was a 56% reduction in trainees’ self-assessed competence at SUI surgery. Thirteen percent of trainees are interested in specialising in Female Urology and those trainees had significantly greater exposure to SUI procedures during their training than those who did not (p = 0.0072). Conclusions This study has identified a downward trend in SUI surgery, which is concerning for the undertreatment of females with SUI. A decline in SUI surgery training has resulted in reduced trainee confidence and interest in this subspecialty.

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

Objectives: Vinyl dimethyl polydimethylsiloxane (VDPDMS) is a urethral bulking agent used for female stress urinary incontinence (SUI), that is clearly visible on computed tomography (CT). Clinical effects are promising, but it remains difficult to identify factors predicting clinical success. Clinical outcome might depend on the shape and position of the implants after injection. Objective of this study is to analyze the appearance and position of bulk material on CT scans and to see whether it is delivered the intended circumferential and mid-urethral position. Methods: A single-center retrospective study was performed in 20 women, treated with VDPDMS for SUI. A senior radiologist analyzed all CTs, using an assessment scheme. This scheme describes whether the bulk is scattered, mid-urethral, and/or circumferentially distributed. The imaging findings were subsequently correlated to the patient global impression of improvement (PGI-I) and the percentage of subjective improvement experienced 6 weeks post-operatively. Results: The patient’s mean age was 61 years, and they underwent median 2.0 previous surgical treatments for SUI. Three patients reported no improvement, 9 patients had 20–90% improvement and 8 reported >90% improvement of their SUI. In 17/74 (24%) positions, the implant was scattered rather than spherical. In 9/20 (45%), the implants were not located in the intended mid-urethral position. In 8/20 patients (40%), the material was distributed circumferentially. Conclusion: This is the first study describing the position and shape of VDPDMS in patients after treatment. The appearance and position of the implants appears to be variable, but optimal positioning or shape seems to be no absolute requisite for success.

Five-year data on the first UK experience of using urethral bulking agents in treating men with stress urinary incontinence

Level of evidence: 4

Urethral Bulking for Stress Urinary Incontinence or Mixed Incontinence in Women Not Suitable for Treatment With a Midurethral Sling: 5-Year Follow-Up

Aim: To compare outcome of injection with the bulking agent polyacrylamide hydrogel (PAHG) with no treatment in women with urinary incontinence who were not candidates for treatment with a midurethral sling. Methods: Women were randomized to treatment with PAHG or no treatment. After 2 months follow-up the women in the non-treatment group were also given PAHG treatment. All patients were then followed for 12 months. Patients were assessed with a patient satisfaction questionnaire, the UDI-6 (lower urinary tract symptoms) and IIQ-7 (quality of life). A new questioner was sent after 5 years. Results: At 2 months, IIQ-7 scores decreased by 55% and the UID-6 by 38% in women in the treated group compared with -4% and 2%, respectively in the non-treatment group. A total of 63% of patient were much satisfied/ satisfied in the treatment group compared with 19% in the non-treatment group. The 12-month follow-up showed a subjective satisfaction rate of 62%. The objective results show that women who were satisfied (n = 18) had a decrease in IIQ-7 of 61% and UID-6 of 41% compared with 20% and 10% in patients who were not satisfied (n = 11). At a mean (range) follow-up of 5 years (3–7), 44% of patients were still satisfied with treatment results. Conclusion: Bulking treatment with PAHG can be offered to patients not suited to treatment