Urethral bulking for recurrent stress urinary incontinence after midurethral sling failure

Aims

To assess the effectiveness of a polyacrylamide hydrogel (PAHG; Bulkamid®) in treating recurrent stress urinary incontinence (SUI) following a previous midurethral sling (MUS) implant.

Methods

This observational study, conducted since 2009, included 60 patients with recurrent SUI or mixed urinary incontinence (MUI) after a previous MUS and who chose to be treated with PAHG. Objective and subjective outcomes were assessed at 1, 6, and 12 months after the initial injection. Patients were classified as cured based on a negative cough test (supine and standing) and <2 g urine on 1‐hr pad test and a VAS score improved by ≥90%. Improved were those with the loss of only a few drops of urine during the cough test and 2–10 g urine on 1‐hr pad test or a reduction >50% compared with preoperative urine loss and a VAS score improved by ≥75%.

Results

The volume of PAHG injected in the current study ranged from 1–3 ml. Cured/improved rates were 93.3% (56/60), 88.3% (53/60), and 83.6% (46/55) at 1, 6, and 12 months, respectively. Patients with MUI had a cured urgency urinary incontinence rate of 36.8%, 47.4%, and 38.9%, respectively. Voiding dysfunction rates were 13.3% (8/60), 8.3% (5/60), and 1.8% (1/55) at 1, 6, and 12 months and urinary tract infection rates were 5% (3/60), 11.7% (7/60), and 3.6% (2/55), respectively. Other adverse events were short‐term and/or observed in <4% of patients.

Conclusions

PAHG can be used to treat recurrent SUI after MUS failure with good outcome and low complication rates. Neurourol. Urodynam. 36:722–726, 2017. © 2016 The Authors. Neurourology and Urodynamics published by Wiley Periodicals, Inc.     

Disabling complications with slings for managing female stress urinary incontinence

OBJECTIVE

To report an increase in the referral of patients with disabling complications after the failure of conservative therapy, their presentation, final surgical management and clinical outcome, following the use of non‐autologous slings (NAS), currently the primary surgical procedure for managing stress urinary incontinence (SUI) in women.

PATIENT AND METHODS

Thirty‐eight patients (mean age 64 years) required surgical management for disabling complications after placing a NAS for SUI. Sling types were synthetic (25), xenografts (six) and allografts (four). Twenty (53%) patients presented with bladder outlet obstruction, 13 (34%) with sling erosion, three (8%) with worsened SUI, and two (5%) with unobstructive severe urgency and frequency.

RESULTS

The sling was dissected and incised with no complication in 19 of 20 patients. One had a posterior urethral defect during sling dissection. Twelve patients (60%) acquired normal voiding and were continent. Among the 13 patients who had the sling dismantled and urethrolysis, two had recurrent or persistent SUI, two de‐novo urgency/frequency and one developed osteitis pubis. Three patients with disabling SUI received a pubovaginal sling placed proximal to the bladder neck, and had an overall improvement in their urinary control with no retention. Two unobstructed patients with urgency and frequency did not improve with anticholinergic medication and pelvic floor therapy, and are now candidates for botulinum toxin injection or neurostimulation.

CONCLUSIONS

The complication rate with periurethral NAS for managing SUI in females is substantial. Patients with refractory urgency/frequency after the sling need a complete evaluation with cystoscopy and video‐urodynamics. Obstruction and erosion are the commonest problems and require surgical correction.     

Urethral injections for female stress incontinence

Emphasis on minimally invasive options for the surgical treatment of stress urinary incontinence (SUI) has resulted in the development of agents and techniques that improve these conditions substantially towards social continence, but currently give suboptimal cure/dry rates. The application of injectable therapy as an office procedure implies the potential for cost-efficient treatment for selected patients with UI. Continuous advances in materials technology have provided the possibility that many new urethral bulking agents will soon be available. Experience continues to accrue in clinical trials for urethral bulking with these agents, while parallel use for the indication of paediatric vesico-urethral reflux has also provided evidence of biological activity related to these compounds. The agents that are closest to complete analysis are synthetic and represent various material types and characteristics. As these materials develop, understanding of the preferred injection technique also is being gained. The delivery method and site might prove to substantially alter the biological activity of these compounds.     

Three-year outcomes of Uretex Urethral Support System for treatment of stress urinary incontinence

To assess the medium-term performance of the Uretex Urethral Support System, patients were evaluated by the 1-h pad test, cough stress test (CST), Valsalva leak-point pressure test (VLPP), and validated questionnaires. Seventy-five patients were enrolled; median follow-up was 3.6 years (range, 3.1-4.3 years). All patients had a negative CST, 65 (87%) had no leakage during VLPP, and 62 of 72 patients (86%) had a negative 1-h pad test. Compared with baseline values of 50.0 and 28.6, median Urogenital Distress Inventory and Incontinence Impact Questionnaire-7 scores at 3-year follow-up were 16.7 and 0, respectively (P<0.001). Observed medium-term morbidity included de novo urgency in four (5%), frequency in three (4%), and urge incontinence in one (1%). No patients reported graft erosion. The Uretex Urethral Support System is highly effective (both objectively and subjectively) for treatment of stress urinary incontinence and improves quality of life in women with minimal adverse sequelae.     

Urethral erosion of tension-free vaginal tape presenting as recurrent stress urinary incontinence

The suburethral sling with tension-free vaginal tape (TVT) has become a popular treatment for stress urinary incontinence. Erosion of the mesh into the urethra is rare, usually presenting with hematuria, pain, voiding dysfunction or urge incontinence. A patient with stress incontinence was treated with a TVT suburethral sling. One month later, symptoms of recurrent stress incontinence developed. Cystourethroscopy revealed urethral mesh erosion. Surgical removal involved cystourethroscopic-assisted transurethral resection of the mesh, followed by vaginal dissection and periurethral withdrawal. Urethral mesh erosion should be considered in a patient who presents with atypical symptoms after being treated with a suburethral sling. It is important to obtain a detailed history and have a high clinical index of suspicion for erosion. Careful and comprehensive urethroscopy, in addition to cystoscopy, should be a mandatory part of the TVT procedure. Further study is needed to determine the optimal technique for mesh removal.Abbreviations TVT Tension-free vaginal tape     

Urethral closure in management of urinary incontinence

Urethral closure with suprapubic catheterization has been used in 50 patients with urethral destruction due to an indwelling catheter. Thirty-seven of the patients were dry after the initial operation. Long-term complications were seen in 33 patients. Those that did occur were not life threatening. This relatively minor procedure offers a good alternative to formal diversion in this group of severely disabled patients.     

Urethral resistance measurement: a new method for evaluation of stress urinary incontinence in women

The aim of this study was to evaluate a new method to measure urethral resistance among 66 women with urinary incontinence. A stainless steel sphere attached to a guide wire was developed. The sphere is inserted into the bladder and withdrawn through the urethra at a steady rate. Serial measurements with spheres of 5, 6 and 7 mm were performed. The mean urethral resistance as measured by the largest sphere (0.07±0.03) was significantly greater than that measured by the medium sphere (0.06±0.02, p<0.0001), which was significantly larger than that measured by the smallest sphere (0.04±0.01, p<0.0001). There was good correlation of urethral resistance with maximum urethral closure pressure (MUCP) by this technique, but no correlation with Valsalva leak point pressure (VLPP).Editorial Comment: This study attempts to demonstrate the validity and reproducibility of measuring maximum urethral resistance. Further studies will need to be performed to see if this technique will be clinically useful, i.e., comparing values in continent and incontinent women, old vs. young population, etc. There is a need to better test to measure urethral function than leak point pressure and urethral pressure profile/MUCP     

Urethral injection for stress urinary incontinence: long-term results with dextranomer/hyaluronic acid copolymer

Urethral injection is a convenient, minimally invasive means of treating stress urinary incontinence (SUI). We present long-term follow-up data from 20 patients originally recruited in 1994–95 (mean age 67 years) to receive urethral injection with dextranomer/hyaluronic acid (Dx/HA) copolymer. The majority of patients had failed previous therapy for SUI. If the first injection was unsuccessful, up to two further injections were offered. Only 3 patients (15%) failed to show a response to treatment. Sixteen women were reassessed during 2001 (4 had died of causes unrelated to the study treatment). A sustained response throughout the follow-up period was reported in 9/16 patients (57%), with incontinence recurring in just 4 (25%). None of the 7 patients with persistent or recurrent incontinence were cured by subsequent treatments, including surgery. In conclusion, urethral injection with Dx/HA copolymer offers promising long-term efficacy in the treatment of SUI, regardless of old age or failure to respond to previous therapy.Abbreviations SUI Stress urinary incontinence - VUR Vesicoureteral refluxEditorial Comment: These investigators present long-term follow-up on a newer periurethral injectable material, dextranomer/hyaluronic copolymer, for stress incontinence. The limited sample size of 20 patients with only 13 patients evaluable at 5 years, is one major disadvantage of this study; however, 69% of patients had a sustained response to urethral injection on post-operative subjective and objective testing which represents an improvement over existing injectable materials. Advantages of this material over some of the presently available agents include improved durability, lack of need for skin-testing and no reported autoimmune or migratory complications. Certainly, long-term data on more patients would be appropriate.     

Surgery for stress urinary incontinence

Stress urinary incontinence is a common problem, with various degrees of disability. Its etiology may be defective external or internal urethral sphincter mechanisms. Evaluation of the patient with symptoms of stress incontinence requires objective testing for diagnostic accuracy. Patient management may be individualized to conservative measures or to one of the various surgical approaches, which produce success rates between 80% and 95%. Retropubic suspension or long needle procedures should be considered for patients with stress incontinence and evidence of bladder neck detachment. Sling procedures, artificial sphincters, and periurethral injections should be considered for patients with minimal bladder neck mobility or low urethral pressures and for those with a high risk of failing other procedures.     

Surgical treatment for stress urinary incontinence

Abstract:   The prevalence of stress urinary incontinence is quite significant with large numbers of women affected. Many of these women will not seek medical help in the belief that they will not be cured or improved. With the increasing numbers of procedures now available we present a review of both established and novel surgical techniques that is intended to help both urologists and primary care physicians in the counselling of patients complaining of stress incontinence. We compare the "gold standards" of surgical treatment for all types of stress incontinence with the newer techniques that have recently become popular among urologists and gynaecologists.     

Retropubic surgery for stress urinary incontinence

More than 150 surgical techniques have been proposed in the literature for treating stress urinary incontinence. Many of the original published approaches were vaginal, but through the years the literature has expanded to include needle suspension, pubovaginal slings, and retropubic procedures. In this chapter, we focus on retropubic approaches for the treatment of SUI and discuss the physiology, indications, technical details and the complications of these procedures.     

Transobturator adjustable tape for severe stress urinary incontinence and stress urinary incontinence with voiding dysfunction

Introduction and hypothesis  

This prospective multicenter study was conducted to evaluate the efficacy and safety of an adjustable mid-urethral sling (MUS) using transobturator adjustable tape (TOA) in women with severe stress urinary incontinence or combined stress urinary incontinence (SUI) and voiding dysfunction (VD).