Combined external urethral bulking and artificial urinary sphincter for urethral atrophy and stress urinary incontinence

OBJECTIVE: To describe a technique of externally bulking the urethra with a soft-tissue graft before placing another artificial urinary sphincter (AUS), as when placing another AUS for recurrent male stress urinary incontinence (SUI) other manoeuvres, e.g. placing a tandem cuff or transcorporal cuff, must be used to obtain urinary continence in an atrophic urethra, and each is associated with morbidity. PATIENTS AND METHODS: From January 2003 to July 2004, five patients (mean age 74 years, range 62-84) treated by radical prostatectomy were referred for recurrent SUI after placing an AUS (four, including one with urethral erosion) or a male sling (one, with a resulting atrophic urethra). Each patient was treated with an external urethral bulking agent (Surgisis) ES, Cook Urological, Spencer, Indiana) and had an AUS placed. RESULTS: In each patient the greatest urethral circumference was <4 cm. To place a functional 4 cm cuff, the diameter of the urethra was enhanced by wrapping it with Surgisis ES. Continence was significantly improved in all patients except one 84-year-old man who had the replanted artificial sphincter removed because of erosion 14 months after surgery. CONCLUSION: In cases of severe recurrent SUI from urethral atrophy after placing an AUS, externally bulking the urethra with Surgisis ES before placing another AUS is well tolerated, and gives satisfactory results.     

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.     

中段尿道吊带术治疗女性压力性尿失禁的多中心研究

目的 探讨中段尿道吊带术治疗女性压力性尿失禁的临床疗效、手术指征和并发症的处理.方法 单纯压力性尿失禁的患者304例和混合性尿失禁的患者8例,均为女性,纳入本研究.其中接受TVT吊带术134例,TVTO吊带术167例,Monarc吊带术11例.围手术期评估包括:手术时间、出血量、术中术后并发症.手术效果分为治愈、显效、无效.在患者出院时、术后3个月、术后每年评价疗效和并发症.结果 TVT组手术时间(18.5±9.6)min和出血量(32.2±12.6)ml多于TVTO组(11.5±3.1)min,(12.8±8.5)ml和Monarc组(11.1±2.6)min,(12.3±3.5)ml(P<0.05).三种术式均有较高的治愈率和显效率,不同术式的近期和中长期治愈率、显效率和无效率差异无统计学意义(P>0.05).单纯压力性尿失禁患者治愈率(95.7% )显著高于混合性尿失禁患者(37.5% )(P<0.01).3种术式的总并发症发生率差异无统计学意义,但膀胱损伤仅发生在TVT组,闭孔神经损伤和阴道损伤仅发生在TVTO组.术后排尿困难和尿潴留是中段尿道吊带术的最常见并发症.结论 经耻骨上途径(TVT)和经闭孔途径(TVTO、Monarc)中段尿道吊带术治疗压力性尿失禁均具有手术简单、微创、中长期疗效好、并发症少等优点.     

女性尿道内口开放与压力性尿失禁的相关性研究

目的探讨盆底超声检查尿道内口开放与女性压力性尿失禁（SUI）的相关性。 方法以2018年9月至2019年9月在中山三院门诊行经会阴实时三维盆底超声检查的女性为研究对象,其中SUI患者190例,无SUI者742例。观察静息及强力闭呼动作（Valsalva动作）时有无尿道内口开放;对于有尿道内口开放的病例,测量开放的宽度、面积、周长、开放角度、开放长度以及开放长度/尿道长度比值等指标,并分析其与压力性尿失禁的相关性。 结果静息状态下,SUI组及对照组均无尿道内口开放。最大Valsalva动作时,SUI组尿道内口开放的比例明显高于对照组（P<0.05）,尿道内口开放的宽度、面积、周长、开放角度、开放长度以及开放长度/尿道长度比值均大于对照组（P<0.05）。回归分析显示,尿道内口开放角度与SUI有相关性（OR=1.017,95%CI：1.003~1.031）。 结论尿道内口开放与SUI有关,其中内口开放的角度与SUI发病相关。     

Review article: Mid-urethral synthetic slings for female stress urinary incontinence

? Mid-urethral synthetic slings (MUSS) have grown in acceptance and popularity to gain a foremost position in stress urinary incontinence (SUI) surgery. ? There are numerous studies that provide a large amount of Level 1 and 2 evidence that support the concept of a sling placed at the level of the mid-urethra. ? Long-term follow-up has been published for the original tension-free vaginal tape (TVT) procedure with the most recent publication providing Level 2 evidence with mean follow-up of 11.5 years of 69/91 (77%) of patients from the original series. There was objective cure was in 90% of women and 77% considered themselves subjectively cured, based on the Patient Global Impression of Improvement. ? Level 1 evidence with long-term follow-up has been provided comparing colposuspension to TVT at 2 and 5 years. At 5 years for the primary efficacy variable of a negative 1 h stress pad test, there was no difference in success (81% vs 90%). ? Two recent meta-analyses provide Level 1 evidence comparing outcomes for retropubic vs transobturator MUSS. One included 18 studies, randomized and cohort: cohort studies had a 12.3% failure rate for transobturator and 13.7% failure for the retropubic approach, randomized studies showed 5.7% failure in the transobturator vs 7.8% in the retropubic group. The other meta-analysis included 11 studies published 2008-2009, which found that the short-term cure rate was borderline inferior for the transobturator tape group (odds ratio 0.62; 95% confidence interval 0.37-1.00), nearly reaching statistical significance (P= 0.05). ? This review details further comparator evidence and evidence for use in specific patient groups (elderly, obese, intrinsic sphincter deficiency, mixed UI).     

经耻骨后和经闭孔尿道中段无张力悬吊术治疗女性压力性尿失禁的疗效观察

目的:观察经耻骨后和经闭孔尿道无张力悬吊术治疗女性压力性尿失禁(Stress urinary incontinence,SUI)的疗效。方法:选择女性SUI患者198例,病程2~25年,平均7.3年;年龄41~78岁,平均58.3岁。采用经耻骨后无张力阴道吊带术(tension-free vaginal tape,TVT,57例为TVT组)或经闭孔尿道下无张力吊带术(transobturator vaginal tape inside-out,TVT-O,141例为TVT-O组)进行治疗。结果:本文患者随访6~120个月,179例(90.4%)治愈,其中TVT组平均随访86个月,治愈51例(89.5%),改善4例(7%);TVT-O组平均随访38个月,治愈128例(90.7%),改善6例(4.3%);疗效不佳9例(3.5%)。TVT组2例发生膀胱穿孔(3.5%),TVT-O组3例出现腹股沟血肿伴下肢大腿根部疼痛,2例出现短期单下肢活动障碍,但经保守治疗均好转;术后拔除尿管后排尿困难5例,其中TVT组2例,TVT-O组3例,经多次下压式尿道扩张及延长保留尿管后解除梗阻、恢复正常排尿4例;TVT组中1例采用尿道扩张无效而剪断悬吊带。结论:经阴道中段无张力悬吊术(尤其是TVT-O)操作简便,疗效佳,并发症少,是治疗女性SUI的有效方法。     

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.     

Endourethral injection of bulking agents for urinary incontinence in children

OBJECTIVE: To assess the early and late outcome of endourethral injection with bulking agents in children with urinary incontinence (a neuropathic bladder or exstrophy-epispadias complex), by reviewing our experience over a 5-year period. PATIENTS AND METHODS: The records of 15 children (10 boys) were reviewed retrospectively; 10 had spina bifida and a neurogenic bladder, four had a neurogenic bladder from other causes and one had epispadias. All children had a stable low-pressure detrusor and a compliant bladder with sphincteric weakness on preoperative urodynamic testing. Four children had undergone previous enterocystoplasty with a Mitrofanoff stoma, with concomitant urethral lengthening in two and a Goretex trade mark bladder neck sling in two. Three children voided spontaneously while 12 depended on intermittent catheterization. The agent was injected under general anaesthesia in all patients but one, with an endourethral submucosal injection of the bulking agent into four or more points at the junction of the bladder neck and proximal urethra, aiming to obtain visual occlusion of the urethra. The median (range) number of injections was 2 (1-3); five children had one injection, seven had two and three had three. There were no procedure-related complications and most were day-case procedures. Initially PTFE paste was used as the bulking agent, being replaced by bovine collagen or polydimethylsiloxane in the latter half of the series. RESULTS: At a median (range) follow-up of 28 (11-65) months three children were completely dry after a single injection; there was no change in four and a short-term improvement (median 25 months, range 4 days to 37 months) in eight. After this period all children deteriorated to their original incontinence grade; hence the overall cure rate was three of 15. CONCLUSION: This experience with a long-term follow-up differs from previously reported high success rates for the endourethral injection of bulking agents for urinary incontinence in children. Despite a short-term benefit, in the long-term this technique was unreliable and often ineffective. Patients and their carers should be given a realistic and guarded prognosis.     

Complications of teflon injection for stress urinary incontinence

Four significant complications of Teflon injections for stress urinary incontinence are reported in 22 women and eight men. Three of the complications included periurethral abscess, urethral diverticulum, and periurethral Teflon granuloma with urethral wall prolapse occurred in women. These complications needed surgical excision and further surgery for stress incontinence, in two patients the outcome was good. Among the female patients the cure rate for stress incontinence with Teflon injection was only 18% in the 5-year follow-up. One other complication, a Teflon cyst, occurred in a male who had previously undergone radical retropubic prostatectomy. Only two of the eight men (25%) who received Teflon injections had maintained improvement after 1 year.     

Where should bulking agents for female urodynamic stress incontinence be injected?

For bulking agents used for female stress urinary incontinence, the recommendation for the anatomical placement varies as some injectables are to be placed close to the bladder neck and others midurethrally. Aim of the study was to determine if there are differences concerning the outcome after transurethral collagen injections depending on the anatomical placement midurethrally or at the bladder neck. We randomly assigned 30 elderly female patients with urodynamic stress incontinence to either transurethral collagen injection midurethrally or to the bladder neck. Prior to injection and at ten month follow-up, maximum urethral closure pressure (MUCP), functional urethral length (FUL), maximum flow rate and cough test were performed and the patient was asked to estimate her bladder condition using a visual analogue scale. Postoperative contentness was 8 (median, 95% confidence interval 5–9) in the midurethral group and 8 (median, 95% confidence interval 7–10) in the bladder neck group with a p value of 0.012, 95% confidence interval –2.464 to –0.2859, in favour to midurethral injections. MUCP and FUL increased significantly in both groups and flow rate decreased in both groups. Continence was 66.6% in the midurethral group and 60% for the bladder neck group respectively. Both midurethral and bladder neck collagen injections improve patients’ satisfaction almost equally with a small advantage for midurethral injections.     

女性压力性尿失禁的微创治疗

目的探讨女性压力性尿失禁的发病机制和微创治疗方法。方法女性压力性尿失禁患者25例,经临床、尿动力学检查或膀胱尿道造影确诊,均为稳定性膀胱,无膀胱出口梗阻。采用无张力阴道吊带术(TVT),将吊带无张力置于尿道中段。结果手术时间平均(40±5)min;术中出血量平均(43±10)mL;术后平均留置导尿1.5 d;术后平均住院3 d。23例患者术后尿失禁症状均消失,其中2例患者术后出现尿潴留,留置导尿1周后好转,尿潴留症状消失,尿失禁未复发;2例尿失禁症状显著改善。结论TVT等微创术式因简单、微创、疗效好、并发症少等,目前是女性压力性尿失禁外科手术治疗的发展方向。     

Systematic review on the efficacy and safety of injectable bulking agents for passive faecal incontinence

Objective The aim of this study was to systematically review all published evidence to determine the efficacy and safety of injectable bulking agents for passive faecal incontinence (FI) in adults. Method Electronic searches were performed for MEDLINE, EMBASE, ISI Web of Knowledge and other relevant databases. Hand searching of relevant conference proceedings was undertaken. Studies were considered if they met the predefined inclusion criteria of more than ten adult patients and receiving an injectable bulking agent for passive FI with a validated means of assessing preoperative and postoperative incontinence. Results Thirteen case series studies and one randomized placebo‐controlled trial (RCT) were included with a total of 420 patients. Two completed RCTs with placebo control were identified but results were unobtainable. Coaptite, Contigen, Durasphere, EVOH and PTQ injections were assessed with 24, 73, 83, 21 and 208 patients respectively. Most studies reported a statistically significant improvement in incontinence scores and quality of life. No statistically significant difference was found between the treatment and placebo arms in the RCT. No serious adverse events were reported. Conclusions Currently there is little evidence for the effectiveness of injectable bulking agents in managing passive FI. The inability to obtain results from two further RCTs concerned the reviewers and hindered their ability to make strong recommendations. The identified injectable bulking agents appear to be safe with only minor complications reported.