Three-dimensional endovaginal ultrasound examination following injection of Macroplastique for stress urinary incontinence: outcomes based on location and periurethral distribution of the bulking agent

Role of 3D ultrasound in the treatment of stress urinary incontinence with polyacrylamide hydrogel (Bulkamid®) - A pilot study

INTRODUCTION AND HYPOTHESIS

Polyacrylamide hydrogel (PAHG) is a bulking agent used in treatment of stress urinary incontinence (SUI) in women. Some women experience an improvement or cure in stress urinary incontinence (SUI) symptoms lasting only a few weeks after the injection of the bulking agent. The aim of this study was to use three-dimensional ultrasound (3DUS) to describe the changes in volume, number of deposits and echogenicity of the bulking agent 3 months after PAHG injection.

METHODS

Prospective cohort study of fourteen women with SUI or mixed primarily SUI, who underwent an injection of PAHG. The subjective outcome was evaluated with Patient Global Impression of Improvement questionnaire. 3DUS was performed in all patients immediately after injection of PAHG and again at 3 months follow-up.

RESULTS

The study found a mean 36.5 % loss in bulking agent volume during the study period. A total of 53 PAHG deposits were found by ultrasound immediately after injection. At 3 months follow-up 41 PAHG deposits were left. All deposits were hypoechogenic immediately after injection and only 24 % of demonstrated PAHG collections had a hypoechoic echogenicity at 3 months follow-up.

CONCLUSIONS

More than 1/3 of volume of injected PAHG and 23 % of deposits could not be found by 3DUS at 3 months follow-up. Only 24 % of PAHG injections in our patients had hypo-echoic echogenicity at 3 months follow-up. Larger 3DUS studies with longer follow-up and focus on exact location of the PAHG injections are important future studies.

Using clinical estimate or catheter measurement of urethral mid-point result in similar retropubic mid-urethral sling position: a randomized trial

INTRODUCTION AND HYPOTHESIS

The objective was to determine whether standardized, intraoperative urethral measurement improves retropubic mid-urethral sling (RPMUS) positioning and if the intraoperative position remains stable at 2 weeks postoperatively.

METHODS

Participants undergoing a RPMUS were randomized to mid-urethral placement as per usual surgical care (no Foley catheter measurement, no-FCM) vs urethral mid-point Foley catheter measurement (FCM). The primary outcomes were RPMUS location as determined by 2D and 3D ultrasound 2 weeks postoperatively (as percentage from urethral meatus - relative to the urethral length) and intraoperatively following the RPMUS placement.

RESULTS

Forty-four women enrolled, underwent RPMUS, and provided baseline data and intraoperative ultrasound measurements; of these, 36 (82%) had interpretable intraoperative and postoperative ultrasound measurements. Demographic data were similar in the two groups. The mean RPMUS mid-point was 57 % and 55 % in measured and controls (p = 0.685); this same measurement was relatively unchanged at 2 weeks postoperatively at 57% and 54% respectively (p = 0.538). Very much and much improvement was reported on the PGI-I by 84% and 85% of participants in the FCM and no-FCM groups respectively.

CONCLUSIONS

Intraoperative RPMUS position at 2 weeks after surgery is similar to the intraoperative position. Compared with usual surgical care, intraoperative measurement of urethral mid-point with a Foley catheter did not affect RPMUS sling position.

ACR Appropriateness Criteria® Pelvic Floor Dysfunction in Females

Pelvic floor disorders including pelvic organ prolapse (POP), urinary dysfunction, defecatory dysfunction, and complications after pelvic floor surgery are relatively common in the female population. Imaging tests are obtained when the initial clinical evaluation is thought to be incomplete or inconclusive or demonstrates findings that are discordant with patients' symptoms. An integrated imaging approach is optimal to evaluate the complex anatomy and dynamic functionality of the pelvic floor. Fluoroscopic cystocolpoproctography (CCP) and MR defecography are considered the initial imaging tests of choice for evaluation of POP. Fluoroscopic voiding cystourethrography is considered the initial imaging test for patients with urinary dysfunction. Fluoroscopic CCP and MR defecography are considered the initial imaging test for patients with defecatory dysfunction, whereas ultrasound pelvis transrectal is a complementary test in patients requiring evaluation for anal sphincter defects. MRI pelvis without and with intravenous contrast, MRI pelvis with dynamic maneuvers, and MR defecography are considered the initial imaging tests in patients with suspected complications of prior pelvic floor surgical repair. Transperineal ultrasound is emerging as an important imaging tool, in particular for screening of pelvic floor dysfunction and for evaluation of midurethral slings, vaginal mesh, and complications related to prior pelvic floor surgical repair. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

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.

Ultrasonographic Imaging of the Pelvic Floor

This article discusses various pelvic floor ultrasonographic modalities and the clinical applications of ultrasonography of the pelvic floor. Ultrasonography provides a detailed anatomic assessment of the muscles and surrounding organs of the pelvic floor. Different anatomic variabilities and pathologic conditions, such as prolapse, fecal incontinence, urinary symptoms, vaginal wall cysts, synthetic implanted material, and pelvic pain, are assessed with pelvic floor ultrasonography. This imaging modality is an important adjunct to the evaluation and diagnosis of pelvic floor disorders.

Durability of Macroplastique volume and configuration in women with stress urinary incontinence secondary to intrinsic sphincter deficiency: A retrospective review

OBJECTIVES

To evaluate the durability of Macroplastique® (MPQ) volume and configuration in women with stress urinary incontinence (SUI) secondary to intrinsic sphincter deficiency (ISD) using serial three-dimensional ultrasound (3DUS) measurements.

METHODS

Following Institutional Review Board approval, charts of women with SUI and ISD (defined based on leak point pressure; lateral imaging of urethral support without hypermobility) who underwent MPQ were reviewed from a prospectively maintained database. All had at least two serial transperineal 3DUS measurements with no MPQ or other bulking agent injection between measurements. 3DUS was performed using the Philips IU22 ultrasound system with endovaginal 3D 9-3V end-fire probe typically at 6-8 weeks post-injection and yearly thereafter. The same imaging team blinded to clinical outcomes evaluated volume and configuration (circumferential/symmetric or asymmetric) at each 3DUS.

RESULTS

Between 2011 and 2019, 62 of 174 women met study criteria. Those with prior other bulking agent injection or having ≤1 3DUS follow-up were excluded. Seventy-one percent of patients had one injection, while the remainder had two or more (29%). Median time between first and second 3DUS was 12 months. The mean change in MPQ volume between the first and last 3DUS measurement was -0.2 cc (95% CI: -0.5 to 0.004; P = .054). A median of 5.0 cc were injected in each patient. Forty-seven women had symmetric MPQ at first 3DUS, of whom only five (11%) had a follow-up 3DUS showing asymmetric MPQ distribution.

CONCLUSIONS

At mid-term follow-up, repeat transperineal 3DUS after MPQ injection revealed minimal change in volume and configuration in the urethral wall.

Association between 3D endovaginal and 2D perineal pelvic floor ultrasound findings and symptoms in women presenting with mid-urethral sling complications

OBJECTIVES

To present the characteristics of women attending a tertiary urogynecology pelvic floor scan clinic with mid-urethral sling (MUS) complications and examine the association between patient symptoms and findings on two-dimensional (2D) perineal and three-dimensional (3D) endovaginal ultrasound.

METHODS

This was a cross-sectional study of all women with MUS complications referred to a specialist pelvic floor ultrasound clinic between October 2016 and October 2018. Detailed history was obtained regarding their symptoms and time of onset. All patients underwent 2D perineal and 3D endovaginal ultrasound assessment. The association between patient symptoms and ultrasound findings was evaluated using logistic regression analysis. Only symptomatic women with a single MUS, without other pelvic floor mesh, prior mesh excision or bulking agents, were included in the regression analysis.

RESULTS

A total of 311 women with a history of MUS surgery were seen during the study period. Vaginal and/or non-vaginal pain was reported by 80% of patients and this was the primary presenting complaint in 59% of the patients. One-third of the patients reported symptoms starting within 4 weeks after surgery. The data of 172 patients were included in the regression analysis. MUS position within the rhabdosphincter was significantly associated with voiding dysfunction (odds ratio (OR), 10.6 (95% CI, 2.2-50.9); P = 0.003). Voiding dysfunction was highest in those with C-shaped MUS both at rest and on Valsalva maneuver (OR, 3.2 (95% CI, 1.3-7.6); P < 0.001). MUS position in the distal third of the urethra was significantly associated with a higher rate of recurrent urinary tract infection (OR, 2.9 (95% CI, 1.3-6.3); P = 0.01).

CONCLUSIONS

Pelvic floor ultrasound can provide insight into the position and shape of the MUS, which could explain some patient symptoms and guide management or surgical planning. © 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Injection of Urethral Bulking Agents

Urethral injection is a safe and minimally invasive method of treating female stress urinary incontinence with multiple bulking agents currently commercially available. Although there are numerous studies that demonstrate efficacy, long-term success is not yet proven. This article aims to describe the mechanism of action and properties of various agents, patient selection factors, available techniques for injection, outcomes of urethral injections, and complications associated with the procedure.

Agreement between simple catheter method and 3D transperineal ultrasound for assessing urethral length measurement before stress urinary incontinence treatment

AIMS

Optimal placement of periurethral material has an important role in treatment efficacy with stress urinary incontinence (SUI). The validity of methods for determining urethral length and the precise location of the mid-urethral complex for SUI treatment have been sparsely studied. The aim of this study was to investigate the agreement between urethral lengths measured with a catheter and by transperineal ultrasound.

METHODS

Fifty-seven women with SUI or mixed urinary incontinence (MUI) with predominant stress symptoms were recruited. The urethral length was assessed with 3D transperineal ultrasound and measurements were taken offline from the postero-inferior margin of the pubic symphysis to the bladder neck. Then, it was measured with a foley catheter by another evaluator, blinded to the ultrasound data. The distance between the inflated balloon and the urethral meatus was considered.

RESULTS

Thirty-three women (58%) had SUI and 24 (42%) had MUI. The mean urethral length evaluated with ultrasound and the catheter were 3.03 ± 0.34 cm and 3.02 ± 0.41 cm (P = 0.857), respectively. Agreement between the two methods as assessed by the intra-class correlation coefficient was 0.90 (CI0.82-0.94, P ≤ 0.001). Limits of agreement (Bland-Altman) were +0.46 to -0.45 cm, with a mean difference of -0.01 ± 0.23 cm.

CONCLUSIONS

Findings of this study, reveal an excellent agreement between a simple catheter technique and ultrasound assessment for measuring urethral length, with a small mean bias and clinically acceptable limits of agreement. This provides relevant information in clinical practice for determining optimal placement of periurethral material or mid-urethral tape for SUI treatment.

The Location and Distribution of Transurethral Bulking Agent: 3-Dimensional Ultrasound Study

OBJECTIVES

To use 3-dimensional endovaginal ultrasound to describe the location and distribution of bulking agent after an uncomplicated transurethral injection.

METHODS

Endovaginal ultrasound was performed in 24 treatment-naive patients immediately after bulking agent was injected. The distance between the center of the hyperechoic density of bulking agent and the urethrovesical junction (UVJ) was measured in the sagittal and axial views. This was calculated in percentile length of urethra. Also, the pattern of tracking of bulking agent was assessed if it is presented.

RESULTS

After the 2 subjects were excluded because of the poor quality of images, 22 patients were included in this study. Eighteen (82%) subjects showed 2 sites of bulking agents, and mostly, they were located around 3- and 9-o'clock positions. The average distance of bulking agent from left UVJ was at 16.9% of the length of the urethra (6.2 mm; range, 0.5-17 mm) and at 25.5% of the length of the urethra (8.9 mm; range, 0-24.8 mm) in the right side. The average length of urethra was 36.7 mm. Eleven of the 22 subjects (50%) had both sides within upper one third of urethra. The difference in distance between the 2 sides was less than 10 mm in 12 of 22 patients (54%). Nine of the 22 patients (41%) had a significant spread of bulking agent mostly either into the bladder neck or toward the distal urethra.

CONCLUSIONS

Although the bulking agent is most often found at 3- and 9-o'clock positions as intended, the distance from the UVJ is highly variable after an uncomplicated office-based transurethral injection. The bulking material does not form the characteristic spheres in 41% of cases and tracks toward the bladder neck or the distal urethra.

Three-dimensional endovaginal sonography of synthetic implanted materials in the female pelvic floor

The objective of this pictorial essay is to emphasize the ability of 3-dimensional endovaginal sonography to image synthetic implanted materials in the female pelvic floor. Implanted materials discussed in this pictorial essay include polypropylene vaginal mesh, polypropylene suburethral slings, and urethral bulking agents. Three-dimensional endovaginal sonography allows for more detailed imaging compared to computed tomography and magnetic resonance imaging of the female pelvic floor, in that each plane can be manipulated to show unique images of synthetic implanted materials.

Imaging of Urethral Bulking Agents

Urethral bulking is an office procedure for treatment of stress urinary incontinence that has increased in popularity in recent years. Numerous types of urethral bulking agents have been used since its introduction in the 1930s. Typically, these agents are imaged using specialty 3D 360° field-of-view transducers; however, a sonographer, during a pelvic or renal examination, may inadvertently find and image an echogenic structure near the urethrovesical junction in patients with a history of urethral bulking. Familiarizing oneself with the sonographic appearance of urethral bulking agents and optimizing techniques to obtain improved images of these agents may eliminate the need for additional imaging for the patient. Urethral bulking can be readily imaged with transducers commonly found in most ultrasound departments. This review will focus on the sonographic characteristics of urethral bulking agents and knowing when and how to use appropriate transducers to image the urethra.