Effectiveness and safety of bulking agents versus surgical methods in women with stress urinary incontinence: a systematic review and meta-analysis

Efficacy and safety of repeated synthetic mid-urethral sling for recurrent stress urinary incontinence: A systematic review and metanalysis

INTRODUCTION

There is no clinical consensus concerning the best surgical procedure for recurrent stress urinary incontinence (rSUI) after primary mid-urethral sling (pMUS). The aim of this meta-analysis was to evaluate efficacy and safety of repeated MUS (rMUS) in women previously submitted to pMUS.

METHODS

We performed systematic research and meta-analysis from PubMed/MEDLINE and EMBASE, according to PRISMA 2020 guidelines, until 11th of November 2024. Women with rSUI after pMUS, submitted to rMUS were included. Primary- versus repeated-MUS and retropubic (RP) versus transobturator (TO) approach were compared. rSUI cure and re-operation rates were evaluated. Seventeen articles were included. KEY FINDINGS AND LIMITATIONS: rMUS subjective and objective success rates were 68 % (95 %CI: 62 %-74 %; I2-test 70.3 %, p < 0.001) and 74 % (95 %CI: 66 %-82 %; I2-test 61.4 %, p = 0.003) respectively. No difference emerged between RP and TO approach subjectively [OR 0.92, 95 %CI 0.52-1.64; p = 0.78 (I2-test 34 %, p = 0.18)] and objectively [OR 0.80, 95 %CI 0.03-23.62; p = 0.90 (I2-test 79 %, p = 0.03)]. No difference was highlighted between pMUS and rMUS [OR 0.42, 95 %CI 0.16-1.09; p = 0.08 (I2-test 78 %, p = 0.03)] in subjective cure. No severe adverse events were reported. Reoperation rate for any indication was 5 % (95 %CI: 1 %-9%; I2-test 56.9 %, p = 0.04). Reoperation rate for rSUI was 1 % (95 %CI: 0 %-2%; I2-test 0.24 %, p = 0.37). Reoperation rate for other indications was 3 % (95 %CI: 1 %-4%; I2-test 10.9 %, p = 0.34).

CONCLUSION

rMUS is a highly effective and safe option for women with rSUI. Its excellent effectiveness, comparable to that of pMUS, and the lack of significant differences between RP and TO techniques underscore the flexibility and validity of this approach.

Outpatient Periurethral Injections of Polyacrylamide Hydrogel (Bulkamid) Under Local Anesthesia in the Office: A Prospective Single-center Series

OBJECTIVE

To report our experience of outpatient periurethral injections of Bulkamid under local anesthesia in the office in female patients for stress urinary incontinence (SUI). Polyacrylamide hydrogel (Bulkamid) is a relatively recent bulking agent which may have a better safety profile than previous generations.

METHODS

The data of all women who underwent outpatient periurethral Bulkamid injections under local anesthesia in the office at a single academic center were collected prospectively between November 2019 and August 2023. This therapeutic option was offered to patients who had SUI if >80 years old and/or had multiple comorbidities or if they declined all other therapeutic options.

RESULTS

Ninety-two patients were included. The mean age was 78 years (30-97). Twenty-two patients experienced postoperative complications (21%), 17 were Clavien 1 complication, only 1 complication was Clavien= 4. The urinary symptoms profile (USP) SUI and overactive bladder symptom (OAB) subscores and the ICIQ-SF were all significantly improved at 3 months (P <.001). The VAS for urethral coaptation self-assessed by the surgeon at the end of the procedure was the strongest predictor of postoperative outcomes. Periurethral Bulkamid injections are feasible in an outpatient setting in the office using a simplified local anesthesia protocol with great tolerance and with similar functional outcomes than previously reported. The injections have a low rate of complications and every complication has been well tolerated.

CONCLUSION

These options may be of great value in frail patients and those looking for a minimally invasive treatment. The local anesthesia protocol with the office setting may be of particular interest.

Prevalence, Diagnosis, and Management of Stress Urinary Incontinence in Women: A Collaborative Review

BACKGROUND AND OBJECTIVE

Stress urinary incontinence (SUI), defined as any involuntary leakage of urine associated with physical activity, remains underdiagnosed and undertreated. This review aims to provide an updated overview of the prevalence, diagnosis, and treatment of SUI in women, drawing upon recent evidence-based literature and clinical guidelines.

METHODS

A systematic search of the MEDLINE database was conducted to identify only the most up-to-date and relevant studies published up to February 26, 2024, including the reference ESTER systematic review. The search was limited to systematic reviews published in the preceding 1 yr. Any additional included publications were limited to those published or referenced as part of the existing/current guidelines.

KEY FINDINGS AND LIMITATIONS

Diagnosis of SUI involves a comprehensive assessment, including medical history, physical examination, and in some cases, invasive urodynamics. Pelvic floor muscle training emerges as a first-line management strategy, showing efficacy in symptom improvement when good educational instructions and supervision are provided. Surgical interventions with midurethral and single-incision slings offer a second-line option, although concerns regarding mesh-related complications persist with a decrease in its use. Moreover, the long-term efficacy of single-incision slings remains to be confirmed. Urethral bulking agents, colposuspension, and autologous fascial slings are existing alternatives supported by robust evidence, albeit with a different adverse event profile. Management of complicated and severe SUI remains challenging, with autologous fascial sling and artificial urinary sphincters being established treatments, but high-quality data remain lacking.

CONCLUSIONS AND CLINICAL IMPLICATIONS

Heightened awareness and accessibility to SUI treatment are imperative to address the gap between prevalence and medical care-seeking behavior. Pelvic floor muscle training and surgical interventions represent key modalities. However, a notable escalation in invasiveness and complication rates when transitioning to surgical interventions is clear and has resulted in a hesitance among patients to proceed along the treatment continuum, particularly in light of mesh-related complications. Ongoing research is necessary to optimize outcomes and ensure patient safety, particularly for complicated SUI where data on comparative effectiveness remain limited.

Effectiveness and Safety Profile of Urethral Bulking with Bulkamid® for Stress Urinary Incontinence: A French Multi-Center Cohort Study

INTRODUCTION AND HYPOTHESIS

Various treatment options are currently available for the management of stress urinary incontinence (SUI). This study was aimed at determining the effectiveness and safety profile of Bulkamid®, and identify predictive factors of clinical success.

METHODS

This retrospective study conducted in two French urogynecology university centers between September 2019 and December 2023 included all patients with urinary incontinence who received Bulkamid®.

RESULTS

Among the 320 patients included (median age 58.2 years), the median follow-up was 24 months. Urethral hypermobility was found in 93.4% of patients (n = 282) and 92% (n = 275) had a positive cough test. At 1 month, 68.7% of patients (n = 220) achieved clinical success, 25.6% (n = 82) improved, and 5.6% (n = 18) reported failure. At last follow-up, 63.7% of patients (n = 204) were still cured, 21.9% (n = 70) had improved, and 14.4% (n = 46) reported failure. Among the 16 patients with overactive bladder (OAB) 43.7% had a Patient Global Improvement (PGI) score of 1-2 at 1 month and 50.0% at last follow-up, with significant difference compared with patients without OAB, 81.0% had a PGI score of 1-2 at 1 month and 74.8% at last follow-up (p = 0.0006 and p = 0.04 respectively). Regarding complications, acute urinary retention occurred in 3.1% of patients (n = 10), urinary infections in 2.2% (n = 7), and transient hematuria in 7.2% (n = 23). In multivariate analysis, follow-up time was significantly associated with failure compared with improvement/cure (OR = 1.05, 95% CI 1.02-1.08, p = 0.0002).

CONCLUSION

The present large series of patients reported the effectiveness of Bulkamid® injection, a minimally invasive procedure providing good clinical outcomes at 2 years' follow-up.

Macroplastique Is a Safe and Effective Long-term Surgical Treatment for Stress Urinary Incontinence: Prospective Study with 10-Year Follow-up

BACKGROUND AND OBJECTIVE

Until a few years ago, a midurethral sling was considered the gold standard for the treatment of female stress urinary incontinence (SUI) after failure of conservative therapies. However, criticisms regarding the rate of mesh exposure and lack of long-term efficacy have led to reconsideration of other surgical procedures. Our aim was to investigate long-term subjective and objective outcomes after injection of Macroplastique, a urethral bulking agent.

METHODS

We prospectively enrolled all consecutive women complaining of pure SUI symptoms with urodynamically proven SUI who received a Macroplastique injection. We investigated patient-reported subjective outcomes using International Consultation on Incontinence Questionnaire-Short Form, Urogenital Distress Inventory, Patient Global Impression of Improvement, and Visual Analog Scale (VAS) questionnaires, and the cough stress test to assess objective outcomes. Adverse events were recorded during follow-up.

KEY FINDINGS AND LIMITATIONS

At 10 yr after Macroplastique injection, the objective cure rate was 56% and 71% of patients reported that they were satisfied. Long-term data revealed no significant decline in subjective or objective cure rates. No serious complications were reported. Study limitations include the small sample size and the lack of pad tests and bladder diaries for postoperative evaluations.

CONCLUSIONS AND CLINICAL IMPLICATIONS

Our study shows that Macroplastique injection can be an effective and safe option for the treatment of female SUI in the long term, even when used in the first-line setting.

PATIENT SUMMARY

We evaluated outcomes for women with stress urinary incontinence (SUI) who were treated with an injection of Macroplastique gel into the wall of the urethra to prevent leakage of urine. We found that this is a safe option for treatment of female SUI that is effective in the long term.

Management of Stress Urinary Incontinence by Obstetricians and Gynecologists in Jordan: A Nationwide Survey Study

BACKGROUND

Stress urinary incontinence (SUI) is a common condition that can significantly impact a patient's quality of life. Although multiple diagnostic and treatment options exist, significant variability in SUI management exists between countries. Since women's SUI prevalence in Jordan is high, and Jordan is a lower-middle-income country, this study aimed to investigate how obstetricians and gynecologists (OBGYNs) across Jordan manage and treat women with SUI.

METHOD

A Google Forms survey was prepared and sent out to Jordanian OBGYNs via WhatsApp. The results were collected and arranged in Microsoft Excel and then transferred to SPSS for statistical analysis.

RESULTS

Out of the 804 Jordanian registered OBGYNs, 497 could be reached, 240 conduct gynecological surgeries, and 94 completed the survey, providing a response rate of 39.2%. Most of the respondents were females between 41 and 55 years old. More than 70% of the OBGYNs worked in the private sector, and 88.3% operated in the capital of Jordan. Most of the respondents favored lifestyle and behavior therapy (43.6%) or pelvic floor physiotherapy (40.4%) as the first-line management for SUI. The transobturator mid-urethral sling (MUS) was the most common initial surgical treatment option. The physicians preferred two-staged procedures for the repair of pelvic organ prolapse alongside concomitant SUI. In the case of recurrent SUI following surgery, 77% of the respondents chose to refer to a urologist or urogynecologist.

CONCLUSIONS

The Jordanian OBGYNs preferred using lifestyle/behavioral therapy and pelvic floor muscle physiotherapy as the first-line treatment to manage SUI. Secondly, the MUS would be the most frequently preferred surgical choice. To effectively manage SUI, adequate training in urogynecology and referral resources are essential in lower-middle-income countries.

Current Treatment of Stress Urinary Incontinence by Bulking Agents and Laser Therapy-An Update

Stress urinary incontinence (SUI) affects around 20% of women. In addition to the established suburethral sling insertion, two less invasive approaches are of interest today: urethral bulking agents and vaginal laser therapy. This review discusses articles through December 2023 identified by a PubMed literature search using the keywords "incontinence" and "bulking" or "laser". Although the two approaches are less effective than sling insertions, there are specific conditions in which one or the other technique is more advantageous. Injecting bulking agents into the urethra only takes some minutes and works without general anesthesia. The method is particularly suited for elderly, frail, or obese patients with multiple comorbidities, but is also applicable for all patients and in combination with other therapies. Generally, the safety profile is good but differs between bulking materials. Two laser types-the Erbium:YAG laser with SMOOTH-mode and the fractional ablative CO2 laser-deliver heat into the tissue to induce tissue tightening and regeneration. Intravaginal laser therapy improves mild to moderate SUI, while studies describe how intraurethral laser therapy is also beneficial for severe SUI. Young women between childbirths, as well as postmenopausal women, may benefit from laser therapy. The method is safe, can be performed on an outpatient basis, and does not require any artificial material.

[Slings in the era of the mesh ban: now what?]

BACKGROUND

Use of midurethral slings (MUS) as gold standard for stress urinary incontinence declined after the recent US Food and Drug Administration (FDA) communication.

OBJECTIVES

What is the current status in the surgical treatment of stress urinary incontinence? What impact do regular FDA communications and numerous restrictions around the world have?

MATERIALS AND METHODS

The current literature on surgical treatment of incontinence was evaluated; medical press information and literature regarding the FDA communication were assessed. The legal situation is illustrated using the example of the Montgomery case in England.

RESULTS

Despite positive results from literature and gynecological and urological societies, there has been a significant decline in the use of MUS. The current 2022 German interdisciplinary 2k-guideline for the treatment of female stress urinary incontinence confirms the efficacy and safety of MUS.

CONCLUSION

Analysis of recent literature supports the importance of continued long-term outcome data regarding the safety and efficacy of suburethral slings for treatment of female stress urinary incontinence.

Cost-effectiveness of urethral bulking polydimethylsiloxane-Urolastic® compared with mid-urethral sling surgery for stress urinary incontinence: A two-arm cohort study

OBJECTIVE

To investigate the cost-effectiveness of urethral bulking polydimethylsiloxane-Urolastic® (PDMS-U) compared with mid-urethral sling (MUS) surgery for stress urinary incontinence (SUI) at 1-year follow-up.

DESIGN

Prospective, two-arm cohort study with 2-year follow-up.

SETTING

International multicentre.

POPULATION

Women with moderate to severe SUI.

MAIN OUTCOME MEASURES

Primary outcome was subjective cure (Patient Global Impression of Improvement).

SECONDARY OUTCOMES

objective cure (negative cough stress test), Urogenital Distress Inventory (UDI-6), complications and re-interventions. Cost-effectiveness outcomes: total costs, quality-adjusted life year (QALY) using IIQ7-scores (Incontinence Impact Questionnaire) and EQ-5D-5L, incremental cost-effectiveness ratio (ICER) and monetary benefit (adjusted for baseline confounders).

RESULTS

In all, 131 PDMS-U and 153 MUS surgery patients were treated. Subjective cure rates for MUS surgery and PDMS-U were, respectively: 101/112 (90%) versus 40/87 (46%), adjusted odds ratio (aOR; for age, body mass index [BMI], severity, type of urinary incontinence and previous SUI procedure) was 4.9. Objective cure rates for MUS surgery and PDMS-U were respectively: 98/109 (90%) versus 58/92 (63%), aOR 5.4. Average total costs for PDMS-U and MUS surgery were €3567 and €6688. ICER for MUS surgery cost €15 598 per IIQ QALY and €37 408 per EQ-5D-5L QALY. With a willingness to pay (WTP) of €25 000, MUS has a 84% chance of being cost-effective using IIQ, whereas PDMS-U has a 99% chance of being cost-effective using EQ-5D-5L.

CONCLUSION

MUS surgery is more cost-effective in realising improved disease-specific quality of life (QoL), while PDMS-U is more cost-effective in realising improved generic QoL.

Clinical Outcomes of Mid-Urethral Sling (MUS) Procedures for the Treatment of Female Urinary Incontinence: A Multicenter Study

Introduction: Stress urinary incontinence (SUI) has a significant impact on the quality of life of many women. Due to embarrassment, most women do not seek medical attention for this condition. The treatment of this problem includes preventive therapies, and in the more advanced stage of urinary incontinence, surgery is a solution. Despite doubts regarding the implantation of urological tapes, the use of tension-free minimally invasive methods constitutes the “gold standard” in the treatment of stress urinary incontinence in women. Objective: The purpose of this article was to evaluate the efficacy and safety of ultralight, polypropylene urogynecological tape (Dallop® NM ULTRALIGHT, Tricomed S.A., Poland) in the surgical treatment of female stress urinary incontinence and mixed urinary incontinence. Methods: This is a multicenter, retrospective cohort study. The included women were adults with stress urinary incontinence (Grade 2 with a positive cough test or Grade 3) or had mixed urinary incontinence and who had undergone “retropubic” or “transobturator” surgery and completed a postoperative follow-up. Results: The study included 68 women from three hospitals. All women completed <6-month and >6-month follow-ups. The median age was 55 (range 36−80). The average value of BMI in the “retropubic” group was 28.6 ± 5.58, and in the “transobturator” group, it was 26.1 ± 4.60. Sixty-three percent (63%, n = 43) of patients were operated on using the “transobturator” method, while thirty-seven percent (37%, n = 25) were operated on using the “retropubic” method. Both the “retropubic” and “transobturator” groups had comparable results in the treatment of SUI. The study showed efficiencies of 84% for the “transobturator” method and 80% for the “retropubic” method. In the “retropubic” group, intraoperative complications were reported in three patients (7%), in comparison to none in the “transobturator” group. There were no tape-related adverse events or infections reported in any case. Conclusions: The presented research confirms the safety and efficacy of retropubic and transobturator tape methods in both short- and long-term follow-up—the success rate was over 80%. In addition to the surgical method used, the experience of the surgeons also has an impact on the final outcome of the surgery. The conducted multi-center study offers the opportunity to eliminate the influence of the human factor on the effectiveness of the procedure.

Vaginal Laser Therapy for Female Stress Urinary Incontinence: New Solutions for a Well-Known Issue-A Concise Review

Background and Objectives: Insufficient connective urethra and bladder support related to childbirth and menopausal estrogen decrease leads to stress urinary incontinence (SUI). The aim of this review is to narratively report the efficacy and safety of new mini-invasive solutions for SUI treatment as laser energy devices, in particular, the microablative fractional carbon dioxide laser and the non-ablative Erbium-YAG laser. Materials and Methods: For this narrative review, a search of literature from PubMed and EMBASE was performed to evaluate the relevant studies and was limited to English language articles, published from January 2015 to February 2022. Results: A significant subjective improvement, assessed by the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-UI-SF) was reported at the 6-month follow up, with a cure rate ranged from 21% to 38%. A reduction of effect was evidenced between 6 and 24-36 months. Additionally, the 1-h pad weight test evidence a significant objective improvement at the 2-6-month follow up. Conclusions: SUI after vaginal laser therapy resulted statistically improved in almost all studies at short-term follow up, resulting a safe and feasible option in mild SUI. However, cure rates were low, longer-term data actually lacks and the high heterogeneity of methods limits the general recommendations. Larger RCTs evaluating long-term effects are required.

Effectiveness and safety of bulking agents versus surgical methods in women with stress urinary incontinence: a systematic review and meta-analysis

INTRODUCTION AND HYPOTHESIS

The objective was to evaluate the efficacy and safety of bulking agents compared with surgical methods for female stress urinary incontinence.

METHODS

Inclusion and exclusion criteria: women with stress urinary incontinence. Bulking agents versus any surgical treatment as a comparison. Patients with other types of incontinence and treatment were excluded. Electronic databases (PubMed, MEDLINE, and the Cochrane Library) were searched from 2000 until 2021 to identify articles evaluating the effectiveness and safety of urethral bulking agents versus surgical methods. Risk-of-bias assessment tools recommended by the Cochrane Society were used to evaluate the risk of bias in the studies included.

RESULTS

Six studies were included in the quantitative synthesis for a total of 710 patients. Our systematic review and meta-analysis showed that bulking agents are less effective than surgical procedures according to subjective improvement after treatment (RR = 0.70, 95% CI: 0.53 to 0.92, p = 0.01). There was no statistically significant difference between these two methods with regard to complications after the intervention (RR = 1.30, 95% CI: 0.30 to 5.66, p = 0.73).

CONCLUSION

The main limitation of this systematic review and meta-analysis was the absence of a common objective outcome measure to evaluate effectiveness. However, it shows that bulking agents are less effective than surgical procedures in subjective improvement. Safety analysis showed no significant difference between these methods. Hence, we believe that the first and final surgery is considered to be the best.

Urethral Bulking in the Treatment of Stress and Mixed Female Urinary Incontinence: Results from a Multicenter Cohort and Predictors of Clinical Outcomes

The aim of the present study is to analyze the outcomes of urethral bulking in the treatment of non-neurogenic female stress and mixed urinary incontinence and to assess predictors of clinical outcomes. We retrospectively included all consecutive patients affected by stress or mixed urinary incontinence and treated with urethral bulking. Outcomes were evaluated via the PGI-I questionnaire and the 24-h pad test. Between January 2010 and January 2020, we treated 216 patients (Bulkamid n = 206; Macro-plastique n = 10). The median age at surgery was 66 years (IQR 55−73.75). The median follow-up was 12 months (IQR 12−24). In total, 23.8% of patients were subjected to prior incontinence surgery, 63.8% of patients were affected by genuine stress urinary incontinence, 36.2% reported mixed urinary incontinence, whereas detrusor overactivity was confirmed in only 24.9%. The dry rate was 32.9%; nevertheless, 69.9% of patients declared themselves “very improved” or “improved” (PGI-I1-2). Low complications were observed, mostly classified as Clavien I. After univariate and multivariate analyses, the only statistically significant independent predictor of “dry” outcome was the 24 h pad test, p < 0.001. Urethral bulking could be proposed with more expectations of success in patients with mild urinary incontinence. Patients affected by moderate−severe incontinence are less likely to obtain clinical success; therefore, they should be carefully counselled about clinical expectations before the procedure.