1
|
Fleischmann N, Chughtai B, Plair A, Hurtado E, Jacobson N, Segal S, Panza J, Cichowski SB. Urethral Bulking. UROGYNECOLOGY (PHILADELPHIA, PA.) 2024; 30:667-682. [PMID: 39051928 DOI: 10.1097/spv.0000000000001548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/27/2024]
Abstract
OBJECTIVE This Clinical Practice Statement aims to provide clinicians with evidence-based guidance for the use of urethral bulking agents (UBAs) in the treatment of stress urinary incontinence (SUI). METHODS We conducted a structured search of the English literature published from January 1960 to November 2022. Search terms identified studies of both current and historic UBAs. Data extracted at the time of full-text review included type of study, research setting, number of participants, age group, bulking agent, primary outcome, secondary outcome, efficacy, and complications. RESULTS One thousand five hundred ninety-four nonduplicate articles were identified using the search criteria. After limiting the article types to randomized control led trials, prospective studies, guideline documents, reviews, meta-analyses, and case reports of complications, 395 studies were screened. CONCLUSIONS Based on our findings, we propose the following recommendations for clinicians when considering UBA: First, UBA is indicated in cases of demonstrable SUI. Intrinsic sphincter deficiency is not predictive of patient outcomes. Second, patients should be counseled on the risks, lack of long-term efficacy data, potential need for repeat injections, possible need for surgery for recurrent SUI, implications for future procedures, and pelvic imaging findings that may be observed after UBA. Third, UBA may be considered for initial management of SUI. Fourth, UBA is an option for patients with persistent or recurrent SUI after a sling procedure. Fifth, clinicians may prioritize UBA over surgery in specific patient populations. Sixth, polyacrylamide hydrogel demonstrates marginally improved safety and durability data over other available agents.
Collapse
Affiliation(s)
| | | | - Andre Plair
- Stony Brook Medicine University Hospital, Stony Brook, NY
| | | | - Nina Jacobson
- Hackensack Meridian School of Medicine/Jersey Shore University Medical Center, Neptune, NJ
| | - Saya Segal
- Weill Cornell Medical College, New York, NY
| | - Joseph Panza
- University of Rochester Medical Center, Rochester, NY
| | | |
Collapse
|
2
|
Russell R, Rhodes S, Gupta A, Bretschneider CE, Ferrando CA, Hijaz A, Shoag J, Sheyn D. Comparison of Morbidity and Retreatment After Urethral Bulking or Midurethral Sling at the Time of Pelvic Organ Prolapse Repair. Obstet Gynecol 2023; 142:1468-1476. [PMID: 37917942 DOI: 10.1097/aog.0000000000005427] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 09/11/2023] [Indexed: 11/04/2023]
Abstract
OBJECTIVE To compare postprocedure retreatment rates for stress incontinence in patients who underwent either midurethral sling or urethral bulking at the time of concomitant repair of pelvic organ prolapse (POP). METHODS This was a retrospective cohort study using data from the Premier Healthcare Database. Using Current Procedural Terminology codes, we identified patients who were undergoing POP repair and concomitant urethral bulking or midurethral sling between the years 2001 and 2018. Patients who underwent concomitant nongynecologic surgery, Burch urethropexy, or oncologic surgery, and those who did not undergo concomitant POP and anti-incontinence surgery, were excluded. Additional data collected included patient demographics, hospital characteristics, surgeon volume, and comorbidities. The primary outcome was a repeat anti-incontinence procedure at 2 years, and the secondary outcome was the composite complication rate. RESULTS Over the study period, 540 (0.59%) patients underwent urethral bulking, and 91,005 (99.41%) patients underwent midurethral sling. The rate of a second procedure within 2 years was higher for urethral bulking, compared with midurethral sling (9.07% vs 1.11%, P <.001); in the urethral bulking group, 4.81% underwent repeat urethral bulking and 4.81% underwent midurethral sling. In the midurethral sling group, 0.77% underwent repeat midurethral sling and 0.36% underwent urethral bulking. After adjusting for confounders, midurethral sling was associated with a decreased odds of a repeat anti-incontinence procedure at 2 years (adjusted odds ratio 0.11, 95% CI 0.08-0.16). The probability of any complication at 2 years was higher with urethral bulking (23.0% vs 15.0%, P <.001). CONCLUSION Urethral bulking at the time of POP repair is associated with a higher rate of repeat procedure and postoperative morbidity up to 2 years after surgery.
Collapse
Affiliation(s)
- Rebekah Russell
- Case Western Reserve University School of Medicine, University Hospitals Cleveland, the Urology Institute, University Hospitals Cleveland, and the Department of Obstetrics and Gynecology, Cleveland Clinic, Cleveland, Ohio; the Department of Obstetrics and Gynecology, University of Louisville, Louisville, Kentucky; and the Department of Obstetrics and Gynecology, Northwestern University, Chicago, Illinois
| | | | | | | | | | | | | | | |
Collapse
|
3
|
Braga A, Caccia G, Papadia A, Treglia G, Castronovo F, Salvatore S, Torella M, Ghezzi F, Serati M. Urethral bulking agents for the treatment of recurrent stress urinary incontinence: A systematic review and meta-analysis. Maturitas 2022; 163:28-37. [PMID: 35679770 DOI: 10.1016/j.maturitas.2022.05.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 04/30/2022] [Accepted: 05/16/2022] [Indexed: 10/18/2022]
Abstract
Recurrent stress urinary incontinence (rSUI) represents a major challenge for most clinicians as there is little evidence in the literature on the best option after sling failure. The objective of this study is to summarise the findings on the use of urethral bulking agents (UBAs) in the management of rSUI after the failure of a mid-urethral sling (MUSs). We performed a systematic review and meta-analysis, according to PRISMA 2020 guidelines, and selected eleven publications for inclusion in the analysis. We found that the overall cure and improvement rate ranged from 64% to 85% in the included studies, with a pooled value of 75%, compared with pooled failure and re-operation rates of 32% (95% CI: 22%-43%) and 25% (95% CI: 17%-34%), respectively. The I2 test indicated significant statistical heterogeneity among the studies in relation to all the outcome measures; however, no risk of publication bias was found. To explore this heterogeneity in more depth, we performed a sub-group analysis of the two most commonly used bulking agents (Bulkamid and Macroplastique). The pooled values of the cure and improvement rate were 84% (95% CI: 77.0%-90.0%) and 80% (95% CI: 74.0%-85.0%) for Macroplastique and Bulkamid, respectively. We did not find significant heterogeneity or significant differences in the outcome measures in either group. For the first time in literature, our study provides an insight into the use of UBAs after failed MUSs. Although the results seem very promising, future studies with shared protocols are needed in order to recommend the use of UBAs in the treatment of recurrent cases.
Collapse
Affiliation(s)
- Andrea Braga
- Department of Obstetrics and Gynaecology, EOC - Beata Vergine Hospital, Mendrisio, Switzerland; Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland.
| | - Giorgio Caccia
- Department of Obstetrics and Gynaecology, EOC - Beata Vergine Hospital, Mendrisio, Switzerland
| | - Andrea Papadia
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland; Department of Obstetrics and Gynaecology, EOC - Civico Hospital, Lugano, Switzerland
| | - Giorgio Treglia
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland; Academic Education, Research and Innovation Area, General Directorate, Ente Ospedaliero Cantonale, Bellinzona, Switzerland; Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Fabiana Castronovo
- Department of Obstetrics and Gynaecology, EOC - Beata Vergine Hospital, Mendrisio, Switzerland
| | - Stefano Salvatore
- Department of Obstetrics and Gynaecology, IRCSS San Raffaele Scientific Institute, Milan, Italy
| | - Marco Torella
- Department of Gynaecology, Obstetric and Reproductive Science, Second University of Naples, Naples, Italy
| | - Fabio Ghezzi
- Department of Obstetrics and Gynaecology, Del Ponte Hospital, University of Insubria, Varese, Italy
| | - Maurizio Serati
- Department of Obstetrics and Gynaecology, Del Ponte Hospital, University of Insubria, Varese, Italy; President of European Urogynaecological Association (EUGA), Italy
| |
Collapse
|
4
|
Pivazyan L, Kasyan G, Grigoryan B, Pushkar D. Effectiveness and safety of bulking agents versus surgical methods in women with stress urinary incontinence: a systematic review and meta-analysis. Int Urogynecol J 2022; 33:777-787. [PMID: 34351463 DOI: 10.1007/s00192-021-04937-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 07/03/2021] [Indexed: 01/21/2023]
Abstract
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.
Collapse
Affiliation(s)
- Laura Pivazyan
- First Moscow State Medical University by I.M. Sechenov (Sechenov University), Moscow, Russian Federation
| | - George Kasyan
- Urology Department, Moscow State University of Medicine and Dentistry, 127206, Vuchetich str. 21/2, Moscow, Russian Federation.
| | - Bagrat Grigoryan
- First Moscow State Medical University by I.M. Sechenov (Sechenov University), Moscow, Russian Federation
| | - Dmitry Pushkar
- Urology Department, Moscow State University of Medicine and Dentistry, 127206, Vuchetich str. 21/2, Moscow, Russian Federation
| |
Collapse
|
5
|
Giammò A, Ammirati E, Geretto P, Manassero A, Squintone L, Falcone M, Del Popolo G, Pistolesi D, Risi O, Costantini E, Giannantoni A, Mancini V, Marzi VL, Agrò EF, Pastorello M, Musco S, Gontero P. Can urethral re-bulking improve the outcomes of a prior urethral bulking? Ther Adv Urol 2022; 14:17562872211069265. [PMID: 35069806 PMCID: PMC8771729 DOI: 10.1177/17562872211069265] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 12/08/2021] [Indexed: 11/16/2022] Open
Abstract
Aims: To analyze the outcomes of urethral re-bulking in the treatment of female stress urinary incontinence. Materials and Methods: We performed a multicenter observational retrospective study, which included all consecutive patients treated with urethral re-bulking for the treatment of persistent stress or mixed urinary incontinence after a previous urethral bulking. Objective outcomes were evaluated with the 24 h pad-test, while PGI-I questionnaires were administered to evaluate subjective outcomes. Clinical outcomes were assessed before re-bulking procedure and at last follow-up. Mann–Whitney’s U test was used for subgroup analysis. Shapiro-Wilk’s tests were used as normality tests. Results: In total, 62 patients who underwent urethral re-bulking between 2013 and 2020 in a multicenter setting were included. Most patients did not reach complete continence after the first procedure (n = 56) while the remainder reported recurrence of urinary incontinence after initial benefit. Median age at surgery was 66 (IQR: 55-73). Median overall follow-up was 30 months (IQR: 24-41). Median time occurred between the first procedure and reintervention was 12 months (IQR: 7-27). Bulking agents for the re-bulking procedures were bulkamid(n = 56), macroplastique(n = 4), and Prolastic(n = 2). A statistically significant reduction of median 24 h pad test from 100 g(IQR: 40-200) to 35 g(IQR: 0-120) was observed (p = 0.003). Dry rate after rebulking was 36.6%, while 85.4% patients declared themselves ‘very much improved’ or ‘much improved’ (PGI-I 1-2). Very few low-grade complications were observed (n = 4). A single case of major complication occurred. Conclusions: Urethral re-bulking can be an effective technique for the treatment of stress urinary incontinence refractory to a previous urethral bulking and can determine a cumulative benefit after the first procedure.
Collapse
Affiliation(s)
- Alessandro Giammò
- SC Neuro-Urologia, Spinal Cord Unit/CTO, Città della Salute e della Scienza di Torino, Torino, Italy
| | - Enrico Ammirati
- Neuro-Urology Department, CTO-Spinal Cord Unit, Città della Salute e della Scienza di Torino, Via Zuretti 24, 10126 Torino, TO, Italy
| | - Paolo Geretto
- SC Neuro-Urologia, Spinal Cord Unit/CTO, Città della Salute e della Scienza di Torino, Torino, Italy
| | - Alberto Manassero
- SC Neuro-Urologia, Spinal Cord Unit/CTO, Città della Salute e della Scienza di Torino, Torino, Italy
| | - Luisella Squintone
- SC Neuro-Urologia, Spinal Cord Unit/CTO, Città della Salute e della Scienza di Torino, Torino, Italy
| | - Marco Falcone
- SC Neuro-Urologia, Spinal Cord Unit/CTO, Città della Salute e della Scienza di Torino, Torino, Italy
| | | | - Donatella Pistolesi
- Division of Urology, Department of Translational Research and New Technologies, University of Pisa, Pisa, Italy
| | - Oreste Risi
- SSD Urodinamica, ASST Bergamo Ovest, Bergamo, Italy
| | - Elisabetta Costantini
- Andrology and Urogynecology Clinic, Santa Maria Terni Hospital, University of Perugia, Terni, Italy
| | - Antonella Giannantoni
- Functional and Surgical Urology Unit, Department of Medical and Surgical Sciences and Neurosciences, University of Siena, Siena, Italy
| | - Vito Mancini
- Department of Urology and Organ Transplantation, University of Foggia, Policlinico Riuniti, Foggia, Italy
| | - Vincenzo Li Marzi
- Urology Clinic, Careggi Hospital, University of Florence, Florence, Italy
| | | | - Mauro Pastorello
- Department of Urology, ‘Sacro Cuore-Don Calabria’ Hospital, Negrar, Italy
| | - Stefania Musco
- SOD of Neuro-Urology, Careggi University Hospital, Florence, Italy
| | - Paolo Gontero
- SC Neuro-Urologia, Spinal Cord Unit/CTO, Città della Salute e della Scienza di Torino, Torino, Italy
| |
Collapse
|