Particulate Versus Non-Particulate Bulking Agents In The Treatment Of Stress Urinary Incontinence

Tension-Free Vaginal Tape versus Polyacrylamide Hydrogel Injection for Stress Urinary Incontinence - 5-Year Follow-Up

BACKGROUND

Tension-free vaginal tape has been the gold standard of treatment for female stress urinary incontinence, but concerns have risen about the safety of mesh. Transurethral injection of polyacrylamide hydrogel (PAHG) is a minimally invasive alternative. However, the long-term safety, efficacy, and patient satisfaction of PAHG is undefined.

METHODS

We conducted a randomized, controlled, noninferiority (margin 20%) trial at Helsinki University Hospital, Finland, comparing tension-free vaginal tape with PAHG treatment. The primary outcome was patient satisfaction. Secondary outcomes were effectiveness and complications. The results at 1 and 3 years have been previously reported. Herein, we report the 5-year follow-up.

RESULTS

Of the 223 women originally randomly assigned to a treatment group, 212 women underwent treatment as randomly assigned and, at 5 years, 195 (92.0%) women attended the follow-up. The median satisfaction score (visual analog scale: range, 0 to 100; higher scores indicated higher satisfaction) was 98 (interquartile range, 86 to 100) in the tension-free vaginal tape group, and 90 (interquartile range, 75 to 99) in the PAHG group, whereas a score of 80 or more was reached in 89 (92.7%) and 74 (74.7%) participants (difference, 18.0 percentage points; 95% confidence interval [CI], 7.7 to 28.0), respectively. Thus, PAHG did not meet the noninferiority criteria set in our trial. Within the 5-year follow-up, a peri- or postoperative complication before crossover between the groups was detected in 42 (43.8%) women in the tension-free vaginal tape group and 22 (22.2%) women in the PAHG group (difference, 21.5 percentage points; 95% CI, 8.4 to 33.8).

CONCLUSIONS

In long-term follow-up, treatment of stress urinary incontinence with PAHG was not noninferior to treatment with tension-free vaginal tape with respect to patient satisfaction scores. Complications were twice as common in the tension-free vaginal tape group. (Funded by Helsinki University Hospital and Contura; ClinicalTrials.gov number, NCT02538991.).

Urethral Bulking

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.

A comprehensive review on hydrogel materials in urology: Problems, methods, and new opportunities

Hydrogel materials provide an extremely promising group of materials that can find an increasingly wide range of use in treating urinary system conditions due to their unique properties. The present review describes achievements to date in terms of the use and development prospects of hydrogel materials applications in the treatment and reconstruction of the urinary system organs, which among others include: hydrogel systems of intravesical drug delivery, ureteral stents design, treatment of vesicoureteral reflux, urinary bladder and urethral defects reconstruction, design of modern urinary catheters and also solutions applied in urinary incontinence therapy (Figure 4). In addition, hydrogel materials find increasingly growing applications in the construction of educational simulation models of organs and specific conditions of the urinary system, which enable the education of medical personnel. Numerous research efforts are underway to expand the existing treatment methods and reconstruction of the urinary system based on hydrogel materials. After conducting the further necessary research, many of the innovative solutions developed to date have high application potential.

A diagnostic conundrum: Is it a periurethral diverticulum/cyst or a bulking agent (Bulkamid)?

INTRODUCTION

Urethral bulking agents are commonly used to manage female stress urinary incontinence (SUI) as they have been suggested to be safe, efficacious, and a minimally invasive surgical option. Bulkamid is a newer bulking agent that has been introduced and promoted in the market for use. It is non-particulate in nature with high tissue biocompatibility, and consequently, it is difficult to differentiate between Bulkamid and a periurethral cyst on magnetic resonance imaging (MRI). This, therefore, presents a diagnostic dilemma.

METHODS AND MATERIALS

Here we describe two cases with previous injections of Bulkamid referred to our Centre for management of a presumed periurethral diverticulum based on MRI findings. Both patients were reviewed and examined in outpatient clinics with MRI findings discussed at MDT, further imaging was required.

RESULTS

We found that a limited noncontrast computed tomography (CT) pelvis, followed by a voiding cystometrogram (VCMG), and then a repeat limited noncontrast CT pelvis effectively differentiated between Bulkamid and these presumed periurethral diverticulae. The theory behind this was that during micturition, the contrast would pass through to the urethral diverticulum and appear as high-density (bright) material within the periurethral region (the pre-VCMG was required to prove that any high-density material was due to the contrast and not pre-existing high-contrast material).

CONCLUSION

A CT scan done in conjunction with a VCMG is likely to be more effective in differentiating between Bulkamid and a true periurethral diverticulum than an MRI scan. Appropriate diagnostic evaluation of periurethral lesions can lead to time-saving and cost-effective patient management as this will bypass the need for unnecessary investigations and possible unwarranted surgical intervention.

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 agents: a retrospective review of primary versus salvage procedure outcomes

PURPOSE

Urethral bulking agents (UBA) have traditionally been offered as salvage procedures for recurrent stress urinary incontinence (SUI). We compare the success of UBA in patients that had undergone a previous procedure for SUI (Salvage-UBA) to the SUI surgery naïve (Primary-UBA). We hypothesised a positive effect in both Primary and Salvage-UBA with potentially poorer rates of response in the salvage group.

METHODS

Retrospective case series of patients having their first UBA (2010-2018). Primary outcome was to assess any difference in patient reported success between groups. Patient-reported improvement was assessed on a 4-point scale: 'cured, improved, no change, worse' and treatment 'success' defined as 'cured' or 'improved'. A multivariate analysis, adjusting for plausible differences between groups, was undertaken in IBM SPSS Statistics (2016).

RESULTS

135 Primary-UBA and 38 Salvage-UBA were performed. Complete follow-up was obtained for 114 patients (66%): 86 Primary and 28 Salvage. Median follow-up time: 33 months. In 2012, 47% (8/17) of all UBA were Salvage-UBA, whilst in 2018, the majority were Primary-UBA (92%, 46/50). Success was not significantly different between Salvage-UBA 75% (21/28) versus Primary-UBA 67% (58/86) (Wald χ2 = 0.687, df = 1, p = 0.407). Top-up rates were similar: 14% (n = 4/28, Salvage-UBA) versus 15% (n = 13/86, Primary-UBA) (χ2 = 0.011, df = 1, p = 0.914).

CONCLUSION

The number of women opting for UBA has increased substantially. No significant differences were noted for success with Salvage-UBA compared to Primary-UBA.