The surgical treatment of female stress urinary incontinence

The Efficacy and Mid-term Durability of Urethral Sphincter Injections of Platelet-Rich Plasma in Treatment of Female Stress Urinary Incontinence

Aims: This study investigated the therapeutic effect of repeated urethral sphincter injections of autologous platelet-rich plasma (PRP) in treatment of stress urinary incontinence (SUI) in women due to intrinsic sphincter deficiency (ISD) refractory to medical treatment or after the first anti-incontinence surgery.

Methods: Twenty-six women with SUI due to urodynamically proven ISD were prospectively enrolled. Five milliliters of PRP (2.5–5 times of the platelet concentrations in peripheral blood) were injected into the external sphincter at 5 sites, with 4 treatments at monthly interval. The primary end-point was post-treatment Global Response Assessment (GRA, scored 0–3) score after four PRP treatments. A GRA ≥ 2 was considered as a successful result. The secondary endpoints included changes in visual analog scale (VAS) of SUI and urodynamic parameters. The follow-up date was 12 months after the fourth PRP treatment.

Results: The mean age was 61.7 ± 15.3 years. The overall success rate was 50% with the post-treatment mean GRA of 1.5 ± 1.1. Complete dryness was achieved in 12 patients (46.2%) after the PRP treatment, and 7 (26.9%) kept total continence at 12 months. The mean VAS of SUI score decreased significantly from 6.4 ± 2.3 to 3.9 ± 2.3 after treatment (p < 0.001). The abdominal leak point pressure increased significantly from 117.5 ± 63.8 to 133.6 ± 61.7 cmH₂O (p = 0.045). No perioperative adverse events or severe complications occurred, except 1 (3.8%) patient reported straining to void which was self-limited.

Conclusion: Repeated urethral sphincter injections of autologous PRP are a safe procedure that provides significant reduction in the severity of female SUI and a mid-term durability, suggesting PRP treatment is effective to increase urethral sphincter resistance for female SUI.

Quality and Reliability of Publicly Accessible Information on Laser Treatments for Urinary Incontinence: What Is Available to Our Patients?

STUDY OBJECTIVE

To determine the quality and reliability of the top 20 internet search results for laser treatment of stress urinary incontinence (SUI).

DESIGN

Review of 20 websites.

SETTING

N/A.

PATIENTS

None.

INTERVENTIONS

An internet search with the most popular search engine, Google, was undertaken to identify the top 20 websites for laser treatment of SUI. The DISCERN instrument, Journal of the American Medical Association (JAMA) benchmarks, and Health on the Net Foundation Code of Conduct certification, which are standardized, validated tools for the analysis of website quality, credibility, and transparency, were used independently by 7 healthcare workers. The readability of the information was assessed by a single reviewer using the Flesch-Kincaid Grade Level and Automated Readability Index. The intraclass correlation coefficient was calculated to document the reliability among website assessors.

MEASUREMENTS AND MAIN RESULTS

Of the 20 websites reviewed, 15 were created by private clinics, 2 by online newspaper or newsletter sites, and 3 by laser medical device manufacturers. None of the websites met all of the JAMA criteria: 1 had attained authorship, 1 had clear attribution, none had adequate disclosure, and 2 achieved currency. None of the websites took part in the Health on the Net Foundation Code of Conduct certification program. The mean DISCERN score (to determine the quality of websites) was 40 (out of 80), with the lowest average scores within the DISCERN tool primarily associated with clarity around sources of information, website bias, posting dates, risks of treatment, and shared treatment decision-making. The intraclass correlation coefficient was calculated for the DISCERN tool (0.72; 95% confidence interval, 0.48-0.87) and JAMA benchmarks (0.85; 95% confidence interval, 0.73-0.93). The mean Flesch-Kincaid Grade Level was 13.2 (±3.1) and the Automated Readability Index scores ranged from 7.6 to 22.8 (mean 13.5 ± 3.5).

CONCLUSION

There is a lack of good quality, reliable, and unbiased information available to patients on laser treatment of SUI on the most commonly searched websites. Information is presented at a reading level that is above that of the average reader, which may indicate that patients will have trouble comprehending the information.

Female stress urinary incontinence MDT

The management of female stress urinary incontinence (SUI) has come under scrutiny in recent years following growing reports of mesh-related complications. Patients require thorough evaluation and management as part of a multidisciplinary team, and extensive counselling about the surgical treatment options is imperative. There is no clear consensus on the optimal management of the complex group of patients with mesh-related complications or recurrent SUI. We present two cases of female SUI to highlight the key factors to be considered when managing these patients.

Level of evidence: Level 5.

Implantable Systems for Stress Urinary Incontinence

Stress urinary incontinence (SUI), the involuntary urine leakage due to failure of the urethral closure mechanism, is a global health challenge with substantial human suffering and socioeconomic costs. Approximately 167 million male and female patients are predicted to suffer from SUI in 2018, worldwide. A wide range of surgical interventions are available for the treatment of SUI. Severe cases, however, usually require the implantation of artificial urinary sphincter devices. This review comparatively presents and analyzes the working principles, as well as the challenges, associated with the current implantable SUI systems in clinical use. These include slings, urethral bulking agents, artificial urinary sphincters, and adjustable continence devices. It further reports on recent research progress and state-of-the-art in the field of SUI implants, including an original approach proposed by the authors with a pressure feedback sensory mechanism. The new emerging field of artificial muscle devices, including electroactive polymers, provides a promising innovative solution for replacing the weakened urethral sphincter in SUI patients.

On the Stiffness of the Mesh and Urethral Mobility: A Finite Element Analysis

Midurethral slings are used to correct urethral hypermobility in female stress urinary incontinence (SUI), defined as the complaint of involuntary urine leakage when the intra-abdominal pressure (IAP) is increased. Structural and thermal features influence their mechanical properties, which may explain postoperative complications, e.g., erosion and urethral obstruction. We studied the effect of the mesh stiffness on urethral mobility at Valsalva maneuver, under impairment of the supporting structures (levator ani and/or ligaments), by using a numerical model. For that purpose, we modeled a sling with “lower” versus “higher” stiffness and evaluated the mobility of the bladder and urethra, that of the urethrovesical junction (the α-angle), and the force exerted at the fixation of the sling. The effect of impaired levator ani or pubourethral ligaments (PUL) alone on the organs displacement and α-angle opening was similar, showing their important role together on urethral stabilization. When the levator ani and all the ligaments were simulated as impaired, the descent of the bladder and urethra went up to 25.02 mm, that of the bladder neck was 14.57 mm, and the α-angle was 129.7 deg, in the range of what was found in women with SUI. Both meshes allowed returning to normal positioning, although at the cost of higher force exerted by the mesh with higher stiffness (3.4 N against 2.3 N), which can relate to tissue erosion. This finite element analysis allowed mimicking the biomechanical response of the pelvic structures in response to changing a material property of the midurethral synthetic mesh.

A study of transobturator tape in stress urinary incontinence

BACKGROUND

Stress urinary incontinence (SUI) is commonly encountered in gynecological practice. Nowadays, midurethral sling surgeries in the form of transobturator tape (TOT) surgery are recommended in its treatment.

AIMS AND OBJECTIVES

To assess the outcome and patient satisfaction of TOT surgery in the treatment of SUI.

MATERIALS AND METHODS

A prospective study was undertaken for patients of SUI who underwent TOT surgery by the outside in method and followed up for 5 years. The patients were assessed clinically and by the Patient Global Impression of Improvement (PGI-I) preoperatively and at postoperative day 3, discharge and 3 months follow-up.

RESULTS

Successful surgical treatment with TOT was seen in all patients at the time of discharge. There was no recurrence of SUI seen up to 1 year, but at 5-year follow-up two patients had a recurrence of SUI on examination though they did not complain of SUI. Urinary retention, tape extrusion, and groin stitch infection were the commonly seen complications following surgery. On subjective assessment, 61 patients were completely satisfied at day 3, and all patients were completely satisfied at discharge and 3 months follow-up as per the PGI-I score.

CONCLUSION

TOT gives an excellent outcome in the treatment of SUI.

Expert Panel Recommendations on Lower Urinary Tract Health of Women Across Their Life Span

Urologic and kidney problems are common in women across their life span and affect their daily life, including physical activity, sexual relations, social life, and future health. Urological health in women is still understudied and the underlying mechanisms of female urological dysfunctions are not fully understood. The Society for Women's Health Research (SWHR^®) recognized the need to have a roundtable discussion where researchers and clinicians would define the current state of knowledge, gaps, and recommendations for future research directions to transform women's urological health. This report summarizes the discussions, which focused on epidemiology, clinical presentation, basic science, prevention strategies, and efficacy of current therapies. Experts around the table agreed on a set of research, education, and policy recommendations that have the potential to dramatically increase awareness and improve women's urological health at all stages of life.

Attachment of Primary Vaginal Fibroblasts to Absorbable and Nonabsorbable Implant Materials Coated With Platelet-Rich Plasma: Potential Application in Pelvic Organ Prolapse Surgery

OBJECTIVES

Pelvic organ prolapse (POP) is a common condition in women. The lifetime risk of undergoing surgery to correct POP is 11%, with 30% recurrence rate. Various types of vaginal implants, absorbable and nonabsorbable, that have been introduced in pelvic floor reconstructive surgeries have numerous serious adverse effects. Platelet-rich plasma (PRP) is an autologous product that accelerates tissue healing and regeneration. We hypothesized that autologous PRP will promote human vaginal fibroblast (HVF) attachment to vaginal implants and increase their healing potential.

METHODS

Vaginal tissue biopsies were collected from postmenopausal patients with POP (n = 10) and asymptomatic control subjects (n = 4) during vaginal hysterectomy or repair. Primary cells were isolated and characterized by immunocytochemistry. Cell attachment and proliferation were compared between POP HVFs and control HVFs (n = 4/group). Twelve weeks after the surgery, blood samples were collected from 6 POP patients to obtain autologous PRP. Two meshes, absorbable (Vicryl) and nonabsorbable (Restorelle), were coated in PRP or control media; autologous POP HVFs (n = 6) were seeded on meshes for 2 hours. Cells attached to the meshes were fixed, stained with DAPI (4,6-diamidino-2-phenylindole dihydrochloride), and counted.

RESULTS

Pelvic organ prolapse HVFs were similar to control HVFs in attachment to different matrix substrates and in proliferation rate. Attachment of POP HVFs to both meshes was significantly increased after coating with PRP versus Dulbecco modified Eagle medium (Vicryl: 9875 vs. 1006 cells/cm, Restorelle: 3724 vs. 649 cells/cm; P < 0.001 for both).

CONCLUSIONS

In vitro, primary POP HVFs show better attachment to implant materials when treated with PRP, which may lead to reduced mesh-related complications in vivo, indicating its great potential for urogynecologic surgeries.

Targeted therapy for stress urinary incontinence: a systematic review based on clinical trials

INTRODUCTION

Controversy exists regarding the therapeutic benefit of cell-based therapy in the treatment of stress urinary incontinence (SUI).

AREAS COVERED

The aim of this systematic review was to evaluate evidence regarding the therapeutic effect and safety of cell-based therapy in the treatment of SUI and to propose a new approach to SUI treatment utilizing tissue engineering methodologies. We have thoroughly reviewed the literature using PubMed in order to identify only original, clinical studies involving cell therapy for SUI.

EXPERT OPINION

Cell-based therapy, as practiced today, is a safe but ineffective method for SUI treatment. The key to an optimal therapeutic outcome in SUI is accurate diagnosis combined with targeted therapy. Targeted therapy in SUI should be based on cell implantation to restore and regenerate the damaged urethral sphincter and/or the construction of a neo-pubourethral ligament utilizing tissue engineering methodologies.

Evaluation of the EmbaGYN™ Pelvic Floor Muscle Stimulator in Addition to Kegel Exercises for the Treatment of Female Stress Urinary Incontinence: A Prospective, Open-Label, Multicenter, Single-Arm Study

Aim: To assess the efficacy and safety of the EmbaGYN™ Pelvic Floor Exerciser, a battery-powered neuromuscular stimulation device with a vaginal, two-electrode stimulation probe in women with stress urinary incontinence. Materials & methods: In this prospective, open-label, multicenter, single-arm study, patients with stress urinary incontinence (n = 83) underwent 12 weeks of treatment with EmbaGYN with Kegel exercises. Results: At week 12, the mean number of incontinence episodes/day (primary end point) fell 56.2% (p = 0.152). A ≥50% decrease from baseline in incontinence episodes was seen in 65.3% of subjects (p = 0.006). The mean number of incontinence pads/day fell 57.1% (p = 0.001). Mean 24- and 1-h in-office urine loss declined 59.0% (p < 0.001) and 67% (p = 0.019), respectively. There was one nonserious device-related adverse event. Conclusion: EmbaGYN with Kegel exercises resulted in significant reductions in urine loss, incontinence pad use and improved incontinence-related quality of life, but did not have a significant effect on incontinence episodes/day.