Abstract 3488: Associations of circulating hormones with mammographic density in postmenopausal women referred to diagnostic breast biopsy

Introduction Elevated mammographic density (MD) is a strong and independent risk factor for breast cancer, though underlying mechanisms are unclear. Prior studies have suggested that increased cumulative exposure to sex-steroid hormones and growth factors may impact both MD and MD-related breast cancer risk; however, most studies have only evaluated individual hormones. In this study, we simultaneously explored the relationship between 29 circulating hormones and growth factors with MD among postmenopausal women undergoing diagnostic breast biopsy.

Methods We used data from 89 postmenopausal women, aged 44-65, who had complete measurements of 29 serum hormones from a single pre-biopsy blood draw (i.e., sex-steroid hormones: 15 estrogen/estrogen metabolites, 7 progesterone/progesterone metabolites; and non-sex hormones: insulin-like growth factor I and binding proteins (IGFBPs) 2-7). Volumetric MD (% fibroglandular volume) was assessed in pre-biopsy digital mammograms using single X-ray absorptiometry. Sufficient dimension reduction methods were used to compute a composite marker score that accommodates correlations among hormones and their relationship to MD. Backward elimination was applied to select log-transformed hormones contributing to the score at α=0.05; multivariable linear regression was used to further examine associations between selected hormones and MD within a single model, adjusting for age and BMI.

Results Pearson correlations between hormones were moderate-to-strong. Dimension reduction methods identified 6 hormones as associated with MD (p<0.05): estradiol, 2-hydroxyestradiol, 2-methoxyestrone, 16-ketoestradiol, IGFBP-2, and 17α-hydroxyprogesterone, in models that considered MD as either continuous or dichotomous (>median vs. ≤median); BMI was consistently identified as the most significant predictor of MD (P <0.0001). In a multivariable linear regression model that included these 6 hormones, in addition to age and BMI, higher levels of 2-methoxyestrone, IGFBP-2, and 17α-hydroxyprogesterone were significantly associated with increased MD, whereas higher levels of age and BMI were significantly associated with lower MD.

Conclusions We identified 6 out of 29 correlated hormones that were significantly associated with MD among postmenopausal women. For several, the directions of their associations with MD were comparable to those observed in prior studies that have separately evaluated these hormones in relation to breast cancer risk. We plan to further explore how circulating hormones concurrently affect MD in premenopausal women, accounting for menstrual cycle phase. Incorporation of dimension reduction methods in studies of multiple correlated hormones can help uncover new etiologic insights into the role of hormones and growth factors in MD and breast carcinogenesis and inform strategies for prevention.

Citation Format: Shaoqi Fan, Ruth M. Pfeiffer, Manila Hada, Roni T. Falk, Maeve Mullooly, Hannah Oh, Berta Geller, Pamela Vacek, Donald Weave, John Shepherd, Jeff Wang, Sally Herschorn, Louise A. Brinton, Xia Xu, Mark E. Sherman, Britton Trabert, Gretchen L. Gierach. Associations of circulating hormones with mammographic density in postmenopausal women referred to diagnostic breast biopsy [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 3488.

Screening Performance of Digital Breast Tomosynthesis vs Digital Mammography in Community Practice by Patient Age, Screening Round, and Breast Density

Importance

Digital mammography (DM) and digital breast tomosynthesis (DBT) are used for routine breast cancer screening. There is minimal evidence on performance outcomes by age, screening round, and breast density in community practice.

Objective

To compare DM vs DBT performance by age, baseline vs subsequent screening round, and breast density category.

Design, Setting, and Participants

This comparative effectiveness study assessed 1 584 079 screening examinations of women aged 40 to 79 years without prior history of breast cancer, mastectomy, or breast augmentation undergoing screening mammography at 46 participating Breast Cancer Surveillance Consortium facilities from January 2010 to April 2018.

Exposures

Age, Breast Imaging Reporting and Data System breast density category, screening round, and modality.

Main Outcomes and Measures

Absolute rates and relative risks (RRs) of screening recall and cancer detection.

Results

Of 1 273 492 DM and 310 587 DBT examinations analyzed, 1 028 891 examinations (65.0%) were of white non-Hispanic women; 399 952 women (25.2%) were younger than 50 years; and 671 136 women (42.4%) had heterogeneously dense or extremely dense breasts. Adjusted differences in DM vs DBT performance were largest on baseline examinations: for example, per 1000 baseline examinations in women ages 50 to 59, recall rates decreased from 241 examinations for DM to 204 examinations for DBT (RR, 0.84; 95% CI, 0.73-0.98), and cancer detection rates increased from 5.9 with DM to 8.8 with DBT (RR, 1.50; 95% CI, 1.10-2.08). On subsequent examinations, women aged 40 to 79 years with heterogeneously dense breasts had improved recall rates and improved cancer detection with DBT. For example, per 1000 examinations in women aged 50 to 59 years, the number of recall examinations decreased from 102 with DM to 93 with DBT (RR, 0.91; 95% CI, 0.84-0.98), and cancer detection increased from 3.7 with DM to 5.3 with DBT (RR, 1.42; 95% CI, 1.23-1.64). Women aged 50 to 79 years with scattered fibroglandular density also had improved recall and cancer detection rates with DBT. Women aged 40 to 49 years with scattered fibroglandular density and women aged 50 to 79 years with almost entirely fatty breasts benefited from improved recall rates without change in cancer detection rates. No improvements in recall or cancer detection rates were observed in women with extremely dense breasts on subsequent examinations for any age group.

Conclusions and Relevance

This study found that improvements in recall and cancer detection rates with DBT were greatest on baseline mammograms. On subsequent screening mammograms, the benefits of DBT varied by age and breast density. Women with extremely dense breasts did not benefit from improved recall or cancer detection with DBT on subsequent screening rounds.

Relationship of circulating insulin-like growth factor-I and binding proteins 1-7 with mammographic density among women undergoing image-guided diagnostic breast biopsy

Background

Mammographic density (MD) is a strong breast cancer risk factor that reflects fibroglandular and adipose tissue composition, but its biologic underpinnings are poorly understood. Insulin-like growth factor binding proteins (IGFBPs) are markers that may be associated with MD given their hypothesized role in breast carcinogenesis. IGFBPs sequester IGF-I, limiting its bioavailability. Prior studies have found positive associations between circulating IGF-I and the IGF-I:IGFBP-3 ratio and breast cancer risk. We evaluated the associations of IGF-I, IGFBP-3, and six other IGFBPs with MD.

Methods

Serum IGF measures were quantified in 296 women, ages 40–65, undergoing diagnostic image-guided breast biopsy. Volumetric density measures (MD-V) were assessed in pre-biopsy digital mammograms using single X-ray absorptiometry. Area density measures (MD-A) were estimated by computer-assisted thresholding software. Age, body mass index (BMI), and BMI²-adjusted linear regression models were used to examine associations of serum IGF measures with MD. Effect modification by BMI was also assessed.

Results

IGF-I and IGFBP-3 were not strongly associated with MD after BMI adjustment. In multivariable analyses among premenopausal women, IGFBP-2 was positively associated with both percent MD-V (β = 1.49, p value = 0.02) and MD-A (β = 1.55, p value = 0.05). Among postmenopausal women, positive relationships between IGFBP-2 and percent MD-V (β = 2.04, p = 0.003) were observed; the positive associations between IGFBP-2 and percent MD-V were stronger among lean women (BMI < 25 kg/m²) (β = 5.32, p = 0.0002; p interaction = 0.0003).

Conclusions

In this comprehensive study of IGFBPs and MD, we observed a novel positive association between IGFBP-2 and MD, particularly among women with lower BMI. In concert with in vitro studies suggesting a dual role of IGFBP-2 on breast tissue, promoting cell proliferation as well as inhibiting tumorigenesis, our findings suggest that further studies assessing the role of IGFBP-2 in breast tissue composition, in addition to IGF-1 and IGFBP-3, are warranted.

Electronic supplementary material

The online version of this article (10.1186/s13058-019-1162-8) contains supplementary material, which is available to authorized users.

Abstract 588: Relationship of serum progesterone and progesterone metabolites with mammographic density

Background:

Mammographic breast density (MBD) is a strong breast cancer (BC) risk factor, but its biologic underpinnings are poorly understood. Use of estrogen plus progestin menopausal hormone therapy is linked to increased MBD and BC risk. Experimental data suggest that ratios of tumor promoting (5α-dihydroprogesterone [5αP]) and anti-tumorigenic (3α-dihydroprogesterone [3αP]) progesterone metabolite levels may be related to BC risk. However, relationships of endogenous progesterone and its metabolites with MBD and BC risk have not been established. Accordingly, we assessed levels of circulating progesterone and its metabolites with MBD.

Methods:

In this cross-sectional study, serum progesterone and its metabolites were quantified using a novel liquid chromatography-tandem mass spectrometry assay in 103 postmenopausal and 52 premenopausal (luteal menstrual cycle phase) women, ages 40-65, undergoing diagnostic image-guided ipsilateral breast biopsy. MBD was measured as percent fibroglandular volume (MBD-V) on pre-biopsy digital mammograms using single X-ray absorptiometry. Square-root transformed MBD-V was examined across tertile categories of progesterone/progesterone metabolites using age and body mass index (BMI)-adjusted linear regression models.

Results:

Concentrations of the hormones were as follows among postmenopausal women: progesterone [mean: 12.6 pmol/L (range: 5.2-45.8)], 3αP [5.6 pmol/L (1.4-18.8)], 5αP [100 pmol/L (16.7-388)], and 5αP/3αP ratio [26.1 (2.1-150)]; and among luteal phase premenopausal women: progesterone [2063 pmol/L (13.6-7098), 3αP [12.7 pmol/L (2.4-64.4)], 5αP [243 pmol/L (25.3-774)], 5αP/3αP ratio [25.9 (2.3-73.7)]. Among postmenopausal women, progesterone was positively associated with MBD-V (Tertile 3 vs. 1: β=0.68, p-trend=0.02). A similar borderline positive association was observed among premenopausal women (β=0.74, p-trend=0.10). Additional adjustment for circulating estradiol did not substantively alter observed associations. Levels of 3αP, 5αP and the 5αP/3αP ratio were not associated with MBD-V among pre- or postmenopausal women.

Conclusions:

Concentrations of progesterone and it metabolites show substantial inter-woman variation. We observed a positive association between endogenous progesterone and MBD-V among both postmenopausal and premenopausal luteal phase women. We did not observe an association with the ratio of 5αP to 3αP levels and MBD-V. These findings suggest the need for additional studies to understand the biological basis of the role of progesterone and its metabolites in MBD and BC risk.

Citation Format: Manila Hada, Hannah Oh, Sharon Fan, Roni T. Falk, Berta Geller, Pamela Vacek, Donald Weaver, John Shepherd, Jeff Wang, Bo Fan, Amir P. Mahmoudzadeh, Serghei Malkov, Sally Herschorn, Louise A. Brinton, Xia Xu, Mark E. Sherman, Britton Trabert, Gretchen L. Gierach. Relationship of serum progesterone and progesterone metabolites with mammographic density [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 588.

Using deep convolutional neural networks to identify and classify tumor-associated stroma in diagnostic breast biopsies

The breast stromal microenvironment is a pivotal factor in breast cancer development, growth and metastases. Although pathologists often detect morphologic changes in stroma by light microscopy, visual classification of such changes is subjective and non-quantitative, limiting its diagnostic utility. To gain insights into stromal changes associated with breast cancer, we applied automated machine learning techniques to digital images of 2387 hematoxylin and eosin stained tissue sections of benign and malignant image-guided breast biopsies performed to investigate mammographic abnormalities among 882 patients, ages 40-65 years, that were enrolled in the Breast Radiology Evaluation and Study of Tissues (BREAST) Stamp Project. Using deep convolutional neural networks, we trained an algorithm to discriminate between stroma surrounding invasive cancer and stroma from benign biopsies. In test sets (928 whole-slide images from 330 patients), this algorithm could distinguish biopsies diagnosed as invasive cancer from benign biopsies solely based on the stromal characteristics (area under the receiver operator characteristics curve = 0.962). Furthermore, without being trained specifically using ductal carcinoma in situ as an outcome, the algorithm detected tumor-associated stroma in greater amounts and at larger distances from grade 3 versus grade 1 ductal carcinoma in situ. Collectively, these results suggest that algorithms based on deep convolutional neural networks that evaluate only stroma may prove useful to classify breast biopsies and aid in understanding and evaluating the biology of breast lesions.

Emerging trends in surgical and adjuvant radiation therapies among women diagnosed with ductal carcinoma in situ

BACKGROUND

The use of surgery and radiation therapy in treating ductal carcinoma in situ (DCIS) is directed by treatment guidelines and evidence from research. This study investigated recent patterns in DCIS treatment by demographic factors.

METHODS

Data for women diagnosed with DCIS between 1998 and 2011 (n = 416,232) in the National Cancer Data Base were assessed for trends in treatment patterns by age group, calendar year, ancestral/ethnic group, and geographic region. The likelihood of receiving specific treatment modalities was analyzed with multivariable logistic regression.

RESULTS

DCIS cases were most frequently treated with breast-conserving surgery (BCS) and adjuvant radiation (45.6%). After an initial rise, the use of adjuvant radiation after BCS plateaued at approximately 70% after 2007, with increasing utilization of mastectomy beyond 2005. In addition, there was an increasing trend in postmastectomy reconstruction over time, and women of African ancestry (odds ratio [OR], 0.69; 95% confidence interval [CI], 0.66-0.72) and Hispanic women (OR, 0.83; 95% CI, 0.78-0.89) were less likely to undergo reconstruction in comparison with women of European ancestry. A similar trend was observed in contralateral risk-reducing mastectomy utilization, with women of European ancestry having a more rapid rise in the utilization of contralateral risk-reducing mastectomy in comparison with all other ancestral/ethnic groups.

CONCLUSIONS

Recent trends demonstrate a plateau in radiation therapy administration after BCS along with increasing utilization of mastectomy, reconstruction, and contralateral risk-reducing mastectomy. There are substantial differences in treatment utilization according to ancestry/ethnicity and geographical region. Further studies examining patient-physician decision making surrounding DCIS treatment are warranted. Cancer 2016. © 2016 American Cancer Society. Cancer 2016;122:2810-2818. © 2016 American Cancer Society.

Circulating insulin-like growth factor-I, insulin-like growth factor binding protein-3 and terminal duct lobular unit involution of the breast: a cross-sectional study of women with benign breast disease

Background

Terminal duct lobular units (TDLUs) are the primary structures from which breast cancers and their precursors arise. Decreased age-related TDLU involution and elevated mammographic density are both correlated and independently associated with increased breast cancer risk, suggesting that these characteristics of breast parenchyma might be linked to a common factor. Given data suggesting that increased circulating levels of insulin-like growth factors (IGFs) factors are related to reduced TDLU involution and increased mammographic density, we assessed these relationships using validated quantitative methods in a cross-sectional study of women with benign breast disease.

Methods

Serum IGF-I, IGFBP-3 and IGF-I:IGFBP-3 molar ratios were measured in 228 women, ages 40-64, who underwent diagnostic breast biopsies yielding benign diagnoses at University of Vermont affiliated centers. Biopsies were assessed for three separate measures inversely related to TDLU involution: numbers of TDLUs per unit of tissue area (“TDLU count”), median TDLU diameter (“TDLU span”), and number of acini per TDLU (“acini count”). Regression models, stratified by menopausal status and adjusted for potential confounders, were used to assess the associations of TDLU count, median TDLU span and median acini count per TDLU with tertiles of circulating IGFs. Given that mammographic density is associated with both IGF levels and breast cancer risk, we also stratified these associations by mammographic density.

Results

Higher IGF-I levels among postmenopausal women and an elevated IGF-I:IGFBP-3 ratio among all women were associated with higher TDLU counts, a marker of decreased lobular involution (P-trend = 0.009 and <0.0001, respectively); these associations were strongest among women with elevated mammographic density (P-interaction <0.01). Circulating IGF levels were not significantly associated with TDLU span or acini count per TDLU.

Conclusions

These results suggest that elevated IGF levels may define a sub-group of women with high mammographic density and limited TDLU involution, two markers that have been related to increased breast cancer risk. If confirmed in prospective studies with cancer endpoints, these data may suggest that evaluation of IGF signaling and its downstream effects may have value for risk prediction and suggest strategies for breast cancer chemoprevention through inhibition of the IGF system.

Electronic supplementary material

The online version of this article (doi:10.1186/s13058-016-0678-4) contains supplementary material, which is available to authorized users.

Abstract 2768: Relationships between mammographic density, microvessel density, and breast biopsy diagnosis

Introduction: Mammographic density (MD) is a strong breast cancer risk factor; however, the majority of women with high MD have neither a prevalent tumor nor will they develop one in immediate follow-up. Magnetic resonance imaging (MRI) studies suggest that background parenchymal enhancement, an indicator of vascularity, is another strong breast cancer risk predictor. However, it is uncertain how correlated microvessel density (MVD), a histological marker of vascularity, is with MD and if it adds information for disease detection. We therefore investigated relationships between MVD, area and volume measures of MD, and biopsy diagnosis among 218 women referred for image-guided vacuum-assisted breast biopsies.

Methods: MVD was determined by counting CD31 (endothelial marker) positive vessels in whole sections of breast biopsies in three areas containing five 40X high power fields. Average MVD per area was calculated and then transformed based on a Box-Cox analysis to approximate a normal distribution. MD volume was quantified using single X-ray absorptiometry (SXA) in digital mammograms and MD area was quantified on the same image using thresholding methods. We used linear regression to evaluate associations between MVD (as the outcome) and MD measures (area and volume) adjusted for age and body mass index (BMI) in the overall population and stratified by biopsy diagnosis: cases (in situ or invasive carcinoma, n = 44) vs. non-cases (non-proliferative or proliferative benign breast disease, n = 174). Logistic regression was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs) for the association between MVD and biopsy diagnosis (cases vs. non-cases) in models adjusted for age, BMI, and MD measures.

Results: MVD was inversely associated with absolute dense area and absolute dense volume in the overall sample (area p = 0.01, volume p = 0.11) and among non-cases (area p = 0.009, volume p = 0.007). In age-, BMI-, and dense area- or dense volume- adjusted logistic regression models, MVD was significantly associated with risk of in situ/invasive disease independent of absolute dense area (OR = 1.16, 95% CI = 1.04, 1.28) and independent of absolute dense volume (OR = 1.16, 95% CI = 1.05-1.29).

Conclusion: Our histopathologic analysis suggests that tissue vascularity, as reflected by MVD, may predict breast cancer risk independently of MD, thus providing theoretical support for the potential utility in breast cancer detection of imaging methods that reflect vascularity, such as contrast-enhanced MRI.

Citation Format: Ashley S. Felix, Petra Lenz, Ruth M. Pfeiffer, Stephen M. Hewitt, Jennifer Morris, Deesha Patel, Berta Geller, Pamela M. Vacek, Donald L. Weaver, Rachael E. Chicoine, John Shepherd, Amir P. Mahmoudzadeh, Jeff Wang, Bo Fan, Sally Herschorn, Jason Johnson, Louise A. Brinton, Mark E. Sherman, Gretchen L. Gierach. Relationships between mammographic density, microvessel density, and breast biopsy diagnosis. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 2768. doi:10.1158/1538-7445.AM2015-2768

Complications following surgery with or without radiotherapy or radiotherapy alone for prostate cancer

BACKGROUND

Men undergoing treatment of clinically localised prostate cancer may experience a number of treatment-related complications, which affect their quality of life.

METHODS

On the basis of population-based retrospective cohort of men undergoing surgery, with or without subsequent radiotherapy, or radiotherapy alone for prostate cancer in Ontario, Canada, we measured the incidence of treatment-related complications using administrative and billing data.

RESULTS

Of 36 984 patients, 15 870 (42.9%) underwent surgery alone, 4519 (12.2%) underwent surgery followed by radiotherapy, and 16 595 (44.9%) underwent radiotherapy alone. For all end points except urologic procedures, the 5-year cumulative incidence rates were lowest in the surgery only group and highest in the radiotherapy only group. Intermediary rates were seen in the surgery followed by radiotherapy group, except for urologic procedures where rates were the highest in this group. Although age and comorbidity were important predictors, radiotherapy as the primary treatment modality was associated with higher rates for all complications (adjusted hazard ratios 1.6-4.7, P=0.002 to <0.0001).

CONCLUSIONS

In patients treated for prostate cancer, radiation after surgery increases the rate of complications compared with surgery alone, though these rates remain lower than patients treated with radiation alone. This information may inform patient and physician decision making in the treatment of prostate cancer.

OnabotulinumtoxinA 100U provides significant improvements in overactive bladder symptoms in patients with urinary incontinence regardless of the number of anticholinergic therapies used or reason for inadequate management of overactive bladder

INTRODUCTION

A prespecified pooled analysis of two placebo-controlled, phase 3 trials evaluated whether the number of prior anticholinergics used or reason for their discontinuation affected the treatment response to onabotulinumtoxinA 100U in overactive bladder (OAB) patients with urinary incontinence (UI).

METHODS

Patients with symptoms of OAB received intradetrusor injections of onabotulinumtoxinA 100U or placebo, sparing the trigone. Change from baseline at week 12 in UI episodes/day, proportion of patients reporting a positive response ('greatly improved' or 'improved') on the treatment benefit scale (TBS), micturition and urgency were evaluated by number of prior anticholinergics (1, 2 or ≥ 3) and reason for their discontinuation (insufficient efficacy or side effects). Adverse events (AE) were assessed.

RESULTS

Patients had taken an average of 2.4 anticholinergics before study enrolment. OnabotulinumtoxinA reduced UI episodes/day from baseline vs. placebo, regardless of the number of prior anticholinergics (-2.82 vs. -1.52 for one prior anticholinergic; -2.58 vs. -0.58 for two prior anticholinergics; and -2.92 vs. -0.73 for three or more prior anticholinergics; all p < 0.001). The proportion of TBS responders was higher with onabotulinumtoxinA vs. placebo (69.0% vs. 37.2% for one prior anticholinergic; 58.8% vs. 24.8% for two prior anticholinergics and 56.4% vs. 22.5% for three or more prior anticholinergics; all p < 0.001). Similar results were observed regardless of the reason for discontinuation. OnabotulinumtoxinA reduced the episodes of urgency and frequency of micturition vs. placebo in all groups. AEs were well tolerated, with a comparable incidence in all groups.

CONCLUSION

In patients with symptoms of OAB who were inadequately managed by one or more anticholinergics, onabotulinumtoxinA 100U provided significant and similar treatment benefit and safety profile regardless of the number of prior anticholinergics used or reason for inadequate management of OAB. ClinicalTrials.gov: NCT00910845, NCT00910520.

Efficacy and safety of fesoterodine 8 mg in subjects with overactive bladder after a suboptimal response to tolterodine ER

AIMS

To assess fesoterodine 8 mg efficacy over time and vs. placebo in subjects with overactive bladder (OAB) who responded suboptimally to tolterodine extended release (ER) 4 mg.

METHODS

In a 12-week, double-blind trial, subjects with self-reported OAB symptoms for ≥ 6 months, mean of ≥ 8 micturitions and ≥ 2 to < 15 urgency urinary incontinence (UUI) episodes/24 h, and suboptimal response to tolterodine ER 4 mg (defined as ≤ 50% reduction in UUI episodes during 2-week run-in) were randomised to fesoterodine (4 mg for 1 week, 8 mg for 11 weeks) or placebo once daily. Change from baseline to week 12 in UUI episodes (primary end-point) was analysed in step-wise fashion: first, baseline vs. week 12 for fesoterodine; if significant, then change from baseline to week 12 for fesoterodine vs. placebo.

RESULTS

By week 12, subjects receiving fesoterodine 8 mg had significantly greater improvement from baseline vs. placebo in UUI episodes, urgency episodes and scores on the Patient Perception of Bladder Control, Urgency Perception Scale and OAB Questionnaire Symptom Bother and Health-Related Quality of Life scales and domains (all p < 0.05). 50% and 70% UUI responder rates were also significantly higher with fesoterodine 8 mg vs. placebo at week 12 (p < 0.05). Dry mouth (placebo, 4%, 12/301; fesoterodine, 16.6%, 51/308) and constipation (placebo, 1.3%, 4/301; fesoterodine, 3.9%, 12/308) were the most frequent adverse events.

CONCLUSIONS

Subjects who responded suboptimally to tolterodine ER 4 mg showed significant improvements in UUI and other OAB symptoms and patient-reported outcomes, with good tolerability, during treatment with fesoterodine 8 mg vs. placebo.

Safety and tolerability of the β3 -adrenoceptor agonist mirabegron, for the treatment of overactive bladder: results of a prospective pooled analysis of three 12-week randomised Phase III trials and of a 1-year randomised Phase III trial

AIMS

To evaluate the safety and tolerability of the β3 -adrenoceptor agonist, mirabegron, in patients with overactive bladder (OAB).

METHODS

Tolerability and safety data from three 12-week, randomised, placebo-controlled, double-blind, Phase III trials (Studies 046, 047 and 074) were pooled by treatment group. The three studies were of a similar design, although the assessed doses of mirabegron [25, 50 or 100 mg once daily (qd)] varied, and tolterodine extended release (ER) 4 mg was included as an active-control arm in Study 046 only. Tolerability and safety data from a 1-year, randomised, double-blind, Phase III trial (Study 049) are also presented. Safety variables included the incidence and severity of treatment-emergent adverse events (TEAEs), vital signs and electrocardiogram data.

RESULTS

Mirabegron (25, 50 or 100 mg qd) was safe and well-tolerated in patients with OAB over 12-week (n = 2736) and 1-year (n = 1632) periods. The incidence of TEAEs and treatment discontinuations as a result of TEAEs was low; the majority were mild in severity and few were serious. Hypertension, nasopharyngitis and urinary tract infection were the most common TEAEs with mirabegron. The mirabegron tolerability profile was similar to that seen with placebo and tolterodine ER 4 mg, except for dry mouth, which occurred, on average, five times less frequently with mirabegron than tolterodine ER 4 mg. In the pooled 12-week analysis, mirabegron 50 mg was associated with placebo-adjusted mean increases of 0.4-0.6 mmHg in blood pressure and approximately one beat per minute in pulse rate, both reversible upon treatment discontinuation. The incidence of Major Adverse Cardiovascular Events as adjudicated by an independent cardiovascular committee was low and similar across treatment groups.

CONCLUSION

The favourable tolerability profile of mirabegron in patients with OAB may allow improved treatment compliance compared with antimuscarinics, with important implications for patient outcomes.

Mirabegron for the treatment of overactive bladder: a prespecified pooled efficacy analysis and pooled safety analysis of three randomised, double-blind, placebo-controlled, phase III studies

INTRODUCTION

To examine pooled efficacy data from three, large phase III studies comparing mirabegron (50 and 100 mg) with placebo, and pooled safety data including additional mirabegron 25 mg and tolterodine extended release (ER) 4 mg results.

METHODS

This prespecified pooled analysis of three randomised, double-blind, placebo-controlled, 12-week studies, evaluated efficacy and safety of once-daily mirabegron 25 mg (safety analysis), 50 or 100 mg (efficacy and safety analyses) and tolterodine ER 4 mg (safety analysis) for the treatment of symptoms of overactive bladder (OAB). Co-primary efficacy measures were change from baseline to Final Visit in the mean number of incontinence episodes/24 h and mean number of micturitions/24 h. Key secondary efficacy end-points included mean number of urgency episodes/24 h and mean volume voided/micturitions, while other end-points included patient-reported outcomes according to the Treatment Satisfaction-Visual Analogue Scale (TS-VAS) and responder analyses [dry rate (posttreatment), ≥ 50% reduction in incontinence episodes/24 h, ≤ 8 micturitions/24 h (post hoc analysis)]. The safety analysis included adverse event (AE) reporting, laboratory assessments, ECG, postvoid residual volume and vital signs (blood pressure, pulse rate).

RESULTS

Mirabegron (50 and 100 mg once daily) demonstrated statistically significant improvements compared with placebo for the co-primary end-points, key secondary efficacy variables, TS-VAS and responder analyses (all comparisons p < 0.05). Mirabegron is well tolerated and demonstrates a good safety profile. The most common AEs (≥ 3%) included hypertension, nasopharyngitis and urinary tract infection (UTI); the incidence of hypertensive events and UTIs decreased with increasing dose. For mirabegron, the incidence of the bothersome antimuscarinic AE, dry mouth, was at placebo level and of a lesser magnitude than tolterodine.

CONCLUSION

The efficacy and safety of mirabegron are demonstrated in this large pooled clinical trial dataset in patients with OAB.

Neoadjuvant chemoradiotherapy and multivisceral resection for primary locally advanced adherent colon cancer: a single institution experience

BACKGROUND

Although there is an extensive body of literature on the role of neoadjuvant chemoradiotherapy (CRT) in the management of rectal cancer, its role in primary locally advanced adherent colon cancer (LAACC) is unclear.

OBJECTIVE

To analyzed the outcomes of neoadjuvant CRT and multivisceral resection in the management of LAACC patietns.

METHODS

We retrospectively reviewed our institutional Colorectal Carcinoma Database for 33 patients with potentially resectable, non-metastatic primary LAACC who received neoadjuvant CRT followed by multivisceral resection. CRT consisted of external beam radiation (45-50 Gy in 25 daily fractions) and concurrent 5-FU infusion (225 mg/m(2)/day).

RESULTS

There were 21 males and 12 females. Median age was 64 (31-83) and median follow-up was 36 months. All patients had microscopically clear resection margins (R0). Complete pathologic response was documented in 1 patient (3%) and 66% had ypT4b disease. Post-operative complications were observed in 36% of patients with no 30-day mortality. The 3-year overall survival and 3-year disease-free survival were 85.9% and 73.7% respectively. Two patients developed a local recurrence.

CONCLUSIONS

Neoadjuvant CRT and en-bloc multivisceral resection may result in high rates of R0 resection and excellent local control with acceptable morbidity and mortality in selected patients with LAACC.

Tolerability of solifenacin and oxybutynin immediate release in older (> 65 years) and younger (≤ 65 years) patients with overactive bladder: sub-analysis from a Canadian, randomized, double-blind study

OBJECTIVE

Overactive bladder (OAB) is a common condition whose prevalence increases with age. Antimuscarinic agents are the pharmacologic treatment of choice, but adverse events such as dry mouth may lead to early discontinuation. The purpose of this analysis was to compare the incidence and severity of dry mouth and other adverse events with solifenacin 5 mg/day and oxybutynin immediate release (IR) 15 mg/day in patients ≤ 65 years and >65 years in the Canadian VECTOR study (VEsicare in Comparison To Oxybutynin for oveRactive bladder patients).

RESEARCH DESIGN AND METHODS

VECTOR was a randomized, multicentre, prospective, double-blind, double-dummy study in 132 subjects with ≥ 1 urgency episode per 24 h, with or without urgency incontinence, and ≥ 8 micturitions per 24 h for ≥ 3 months. After a 2-week washout, patients received solifenacin 5 mg once daily or oxybutynin IR 5 mg tid for 8 weeks. For the current post-hoc analysis, adverse events were evaluated in subgroups of patients ≤ 65 years and >65 years, using a full logistic regression model, multinomial logit regression model and reduced model.

CLINICAL TRIAL REGISTRATION

NCT00431041.

RESULTS

The incidence and severity of dry mouth and other adverse events with solifenacin were similar between younger and older patients. In both age subgroups, solifenacin 5 mg/day was associated with fewer episodes and lower severity of dry mouth, and a lower discontinuation rate, compared with oxybutynin IR 15 mg/day.

CONCLUSIONS

Solifenacin 5 mg/day was better tolerated than oxybutynin IR 15 mg/day in younger (≤ 65 years) and older (> 65 years) subgroups. Solifenacin was equally well tolerated in both age subgroups. Limitations of the analysis were that the study was not preplanned to perform post-hoc subgroup analysis, patients knew that dry mouth was a primary outcome, and the study used fixed doses of each drug.

Canadian cost-effectiveness analysis of solifenacin compared to oxybutynin immediate-release in patients with overactive bladder

OBJECTIVE

To estimate the cost effectiveness of solifenacin 5 mg/day compared to oxybutynin immediate-release (IR) 15 mg/day in patients with overactive bladder, from the perspective of the Canadian healthcare (payer) system.

RESEARCH DESIGN AND METHODS

A Markov model was adapted to estimate the incremental cost per quality-adjusted life-year (QALY) of solifenacin and oxybutynin IR over a 1-year time horizon, based on efficacy and discontinuation data from the Canadian VECTOR (VEsicare in Comparison To Oxybutynin for oveRactive bladder patients) study. In the model, patients who discontinued treatment were offered tolterodine extended release 4 mg/day as second-line. Model robustness was tested using various sensitivity analyses. Utility values were derived from published literature; incontinence pads were included in a secondary analysis.

RESULTS

In the base-case analysis, total costs over 1 year were CAN$695 and CAN$550 in the solifenacin and oxybutynin IR groups, respectively. When including incontinence pad costs, there was an incremental saving of CAN$1,831 per patient with solifenacin. Solifenacin was associated with an incremental QALY gain of 0.01 over 1 year. In the base-case analysis without incontinence pads, the incremental cost-utility ratio for solifenacin was CAN$14,092. Probabilistic analyses showed no overlap in the 95% confidence intervals for total costs or QALYs with or without incontinence pads. Solifenacin was cost effective in >90% of cases, based on a willingness-to-pay threshold of CAN$50,000 per additional QALY, irrespective of whether pad costs were included in the model. The most influential variables were the discontinuation rates and the cost of incontinence pads. Limitations of the analysis relate mainly to the fact that data in the VECTOR study were collected using a direct questioning approach, which might have increased the reporting of dry mouth.

CONCLUSIONS

Solifenacin 5 mg/day was a cost-effective treatment compared with oxybutynin IR 15 mg/day.

TRIAL REGISTRATION

NCT00431041 (of the VECTOR study, upon which the analysis in this paper was based).

Multicenter randomized clinical trial comparing surgery and collagen injections for treatment of female stress urinary incontinence

OBJECTIVES

To compare, in a multicenter, randomized clinical trial, collagen injections versus surgery with regard to efficacy, quality of life, satisfaction, and complications.

METHODS

Of 133 women with stress urinary incontinence, 66 were randomized to collagen injection and 67 to surgery (6 needle bladder neck suspensions, 19 Burch, and 29 slings). After randomization, 15 women refused their allocated treatment. "Intent-to-treat" and "per protocol" analyses were applied. Women assigned to collagen injection could receive up to three injections before it was considered a failure. A "top-up" injection was allowed within 3 months after cure. Success as the primary outcome at 12 months was defined as a dry 24-hour pad test (2.5 g or less of urine) after having received only the allocated intervention.

RESULTS

The per protocol analysis showed that the success rate 12 months after collagen injections (53.1%) was much lower than that after surgery (72.2%). The difference was 19.1% (95% confidence interval -36.2% to -2%). The general and disease-specific quality-of-life scores measured by the Rand Medical Outcomes Study 36-item Health Survey and Incontinence Impact Questionnaire were similar in the two groups (P = 0.306). Women treated by surgery were, on average, more satisfied (79.6%) than those treated by collagen injection (67.2%), but the difference was not significant (P = 0.228). Finally, complications were less frequent and severe with collagen injection: 36 events in 23 subjects for collagen injection versus 84 events in 34 subjects for surgery (P = 0.03).

CONCLUSIONS

One year after intervention, the success rate of collagen injection as a treatment for stress urinary incontinence was about 19% lower than that after surgery. This has to be tempered by the similar changes in quality of life and satisfaction in both groups and that the number and severity of complications were much greater after surgery than after collagen injection. The results of this study indicate that collagen injections might be a worthwhile alternative to surgery for the treatment of stress urinary incontinence.

Urodynamic findings 3 months after radiotherapy in patients treated with conformal external beam radiotherapy for prostate carcinoma

OBJECTIVE

To quantify the effect of radiotherapy (RT) on urodynamic function 3 months after RT in patients with prostate cancer undergoing definitive external beam RT.

PATIENTS AND METHODS

Seventeen patients with clinically localized prostate cancer were accrued into a single-arm prospective study. Sixteen of the patients completed a scheduled multichannel video-urodynamic study at baseline and again 3 months after RT; the urodynamic variables were then compared to assess the nature and extent of urodynamic change caused by RT. Correlations were assessed between these quantitative changes and those in self-assessed qualitative urinary function measured by International Prostate Symptom Score (IPSS), Quality of Life assessment index (QoL) and urinary functional enquiry.

RESULTS

There were significant changes detected by the urodynamic study 3 months after RT in bladder volume at capacity (mean decrease 70 mL) and bladder volume at first sensation when supine (mean decrease 85 mL), and a lower postvoid residual volume (mean 50 mL). There was no significant change in the remaining urodynamic variables (including maximum flow rate and voided volume), nor in bladder compliance, bladder instability or bladder outlet obstruction. The self-assessed qualitative urological function measured by the IPSS, QoL and median urinary frequency/24 h showed no significant change after RT.

CONCLUSIONS

This is the first quantitative study to prospectively evaluate the effect of RT on urodynamics in patients with prostate cancer. Only a few urodynamic variables changed significantly 3 months after RT, while most, including self-assessed qualitative urinary function, did not. This finding corresponds well with the notion that most patients tolerate RT well and that acute RT-induced urinary symptoms resolve successfully, with the return of lower urinary tract function to baseline levels by 3 months after RT.

Current status of injectable agents for female stress urinary incontinence

The purpose of this review is to summarize the results of reports of injectable agents for the treatment of female urinary stress incontinence. Five agents were reviewed: collagen, Teflon, autologous fat, silicone microparticles, and silicone microballoons. Collagen was the most frequently reported agent and yielded short-term cure and improved rates of 74%-100%. This deteriorated to approximately 57% with longer term follow-up. Teflon has similarly lower longer term than short-term success rates, at 33%-76%. The reported local complications and the potential for particle migration have resulted in its lack of widespread acceptance. Autologous fat has yielded the lowest success rate. Longer term success in a small number of silicone microparticle articles was similar to the other injectables at approximately 60%. Early success with silicone microballoons was 70%. The technique is generally free of major morbidity. The indication for injectables is intrinsic sphincter deficiency but hypermobility is not a contraindication. Long-term durability, cost effectiveness, and some safety issues still have to be addressed by further clinical trials.

Female clear cell adenocarcinoma arising within a urethral diverticulum

Clear cell adenocarcinomas arising from female urethral diverticulae are rare. The optimal management of this clinical entity is uncertain. Two cases managed by a combination of surgery and XRT (radiotherapy) are presented. The common histopathological findings and treatment options are highlighted. Individualized patient management in a multi-disciplinary setting is recommended.

Ureteroscopic management of upper tract transitional cell carcinoma in patients with normal contralateral kidneys

PURPOSE

The standard treatment for upper tract transitional cell carcinoma in patients with a normal contralateral kidney is nephroureterectomy with a bladder cuff or segmental ureterectomy. We evaluate whether ureteroscopic tumor resection with vigilant surveillance is a safe alternative in select patients.

MATERIALS AND METHODS

Patients with isolated upper tract filling defects on an excretory urogram and a normal contralateral kidney were diagnosed ureteroscopically with papillary low intermediate grade appearing transitional cell carcinoma. Biopsies of the lesions were obtained, and the tumors were treated with laser ablation or electrofulguration in the same sitting. Patients with cytopathological results of high grade transitional cell carcinoma underwent nephroureterectomy. Surveillance consisted of ureteroscopy every 3 months until tumor-free and ureteroscopy every 6 months thereafter.

RESULTS

Between 1989 and 1998, 23 patients with normal creatinine (mean 1.0, range 0.7 to 1.6) underwent ureteroscopic resection of unilateral upper tract transitional cell carcinoma. On initial biopsy 22 tumors were grade 1 or 2 and 1 was grade 2 to 3. After the primary tumor was treated 8 (35%) patients remained tumor-free and 15 (65%) had multiple recurrences, which were treated ureteroscopically. Mean followup was 35 months (range 8 to 103 months). All 23 patients are alive without evidence of disease progression. At last followup 4 patients (17%) had persistent disease, 4 (17%) elected to undergo nephroureterectomy and 15 (65%) are free of ipsilateral disease for a mean duration of 17 months (range 6 to 77).

CONCLUSIONS

Ureteroscopic treatment of focal low intermediate grade superficial upper tract transitional cell carcinoma is a safe alternative to nephroureterectomy in select patients when vigilant ureteroscopic followup is used.

p53 nuclear accumulation is not associated with decreased disease-free survival in patients with node positive transitional cell carcinoma of the bladder

PURPOSE

Although the majority of patients with node positive transitional cell carcinoma of the bladder have disease progression, a definitive subset is cured by surgery only. Nuclear accumulation of p53 has been associated with disease progression in patients with superficial transitional cell carcinoma and decreased survival in those with muscle invasive disease. We determined whether p53 status would predict survival in a cohort with nodal metastasis.

MATERIALS AND METHODS

We explored the comprehensive database of all 199 radical cystectomies performed at our institution between July 1988 and September 1999. The 59 patients in this database with node positive pathology comprise our study. We performed immunohistochemical analysis of specimens using the MAB1801 antibody with greater than 20% lymph node and primary tumor nucleus staining deemed positive. Additional covariates measured included patient age, sex, pathological disease stage, adjuvant chemotherapy and nodal stage. Disease-free survival curves were generated for the various covariates and compared using the log rank test. The Cox proportional hazards technique was used to determine covariate adjusted p53 survival.

RESULTS

In the cohort overall median disease-free survival was only 21 months, although 18% of patients were disease-free at 5 years. There was evidence of p53 nuclear accumulation in 54% of cases and complete agreement of nodal with bladder p53 nuclear accumulation. No significant baseline differences were noted in the covariates with respect to p53 nuclear accumulation. For stratum specific disease-free survival univariate and multivariate analyses revealed that only pathological stages p0-p2b versus p3-p4 (hazards ratio 2.86, p = 0.03), and nodal stages N2 versus N1 and N3 versus N1 (hazards ratio 3.84, p = 0.01 and hazards ratio 13.3, p = 0.0002, respectively) were significantly associated with prolonged disease-free survival, while p53 nuclear accumulation was not.

CONCLUSIONS

Despite credible evidence for p53 nuclear accumulation prognostication in patients with in situ and invasive transitional cell carcinoma, this marker is not predictive of disease-free survival in node positive disease.

Early experience with small volume periurethral polytetrafluoroethylene for female stress urinary incontinence

PURPOSE

Injectable polytetrafluoroethylene paste has been used to treat female stress urinary incontinence. Since the substance is antigenically nonreactive we postulated that the reported morbidity may be due in part to the relatively large volumes injected. Therefore, we assessed the outcome of injecting small volumes of polytetrafluoroethylene with attention to the durability of success and morbidity.

MATERIALS AND METHODS

A total of 46 women with a median age of 73.8 years (range 26 to 88) with stress urinary incontinence were treated. The procedure was done on an outpatient basis using topical urethral lidocaine and periurethral lidocaine as anesthesia. A 20Fr urethroscope was used to inject polytetrafluoroethylene through an 18 gauge needle periurethrally. Patients were reinjected 1 to 3 months after initial injection if not cured (no incontinence or no pads). Continence was assessed by questionnaire from an interviewer not known to the patient. Subsequent top-up injections were given if required. Morbidity was monitored with clinical examination and imaging as required.

RESULTS

Of the patients 14 (30.4%) were dry, 19 (41.3%) were improved and 13 (28.3%) had treatment failure at a mean of 17.9, 15. 9 and 9.1 months, respectively, after last injection. For cured and improved patients (71.7%) an average of 2 treatments were needed, for a total mean volume of 5.4 cc polytetrafluoroethylene. Using a Kaplan-Meier survival curve the probability of the 14 patients remaining dry without additional polytetrafluoroethylene was 90% at 1 and 60% at 2 years. Outcome was not affected by radiological type of incontinence (that is with or without hypermobility), age, pretreatment bladder instability or previous interventions.

CONCLUSIONS

Periurethral injection of small volumes of polytetrafluoroethylene is effective and safe for treatment of female stress urinary incontinence. Early analysis shows that success is durable with minimal morbidity.

Patient perspective of long-term outcome of augmentation cystoplasty for neurogenic bladder

OBJECTIVES

Although the urologic outcomes of augmentation cystoplasty for neurogenic bladder dysfunction are well known, additional information about the patient perspective is needed. The aim of this study was to assess patient perspective using a standardized questionnaire.

METHODS

Fifty-nine patients, who had undergone augmentation enterocystoplasty as part of reconstruction mainly to correct hyperactive bladders and incontinence, were subjected to a questionnaire after a median of 76.1 postoperative months. The questionnaire addressed medications, catheterization, incontinence, bowel dysfunction, and satisfaction with urinary tract management. The urologic outcomes regarding upper and lower tract changes, complications, and reinterventions were documented as well.

RESULTS

The patients experienced a significant increase in bladder capacity and decrease in pressure at capacity (P < 0.0001). Normal upper tracts remained normal and there was either improvement or stabilization of hydronephrosis. Twenty-four patients (40.6%) had one or more complications, with 21 requiring reinterventions. Twenty-five percent of patients required the reintervention within the first 25 months, and the median time to reintervention was almost 10 years. Thirty-five patients took medications such as anticholinergics, antidiarrheals, or antibiotics. Fifty-six patients were treated with clean intermittent catheterization (CIC) at a mean interval of 4.6 hours. Seven patients had some difficulty with CIC. Thirty-nine patients (67%) were dry, and 17 had mild and 3 severe incontinence. Eleven patients (18.6%) reported bowel dysfunction, although 7 had it preoperatively. Almost all patients were very satisfied with their urologic management.

CONCLUSIONS

The high degree of patient satisfaction attests to the value of the procedure. The complication and reintervention rates underscore the importance of long-term follow-up.

Early experience with intraoperative cavernous nerve stimulation with penile tumescence monitoring to improve nerve sparing during radical prostatectomy

OBJECTIVES

To determine if intraoperative stimulation of the cavernous nerves while monitoring changes in penile tumescence to map the course of these nerves would result in an improvement in nerve sparing and erectile function after radical prostatectomy.

METHODS

Patients were eligible for this pilot study if they were undergoing a radical prostatectomy and were candidates for a nerve-sparing approach. Erectile function was assessed by patient self-reporting and questionnaire before surgery and by patient self-reporting periodically 12 months after surgery. A cavernous nerve stimulator and tumescence-monitoring device was used during radical prostatectomy to identify the course of the cavernous nerves and guide the surgeon in avoiding nerve damage. Patients were monitored for any evidence of complications and/or adverse events for 1 year from time of surgery.

RESULTS

Twenty-six patients were recruited to the trial. Nerve stimulation and tumescence monitoring was performed in 23 patients. Twenty-one of 23 patients demonstrated a tumescence response to intraoperative nerve stimulation. Nineteen of 21 patients reported erectile function preoperatively. Seventeen (89%) of 19 patients demonstrated a tumescence response during surgery. Sixteen (94%) of the 17 patients who demonstrated a response to nerve stimulation and for whom the surgery was guided by the tumescence response reported the ability to have erections after surgery. No side effects due to the use of the device were reported. Only 3 (12%) of 25 patients had positive margins confined to the lateral margin and/or apex whose modifications associated with nerve sparing could conceivably have altered margin status.

CONCLUSIONS

These clinical data suggest that an intraoperative tumescence response to cavernous nerve stimulation may guide the surgeon in preserving cavernous nerves and improving erectile function after radical prostatectomy.

Laparoscopic correction of stress urinary incontinence

The laparoscopic correction of stress urinary incontinence continues to be evaluated. Early results have been encouraging with cure/dry rates equivalent to those with traditional suspensions, but with shorter hospitalization and no significant morbidity. The approach continues to take longer in the operating room than traditional suspensions, although new innovations and refinements have shortened the time. We are still lacking long-term outcome data and well-constructed prospective randomized trials. Cost effectiveness studies are also not consistent.

Collagen injections for genuine stress urinary incontinence: patient selection and durability

The questions of patient selection parameters and durability of response in the use of collagen injections for genuine stress incontinence are addressed. A total of 181 women with a mean age of 64 years (range 26-94) underwent collagen injections for urethral incompetence. Treatment outcome was determined by a change in individual incontinence grades before and after injection. Of the 181 women 42 (23%) are cured, 94 (52%) are improved and 45 (25%) failed. Follow-up in the successful patients, either cured or improved, was a mean of 21 months (range 4-69) after their last collagen injection. No difference in outcome was seen in relation to patient age or pretreatment grade of incontinence. Of the 30 patients with bladder instability, 18 (60%) had a favorable outcome. No significant difference in outcome was seen in patients with or without hypermobility (P = 0.2889). Patients with type III incontinence required the largest amount of collagen for a successful outcome. The persistence of continence in 78 patients who were cured for at least 2 months were plotted on a Kaplan-Meier survival curve. The probability of remaining dry without additional collagen was 72% at 1 year, 57% at 2 years and 45% at 3 years. It was concluded that, collagen injection into the urethra is a safe and well-tolerated procedure. Pretreatment bladder instability may be an adverse factor. Patients with or without hypermobility had equal benefit. Long-term durability was seen. If deterioration occurred repeat collagen injections restored success. The current literature is reviewed and the use of collagen relative to other treatments is discussed.

Followup of intraurethral collagen for female stress urinary incontinence

PURPOSE

We studied patient selection parameters and durability of response of collagen injections for female stress incontinence.

MATERIALS AND METHODS

A total of 187 women 15 to 87 years old (mean age 63) underwent collagen injections for urethral incompetence. Treatment outcome was determined by a change in individual incontinence grades before and after injection.

RESULTS

Of the 187 women 43 (23%) were cured and 97 (52%) improved, while injection failed in 47 (25%). Mean followup in the successful (cured or improved) group was 22 months (range 4 to 69) after the last collagen injection. No difference in outcome was noted in relation to patient age or pretreatment grade of incontinence. Of the 31 patients with bladder instability 13 (42%) had a favorable outcome. No significant difference in outcome was noted in patients with or without hypermobility (p = 0.21235). Patients with type 3 incontinence required the largest amount of collagen for a successful outcome. Persistence of continence in 80 patients who were cured for at least 2 months was plotted on a Kaplan-Meier survival curve. The probability of remaining dry without additional collagen was 71, 58 and 46% at 1 to 3 years, respectively.

CONCLUSIONS

Intraurethral collagen is a safe and well tolerated procedure. Pretreatment bladder instability may be an adverse factor. Patients with or without hypermobility had equal benefit. Long-term durability was noted. If deterioration occurred, repeat collagen injections restored success.