Transurethral radiofrequency collagen denaturation for the treatment of women with urinary incontinence.

BACKGROUND: Transurethral radiofrequency collagen denaturation is a relatively novel, minimally invasive device-based intervention used to treat individuals with urinary incontinence (UI). No systematic review of the evidence supporting its use has been published to date. OBJECTIVES: To evaluate the efficacy of transurethral radiofrequency collagen denaturation, compared with other interventions, in the treatment of women with UI.Review authors sought to compare the following.• Transurethral radiofrequency collagen denaturation versus no treatment/sham treatment.• Transurethral radiofrequency collagen denaturation versus conservative physical treatment.• Transurethral radiofrequency collagen denaturation versus mechanical devices (pessaries for UI).• Transurethral radiofrequency collagen denaturation versus drug treatment.• Transurethral radiofrequency collagen denaturation versus injectable treatment for UI.• Transurethral radiofrequency collagen denaturation versus other surgery for UI. SEARCH METHODS: We conducted a systematic search of the Cochrane Incontinence Group Specialised Register (searched 19 December 2014), EMBASE and EMBASE Classic (January 1947 to 2014 Week 50), Google Scholar and three trials registries in December 2014, along with reference checking. We sought to identify unpublished studies by handsearching abstracts of major gynaecology and urology meetings, and by contacting experts in the field and the device manufacturer. SELECTION CRITERIA: Randomised and quasi-randomised trials of transurethral radiofrequency collagen denaturation versus no treatment/sham treatment, conservative physical treatment, mechanical devices, drug treatment, injectable treatment for UI or other surgery for UI in women were eligible. DATA COLLECTION AND ANALYSIS: We screened search results and selected eligible studies for inclusion. We assessed risk of bias and analysed dichotomous variables as risk ratios (RRs) with 95% confidence intervals (CIs) and continuous variables as mean differences (MDs) with 95% CIs. We rated the quality of evidence using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. MAIN RESULTS: We included in the analysis one small sham-controlled randomised trial of 173 women performed in the United States. Participants enrolled in this study had been diagnosed with stress UI and were randomly assigned to transurethral radiofrequency collagen denaturation (treatment) or a sham surgery using a non-functioning catheter (no treatment). Mean age of participants in the 12-month multi-centre trial was 50 years (range 22 to 76 years).Of three patient-important primary outcomes selected for this systematic review, the number of women reporting UI symptoms after intervention was not reported. No serious adverse events were reported for the transurethral radiofrequency collagen denaturation arm or the sham treatment arm during the 12-month trial. Owing to high risk of bias and imprecision, we downgraded the quality of evidence for this outcome to low. The effect of transurethral radiofrequency collagen denaturation on the number of women with an incontinence quality of life (I-QOL) score improvement ≥ 10 points at 12 months was as follows: RR 1.11, 95% CI 0.77 to 1.62; participants = 142, but the confidence interval was wide. For this outcome, the quality of evidence was also low as the result of high risk of bias and imprecision.We found no evidence on the number of women undergoing repeat continence surgery. The risk of other adverse events (pain/dysuria (RR 5.73, 95% CI 0.75 to 43.70; participants = 173); new detrusor overactivity (RR 1.36, 95% CI 0.63 to 2.93; participants = 173); and urinary tract infection (RR 0.95, 95% CI 0.24 to 3.86; participants = 173) could not be established reliably as the trial was small. Evidence was insufficient for assessment of whether use of transurethral radiofrequency collagen denaturation was associated with an increased rate of urinary retention, haematuria and hesitancy compared with sham treatment in 173 participants. The GRADE quality of evidence for all other adverse events with available evidence was low as the result of high risk of bias and imprecision.We found no evidence to inform comparisons of transurethral radiofrequency collagen denaturation with conservative physical treatment, mechanical devices, drug treatment, injectable treatment for UI or other surgery for UI. AUTHORS' CONCLUSIONS: It is not known whether transurethral radiofrequency collagen denaturation, as compared with sham treatment, improves patient-reported symptoms of UI. Evidence is insufficient to show whether the procedure improves disease-specific quality of life. Evidence is also insufficient to show whether the procedure causes serious adverse events or other adverse events in comparison with sham treatment, and no evidence was found for comparison with any other method of treatment for UI.

Role of robotic surgery in urogynecologic surgery.

PURPOSE OF REVIEW: Robotic surgery with its numerous advantages over conventional laparoscopy has assumed an ever-expanding role in pelvic and pelvic floor reconstructive surgery. Our goal is to review the literature regarding robotic use in urogynecologic surgery. RECENT FINDINGS: The current literature demonstrates the feasibility and safety of performing robotic urogynecologic procedures in a wide variety of cases. Robotic sacrocolpopexy and hysterectomy are most commonly described, but the use of robotics in the repair of complex pelvic fistulae has also been examined. The available studies mainly consist of case series with short-term follow-up, but early outcomes appear to be comparable to open surgery with decreased patient morbidity. SUMMARY: The role of robotics in urogynecologic surgery will continue to grow, as there is an increasing access to the robotic platform, and its use is being incorporated into residency training. More robust studies will be needed to validate the continued use of the robot, as there are concerns regarding cost, training, and credentialing.

Current indications for neuromodulation.

Neuromodulation is becoming a part of the clinical armamentarium for treatment ofa variety of lower urinary tract conditions. Its increased usage stems from the needs of patients who have exhausted all other therapeutic options. Currently, neuromodulation may consist of the use of nerve stimulation and injectable therapies. This article concentrates on nerve stimulation.

Pelvic hematoma as a cause of bladder perforation and gross hematuria.

We present a case of an ulcerated perforation of the bladder caused by a large pelvic hematoma without any direct injury to the bladder in a 71-year-old woman. She developed the hematoma after emergency percutaneous angioplasty and placement of an intra-aortic balloon pump that was complicated by retroperitoneal bleeding from an injured femoral artery. She presented several days later with gross hematuria and right hydroureteronephrosis. Cystoscopy and cystography revealed an extraperitoneal perforation at the right bladder neck. Although conservative management was attempted, the patient eventually required open repair. The perforation had transformed to an intraperitoneal perforation by making a communicating tract through the absorbed hematoma. After debridement and excision of the tract, the bladder perforation was repaired in two layers.

Modern management of women with stress urinary incontinence.

Stress urinary incontinence is a prevalent condition that may have a significant negative impact on a woman's quality of life. With improved awareness and research, new nonsurgical and surgical managements are being developed; noninvasive measures should be considered before invasive treatments. Pelvic floor exercises, biofeedback, and electrical stimulation may be helpful depending on the individual. With the release of duloxetine, the first FDA-approved medication for stress urinary incontinence, pharmacologic therapy (which has not had a significant role in stress urinary incontinence) will gain more attention. Surgical treatments have become minimally invasive with good efficacy. Overall, as the understanding of the pathophysiology of stress urinary incontinence evolves, so will management of this disease state.