Is there a role for periurethral collagen injection in the management of urodynamically proven mixed urinary incontinence?

OBJECTIVES: To investigate the effectiveness of periurethral collagen injection (PCI) in patients presenting with symptoms of mixed urinary incontinence (MUI) and urodynamically demonstrated sphincter deficiency and detrusor overactivity. METHODS: A retrospective review was performed on all patients undergoing PCI from February 1999 to February 2003, during which those with MUI were treated with PCI as first-line therapy. The inclusion criteria were MUI symptoms, detrusor overactivity on urodynamic study, stress urinary incontinence due to sphincter deficiency (determined from physical examination, stress test, urodynamic study with Valsalva leak point pressure, and cystography findings, without urethral hypermobility). The primary outcome measures were the Urogenital Distress Inventory (UDI), Incontinence Impact Questionnaire, and quality-of-life score and the need for anticholinergic medications or additional surgery. Comparisons were performed using the Wilcoxon signed ranks test and paired t test. RESULTS: Of the 56 patients who underwent PCI, 43 presented with symptoms of MUI, and 16 of these (29%) had both detrusor overactivity and stress urinary incontinence on urodynamic study. The mean follow-up after PCI (without additional PCI) was 18 months (range 6 to 39). The mean age was 65 years (range 40 to 84). The mean Valsalva leak point pressure was 54 +/- 40 cm H2O (range 18 to 146). Ten patients had undergone previous anti-incontinence procedures, and anticholinergic medications had failed in six. The questionnaire scores, indicating severe MUI/poor quality of life before PCI, improved after PCI: UDI question 1, 2.3 +/- 0.8 versus 1.3 +/- 1.0 (P = 0.021); UDI question 2, 2.1 +/- 1.2 versus 1.4 +/- 1.0 (P = 0.068); UDI question 3, 2.9 +/- 0.4 versus 1.8 +/- 1.2 (P = 0.010); and quality-of-life question, 8.6 +/- 2.1 versus 5.2 +/- 3.5 (P = 0.026). The mean injected volume/patient was 8.5 cm3 (range 5 to 17) within a mean of 1.9 treatments (range 1 to 3). Four patients continued taking anticholinergic medications and one proceeded to sling placement. CONCLUSIONS: The use of PCI as the primary/initial intervention in patients with MUI may be the preferred approach, particularly in patients with an elevated risk of anticholinergic medication side effects or when voiding dynamics preclude sling placement.

Three-dimensional ultrasonography to assess long-term durability of periurethral collagen in women with stress urinary incontinence due to intrinsic sphincter deficiency.

OBJECTIVES: To investigate the natural history of periurethral collagen injection (PCI) over time using serial three-dimensional ultrasonography (3DUS) of the urethra as an objective measure. METHODS: Retrospective chart review was performed for all patients who underwent PCI between February 1999 and February 2003. All had been diagnosed with stress urinary incontinence due to intrinsic sphincter deficiency without urethral hypermobility, had follow-up data including two or more 3DUS scans within 1 year or more, and had undergone no additional PCIs (ie, remained clinically improved). The follow-up examinations included serial history, symptom and quality-of-life (QOL) questionnaires (Urogenital Distress Inventory, global QOL visual analog scale [scale of 0 to 10, with 0 = best]), physical examination, and 3DUS scans. The primary subjective and objective outcomes were the Urogenital Distress Inventory and QOL scores and the 3DUS-determined periurethral collagen volume and configuration, respectively. RESULTS: Of the 54 patients undergoing PCI during the accrual period, 20 had follow-up of 1 year or longer (mean 2.0, range 1 to 3.8). The mean 3DUS collagen volumes were not statistically different at baseline at a mean of 4 months after PCI (2.9 +/- 1.9 cm3) compared with at the last follow-up visit (2.7 +/- 1.9 cm3; P = 0.34). The volume retention rate was 97% +/- 33% of the baseline volume. The periurethral configuration was circumferential in 80% and asymmetric in 20%, and was maintained over time. The postinjection Urogenital Distress Inventory question 3 (stress urinary incontinence) and QOL scores were significantly improved compared with the pre-PCI evaluations with a mean of 2.4 +/- 0.8 versus 1.4 +/- 0.7 (P = 0.013) and 7.3 +/- 2.6 versus 3.5 +/- 2.5 (P = 0.001), respectively. CONCLUSIONS: This is the first study to demonstrate the long-term durability of PCI on serial 3DUS in association with improved continence and QOL using questionnaire analysis. This new knowledge provides a technical and therapeutic endpoint for PCI.

Role of three-dimensional ultrasound in assessment of women undergoing urethral bulking agent therapy.

PURPOSE OF REVIEW: The technique of three-dimensional ultrasound imaging has been developed over the past 15 years, and has been particularly embraced by the field of obstetrics. More recently, advances have been made in gynecological applications, with promise demonstrated in pelvic floor and lower urinary tract imaging. A clinically useful extension of three-dimensional ultrasound imaging of the lower urinary tract is the assessment of urethral bulking agent therapy, as three-dimensional ultrasound imaging provides an objective means of assessing technical outcomes (i.e. periurethral position, configuration and volume of bulking agent). Our aim is to review recent developments in the use of three-dimensional ultrasound imaging in female incontinence, focusing on its role in the assessment of women undergoing urethral bulking agent therapy for stress urinary incontinence. RECENT FINDINGS: Three-dimensional ultrasound imaging provides reproducible, affordable and clinically relevant information in the assessment of urethral bulking agent therapy with collagen. Serial, long-term three-dimensional ultrasound imaging assessment has enabled a definition of the technical outcome associated with a durable improvement in continence. The optimal volume varies widely between patients, but a circumferential or horseshoe-shaped periurethral configuration of collagen is strongly correlated with a durable improvement in continence. This finding is in agreement with limited data from a two-dimensional ultrasound assessment of Macroplastique. SUMMARY: Three-dimensional ultrasound imaging provides an objective means of assessing technical outcomes from urethral bulking agent therapy not available previously. The volume and configuration information obtained allows for rational therapeutic decision-making, particularly with regard to determining the need for re-injection and recognizing the failure of an adequate therapeutic trial.