Urethral Bulking

Educational Objectives

The goals of this program are to improve diagnosis and treatment of maternal morbidity and thereby reduce maternal mortality, and to improve treatment of stress urinary incontinence (SUI). After hearing and assimilating this program, the clinician will be better able to:

1. Describe the proper technique for injection of urethral bulking agents.

Summary

Goals of bulking: to improve coaptation of proximal urethra and increase resistance while avoiding retention; patient experiences immediate improvement in incontinence; however, durability of bulking agents suboptimal; 3 agents approved in United States

Coaptite (Boston Scientific): calcium hydroxylapatite particles in carrier gel; needle with side opening facilitates injection; material injected into proximal urethra or bladder neck; although typically injected using cystoscopic approach, periurethral technique may be used; key to inject slowly in submucosal plane; circumferential injection maximizes coaptation; if needle placed too deeply, material may be injected into bladder; surgeon should avoid excessive extrusion of material when withdrawing needle; repeat injections may be needed to achieve continence; initial injection usually done with 1 or 2 1-mL syringes; risk for retention rises when greater volume injected, but up to 4 mL of material may be injected; series of 2 to 3 injections at bladder neck may be required; goal to observe coaptation of mucosa at conclusion of injection

Durasphere EXP (Coloplast): pyrolytic carbon-coated graphite beads suspended in aqueous gel; in trial comparing Durasphere with collagen, efficacy of Durasphere equivalent to that of collagen at 12 mo; 80% of patients reported improvement with Durasphere; Durasphere associated with more urgency and retention than collagen; durability compromised as gel degraded or absorbed; injection requires special needle; more challenging to inject than Coaptite; 4 to 6 mL may be injected during initial procedure

Macroplastique (Uroplasty): nonbiodegradable silicone polymer suspended in water-soluble gel; requires special 18g needle and injector; may be injected periurethrally or cystoscopically; bevel inserted upward at angle of 30° to 45°; after penetration into submucosa, needle advanced to second marking to prevent extrusion; with first treatment, 3 injections performed at 10, 2, and 6 o’clock using total volume of ≤2.5 mL

Comparisons with collagen: these 3 products compared with collagen in trials; in Macroplastique study, 61% of patients reported improvement at 1 yr and 37% dry; these results superior to those in collagen group; in Durasphere study, higher rates of improvement at 12 mo observed in Durasphere group; Coaptite equivalent to collagen at 12 mo

Readings

Barski D and Deng DY: Management of mesh complications after SUI and POP repair: review and analysis of the current literature. Biomed Res Int 2015;2015:831285; Berg C et al: Strategies to reduce pregnancy-related deaths: from identification and review to action. Atlanta: Centers for Disease Control and Prevention; 2001. Available at: www.cdc.gov/reproductivehealth/ProductsPubs/PDFs/Strategies_taged.pdf. Accessed May 21, 2015; Berg CJ et al: Pregnancy-related mortality in the United States, 1998 to 2005. Obstet Gynecol 2011 May;117(5):1230; Berg CJ et al: Pregnancy-related mortality in the United States, 1991-1997. Obstet Gynecol 2003 Feb;101(2):289-96; Berg CJ et al: Preventability of pregnancy-related deaths: results of a state-wide review. Obstet Gynecol 2005 Dec;106(6):1228-34; Bonnet P et al: Transobturator vaginal tape inside out for the surgical treatment of female stress urinary incontinence: anatomical considerations. J Urol 2005 Apr;173(4):1223-8; Callaghan WM et al: Facility-based identification of women with severe maternal morbidity: it is time to start. Obstet Gynecol 2014 May;123(5):978-81; Callaghan WM et al: Identification of severe maternal morbidity during delivery hospitalizations, United States, 1991-2003. Am J Obstet Gynecol 2008 Aug;199(2):133.e1-8; Creanga AA et al: Pregnancy-related mortality in the United States, 2006-2010. Obstet Gynecol 2015 Jan;125(1):5-12; Della Torre M et al: Assessing preventability for obstetric hemorrhage. Am J Perinatol 2011 Dec;28(10):753-60; Ghoniem G et al: Cross-linked polydimethylsiloxane injection for female stress urinary incontinence: results of a multicenter, randomized, controlled, single-blind study. J Urol 2009 Jan;181(1):204-10; Isaacs RA et al: A national survey of obstetric early warning systems in the United Kingdom: five years on. Anaesthesia 2014 Jul;69(7):687-92; Kassebaum NJ et al: Global, regional, and national levels and causes of maternal mortality during 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2014 Sep 13;384(9947):980-1004. Erratum in: Lancet 2014 Sep 13;384(9947):956; Kershen RT and Appell RA: De novo urge syndrome and detrusor instability after anti-incontinence surgery: current concepts, evaluation, and treatment. Curr Urol Rep 2002 Oct;3(5):345-53; Kilpatrick SJ et al: Standardized severe maternal morbidity review: rationale and process. Obstet Gynecol 2014 Aug;124(2 Pt 1):361-6; Lightner D et al: A new injectable bulking agent for treatment of stress urinary incontinence: results of a multicenter, randomized, controlled, double-blind study of Durasphere. Urology 2001 Jul;58(1):12-5; Mayer RD et al: Multicenter prospective randomized 52-week trial of calcium hydroxylapatite versus bovine dermal collagen for treatment of stress urinary incontinence. Urology 2007 May;69(5):876-80; Sachs BP et al: Maternal mortality in Massachusetts. Trends and prevention. N Engl J Med 1987 Mar 12;316(11):667-72; Sung VW et al: Comparison of retropubic vs transobturator approach to midurethral slings: a systematic review and meta-analysis. Am J Obstet Gynecol 2007 Jul;197(1):3-11; Tucker MJ et al: The black-white disparity in pregnancy-related mortality from 5 conditions: differences in prevalence and case-fatality rates. Am J Public Health 2007 Feb;97(2):247-51; You WB et al: Validation of a scoring system to identify women with near-miss maternal morbidity. Am J Perinatol 2013 Jan;30(1):21-4.

Disclosures

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the following has been disclosed: Dr. Rosenbloom reported nothing to disclose. The planning committee reported nothing to disclose.

Acknowledgements

Dr. Rosenblum spoke at Advances in Female Pelvic Medicine and Reconstructive Surgery, presented by the New York University Post-Graduate Medical School, and held March 27-28, 2015, in New York, NY. For more information on the annual conferences by the Obstetrical and Gynecological Assembly of Southern California, visit cmebyplaza.com. For more information on the meetings presented by the NYU Post-Graduate Medical School, visit cme.med.nyu.edu. The Audio Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

OB621403

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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