TRANSURETHRAL COLLAGEN INJECTION FOR FEMALE STRESS INCONTINENCE

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TRANSURETHRAL COLLAGEN INJECTION FOR FEMALE STRESS INCONTINENCE

INTRODUCTION:
Urinary incontinence is a significant problem that affects both sexes and all age groups, particularly the elderly. It is estimated that approximately 10 to 12 million adults in North America suffer from this problem. Urinary continence is achieved because of greater urethral resistance remains than intravesical pressure during bladder filling and that increases in intra-abdominal pressure are transmitted approximately equally to the bladder and proximal urethra. One of the mechanisms that lead to stress urinary incontinence is that the urethra no longer functions as a sphincter. This condition is now called intrinsic sphincteric deficiency (ISD). The treatment options for ISD include: sling operations, artificial sphincter, or the injection of bulking material. The injection therapy carries the advantages of being easy outpatient procedure done mostly under local anesthesia with a very low complication rate so, it is suitable to the incontinent population who are usually old patients.

SURGICAL TECHNIQUE:
1.) All injections were performed under local anesthesia assisted with monitored anesthesia care (MAC), an intravenous combination of fentanyl (an opioid analgesic), diprivan (a sedative hypnotic agent) and midazolam (a short acting benzodiazepines) is given. This type of sedation is smooth and short, allowing patients to recover within minutes after cessation of the infusion. A routine intravenous dose of broad-spectrum antibiotic was given to every patient one hour before the procedure. After injection, we continued a course of oral antibiotic for five days.

2.) All injections were carried out transurethrally using a cystoscope with a 20 F sheath and 30- degree lens. After inspection of the urethra and bladder, a 5 F needle-tipped catheter (C.R. Bard) is introduced through the working channel of the cystoscope. The air bubbles in the catheter is displaced while the needle is inside the bladder cavity until the collagen paste appears as a fluffy material extruded from the needle. The needle is then inserted just beneath the surface of the mucosa, piercing the lamina propria but not the muscularis layer. Usually injection is performed at 5 and 7 o'clock, proximal to the external sphincter and distal to the bladder neck. If the needle is placed into the correct submucosal space, the collagen can speak circumferentially producing excellent seal effect. In some other cases injection in multiple sites is needed if the seal effect was unsatisfactory. Injection should be slowly to allow the collagen to raise the mucosa forming blebs till we observe obstruction of the urethral lumen. In most cases, the final appearance is like a bilobar prostate gland.

3). Once injection is completed, cystoscopic maneuvers are minimized to prevent the molding of the urethra. The cystoscope is removed and the bladder is emptied with a 10 F catheter. All patients were discharged at the same day of injection and kept on oral antibiotics for five days. If a patient developes high residual urine, clean intermittent catheterization program is instituted. If the patient is not satisfied with the results, another injection is considered within 3 months with a maximum of 3 injections.

RESULTS:
The cured and improved cases were 83.3% of which 70% needed only one injection to achieve improvement, 25% needed 2 injections while only 5% needed 3 injections. In the dry cases, the mean cumulative volume of collagen injected per patient was 4.7 cc and the mean cumulative number of treatment sessions was 1.44, so, the mean volume of collagen injected per session was 2.9cc. The overall average volume of collagen injected per patient, in both the improved and cured patients, was 4.12 cc.

All patient tolerated the procedure well without any significant side effects. We reported two cases of temporary urinary retention as a complication. Both were managed with self intermittent catheterization for less than one month.