Injection Of Bulking Agents Research Articles

Midterm outcomes of injectable bulking agents for fecal incontinence: a systematic review and meta-analysis.

Various bulking agents have been used to treat fecal incontinence. While short-term outcomes are attractive, there is still a lack of long-term data. The aim of this systematic review and meta-analysis was to investigate the midterm outcomes of treatment with injectable bulking agents and to identify predictive factors for improvement in incontinence. PubMed, EMBASE, Web of Science, and Cochrane Library databases were searched using the terms injection, bulking agents, and fecal incontinence. Studies with a minimum follow-up of 1year were included. The improvement rate in incontinence was calculated by percent change in validated fecal incontinence score (FIS) following injection treatment. To explore the impact of predictive factors on improvement in incontinence, univariate meta-regressions were conducted using the random-effect model. A total of 889 patients in 23 articles were included. The weighted mean follow-up duration was 23.7months (95% CI 19.3-28.2). Eleven different bulking agents were used. Four validated FISs were used. The Cleveland Clinic Fecal Incontinence score (CC-FIS) was used in 19 studies. Most studies reported a statistically significant improvement in FIS. The pooled mean preoperative CC-FIS (n=637) was 12.4 (95% CI 11.4-13.3). The pooled mean CC-FIS at last follow-up (n=590) was 7.7 (95% CI 6.1-9.3). The weighted mean difference in CC-FIS between preoperative visit and last follow-up was 4.9 (95% CI 4.0-5.8). Hence, the rate of improvement in incontinence was 39.5% based on CC-FIS. Meta-regression revealed that the perianal injection route and implants intact on endoanal ultrasonography were predictive of greater improvement in incontinence. The manometric data revealed that the initial increase in the mean resting pressure following injection was attenuated over time. The pooled rate of adverse events was 18.0% (95% CI 10.0-30.1). In most cases, adverse events were minor and resolved within a couple of weeks. Administration of injectable bulking agents results in significant midterm improvement in FIS. Perianal injection route and implants intact on EAUS were predictive of higher improvement in incontinence. However, given the paucity of randomized controlled trials in the literature, further research is needed to improve the quality of the evidence.

070 Efficacy and Safety of a Newly Developed Polylactic Acid Microsphere as an Injectable Bulking Agent for Penile Augmentation: 18-months follow-up

070 Efficacy and Safety of a Newly Developed Polylactic Acid Microsphere as an Injectable Bulking Agent for Penile Augmentation: 18-months follow-up

Injectable Bulking Agents for the Treatment of Stress Urinary Incontinence

Injectable Bulking Agents for the Treatment of Stress Urinary Incontinence

Injectable Bulking Agents for Urinary Incontinence after Radical Prostatectomy, Mimicking Local Recurrence: A Case Report

Injectable Bulking Agents for Urinary Incontinence after Radical Prostatectomy, Mimicking Local Recurrence: A Case Report

Comparison of percutaneous tibial nerve stimulation and bulking agent injection (polyacrylonitrile) in treating fecal incontinence

Comparison of percutaneous tibial nerve stimulation and bulking agent injection (polyacrylonitrile) in treating fecal incontinence

Postoperative Imaging after Surgical Repair for Pelvic Floor Dysfunction.

Pelvic floor dysfunction encompasses an extremely common set of conditions, with various surgical and nonsurgical treatment options. Surgical options include injection of urethral bulking agents, native tissue repair with or without bioabsorbable or synthetic graft material, placement of synthetic midurethral slings or use of vaginal mesh kits, and mesh sacrocolpopexy procedures. Numerous different synthetic products with varied imaging appearances exist, and some of these products may be difficult to identify at imaging. Patients often present with recurrent or new symptoms after surgery; and depending on the presenting complaint and the nature of the initial intervention, imaging with ultrasonography (US), magnetic resonance (MR) imaging, voiding cystourethrography, or computed tomography (CT) may be indicated. US and MR imaging can both be used to image urethral bulking agents; US is often used to follow potential changes in bulking agent volume with time. Compared with MR imaging, US depicts midurethral slings better in the urethrovaginal space, and MR imaging is better than US for depiction of the arms in the retropubic space and obturator foramen. Mesh along the vaginal wall may be depicted with both US and MR imaging; however, the distal arms of the mesh traversing the sacrospinous ligaments or within the ischiorectal fossae (ischioanal fossae) are better depicted with MR imaging. Scarring can mimic slings and mesh at both US and MR imaging. MR imaging is superior to US for depiction of sacrocolpopexy mesh and associated complications. Voiding cystourethrography and CT are used less commonly because they rarely allow direct depiction of implanted material. Online supplemental material is available for this article. (©)RSNA, 2016.

Outcomes of Surgical Management in Patients with Stress Urinary Incontinence and/or Neovesicovaginal Fistula after Orthotopic Neobladder Diversion

To our knowledge there are no guidelines for the evaluation and management of incontinence in women with an orthotopic neobladder. We propose a treatment algorithm based on our experience with treating this patient population. We identified women in whom orthotopic neobladder diversion and surgery for incontinence were performed from January 1, 1995 to January 1, 2014. Charts were reviewed for management, outcomes and complications within 30 days of surgery. At this institution 12 women with orthotopic neobladder diversion were treated with surgery for incontinence between 1995 and 2014. Six women (50%) had an undiagnosed neovesicovaginal fistula, of whom 3 (50%) underwent successful fistula repair. A total of 12 bulking agent injections were performed in 6women (50%). The outcomes were continued dryness after 1 injection (8%), transient improvement after 9 (75%), immediate failure after 1 (8%) and secondary fistula development after 1 (8%). Four transobturator slings and 4 pubovaginal slings were placed in a total of 6 patients (50%), of whom 1 (17%) was dry and 1 (17%) was improved. At a median followup of 22.9 months (IQR 11.1-46.4) 6 women (50%) were dry or improved and 6 (50%) had no improvement in leakage. Of the 6 (50%) women who were dry or improved 2 (17%) achieved planned intermittent catheterization after surgery and 2 (17%) underwent ileal conduit conversion. Bulking agents have low long-term efficacy and carry the risk of fistula formation. The efficacy of tension-free sling placement is low and continence requires an obstructing sling. Counseling should include acceptance of multiple procedures, which may be necessary to achieve continence, and consideration of conduit diversion.

V7-06 PEDIATRIC ROBOTIC-ASSISTED LAPAROSCOPIC APPENDICOVESICOSTOMY REVISION

You have accessJournal of UrologyPediatrics1 Apr 2016V7-06 PEDIATRIC ROBOTIC-ASSISTED LAPAROSCOPIC APPENDICOVESICOSTOMY REVISION David M. Hatcher, Joseph J. Pariser, and Mohan S. Gundeti David M. HatcherDavid M. Hatcher More articles by this author , Joseph J. PariserJoseph J. Pariser More articles by this author , and Mohan S. GundetiMohan S. Gundeti More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.563AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Robotic surgery for reconstructive pediatric urology is an emerging technique, and robotic-assisted Mitrofanoff appendicovesicostomy is associated with relatively high stomal continence rates. However, some children experience incontinence, which may be related to inadequate support and resistance at the anastomosis of the appendix to the bladder. While endoscopic injection is often recommended first, some patients require surgical revision. We demonstrate our approach to surgical revision of a Mitrofanoff appendicovesicostomy in a pediatric patient. METHODS A 14 year old wheelchair bound male (BMI 42) with muscular dystrophy who previously underwent a robotic-assisted laparoscopic appendicovesicostomy creation experienced stomal incontinence at low volumes. Urodynamics demonstrated stomal incontinence at 175mL at low pressures without detrusor instability. Bulking agent injection was attempted first without relief. He was scheduled to undergo robotic revision. He was placed in semi-lithotomy position with minimal Trendelenburg. A 12mm camera port was placed superior and lateral to the umbilicus, given the umbilical stoma. Additionally, two 8mm robotic ports and a 5mm assistant port were placed. Great care was used to avoid disruption of the mesentery to the appendix and umbilical stoma. The appendix and a portion of the bladder was dissected from the anterior abdominal wall. The bladder, which was floppy, was wrapped around the proximal appendiceal channel and secured in place using 2-0 vicryl interrupted sutures without disrupting the previous anastomosis. RESULTS A 3cm bladder wrap was created around the proximal appendiceal channel. After completion of a successful wrap, continence was confirmed with 250mL of fluid. Operative time was 128 min. Estimated blood loss was 20mL. The patient was discharged on postoperative day 1, and a catheter was left in the Mitrofanoff for 20 days. At one month, continence was maintained. He awaits additional follow-up. CONCLUSIONS Stomal incontinence can occur after Mitrofanoff appendicovesicostomy. After failed endoscopic injection, a robotic approach represents a minimally invasive alternative to open revision. A bladder wrap offers additional support to the junction of the appendix to the bladder, which improves continence. Longer follow-up is needed to determine a durable outcome. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e724 Advertisement Copyright & Permissions© 2016MetricsAuthor Information David M. Hatcher More articles by this author Joseph J. Pariser More articles by this author Mohan S. Gundeti More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Endoscopic correction of vesicoureteral reflux in children with solitary functioning kidney: insertion of a double-J stent to avoid transient ureteral obstruction.

Children with solitary functioning kidney, especially those with concomitant vesicoureteral reflux, are at increased long-term risk of kidney damage. Acute obstruction is a rare but relevant concern after endoscopic correction of vesicoureteral reflux and might be more symptomatic in children with solitary functioning kidney. We hereby report our experience and routine practice in using ureteral stents for prevention of the potential acute obstruction after endoscopic correction of reflux in children with solitary functioning kidney. A retrospective chart review was performed to find children with solitary functioning kidney that were endoscopically treated for vesicoureteral reflux. Solitary functioning kidney was defined as congenital or acquired (contralateral renal function <10 % in dimercaptosuccinic acid scan). Data regarding age, sex, grade and side of vesicoureteral reflux, and follow-up information were gathered. A tethered double-J stent was inserted after endoscopic bulking agent injection in all patients. Stents were removed using the extraction string at 2 weeks postoperatively. Between 2008 and 2015, a total of 28 patients (16 females) with solitary functioning kidney were treated endoscopically and underwent concomitant double-J insertion. Reflux was grade II in 12 (42.9 %), grade III in 10 (35.7 %), and grade IV in 6 (21.4 %) patients before treatment. No complication was encountered postoperatively or at removal of the stents using extraction strings. Considering devastating sequelae of acute obstruction following endoscopic management of reflux in children with solitary functioning kidney, routine use of double-J stents might be a feasible and safe approach.

Management of Urinary Incontinence in Complete Bladder Duplication by Injection of Bulking Agent at Bladder Neck Level into the Proximal Urethra.

Bladder duplication is a rare entity in children. The term encompasses a wide spectrum of anomalies from isolated bladder duplication in coronal or sagittal planes to duplicated bladder exstrophy and associated musculoskeletal and visceral anomalies. Given this wide variability, the treatment of these patients is not standardized. We hereby present a female patient with chief complaint of long-standing urinary incontinence who had complete bladder and urethral duplication and pubic diastasis. The patient was treated with bulking agent injection at the incompetent bladder neck and proximal urethra with resolution of incontinence, obviating the need for extensive surgeries.

Trends in surgical management and pre‐operative urodynamics in female medicare beneficiaries with mixed incontinence

We sought to examine the surgical trends and utilization of treatment for mixed urinary incontinence among female Medicare beneficiaries. Data was obtained from a 5% national random sample of outpatient and carrier claims from 2000 to 2011. Included were female patients 65 and older, diagnosed with mixed urinary incontinence, who underwent surgical treatment identified by Current Procedural Terminology, Fourth Edition (CPT-4) codes. Urodynamics (UDS) before initial and secondary procedure were also identified using CPT-4 codes. Procedural trends and utilization of UDS were analyzed. Utilization of UDS increased during the study period, from 38.4% to 74.0% prior to initial surgical intervention, and from 28.6% to 62.5% preceding re-intervention. Sling surgery (63.0%) and injectable bulking agents (28.0%) were the most common surgical treatments adopted, followed by sacral nerve stimulation (SNS) (4.8%) and Burch (4.0%) procedures. Re-intervention was performed in 4.0% of patients initially treated with sling procedures and 21.3% of patients treated with bulking agents, the majority of whom (51.7% and 76.3%, respectively) underwent injection of a bulking agent. Risk of re-intervention was not different among those who did or did not receive urodynamic tests prior to the initial procedure (8.5% vs. 9.3%) CONCLUSIONS: Sling and bulk agents are the most common treatment for MUI. Preoperative urodynamic testing was not related to risk of re-intervention following surgery for mixed urinary incontinence in this cohort. Neurourol. Urodynam. 36:422-425, 2017. © 2015 Wiley Periodicals, Inc.

PD28-04 MANAGEMENT OF COMPLICATIONS IN USE OF URETHRAL BULKING AGENTS IN WOMEN FOR STRESS URINARY INCONTINENCE – A META-ANALYSIS

You have accessJournal of UrologyUrodynamics/Incontinence/Female Urology: Female Incontinence - Therapy II1 Apr 2015PD28-04 MANAGEMENT OF COMPLICATIONS IN USE OF URETHRAL BULKING AGENTS IN WOMEN FOR STRESS URINARY INCONTINENCE – A META-ANALYSIS Majdee Islam, Harpreet Wadhwa, Ryan Dobbs, and Ervin Kocjancic Majdee IslamMajdee Islam More articles by this author , Harpreet WadhwaHarpreet Wadhwa More articles by this author , Ryan DobbsRyan Dobbs More articles by this author , and Ervin KocjancicErvin Kocjancic More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.1901AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Stress urinary incontinence (SUI) is a common condition that adversely impacts the quality of life in effected women. Periurethral injection of urethral bulking agents (UBA) is considered a simple and cost effective treatment of SUI for these women. This meta-analysis critically assesses the safety of the seven most commonly used UBA, along with the management of reported complications. METHODS Using PubMed, Scopus and Ovid Medline, a meta-analysis of the scientific literature from 1996 to July 2014 was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statements to quantitatively summarize the complications and reported treatments of urethral bulking agents. Initially, 1022 studies were identified and evaluated for relevancy and redundancy (Figure 1). Abstracts were excluded. A total of 4,326 patients from eligible 78 study samples were analyzed. Complication incidence was recorded, along with treatment and efficacy. Statistical analysis of complication incidence and type between UBAs was performed. RESULTS 1,999 complications were reported in the 78 studies that were analyzed. Of the reported complications, 3.8% were considered major (Clavien III); of which 70.6% required incision and drainage (I&D) and 29.3% required more invasive procedures. The incidence of major UBA complications for Durasphere was 9.4%, Coaptite was 7.4%, Ziudex was 17.8%, Bulkamid was 0.8%, Contigen was 1.8%, and Tegress was 5.9%. Macroplastique had no serious complications reported. Odds ratio (OR) of any UBA complication compared to control (Contigen) was 4.8 with p<0.0001, and OR of major complication was 58.4 with p=0.0042. CONCLUSIONS Although all urethral bulking agents are associated with complications, some are more prone to major complications than others. Most urethral bulking agent complications are transient and/or do not require treatment. Of the major complications, almost 71% were treated by I&D. For major complications, Macroplastique is the only UBA with a superior safety profile as compared to Contigen. Bulking Agent Odds Ratio Confidence Interval (95%) p-value Durasphere 75.66 4.36-1314.29 0.003 Coaptite 114.23 6.28-3076.95 0.0014 Ziudex 307.48 18.95-4988.08 0.0001 Bulkamid 5.95 0.24-146.29 0.2749 Tegress 82.57 3.32-2051.65 0.0071 Macroplastique∗ N/A N/A N/A Odds Ratios of major complications for each UBA compared to Contigen (control). ∗ Macroplastique did not have any major complications reported. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e645 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Majdee Islam More articles by this author Harpreet Wadhwa More articles by this author Ryan Dobbs More articles by this author Ervin Kocjancic More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

MP81-20 THE LONG-TERM SAFETY, TRENDS AND RE-INTERVENTIONS IN THE SURGICAL MANAGEMENT OF STRESS URINARY INCONTINENCE

You have accessJournal of UrologyUrodynamics/Incontinence/Female Urology: Female Urology1 Apr 2015MP81-20 THE LONG-TERM SAFETY, TRENDS AND RE-INTERVENTIONS IN THE SURGICAL MANAGEMENT OF STRESS URINARY INCONTINENCE Bilal Chughtai, Adrien Bernstein, Jessica Buck, Jialin Mao, Abby Isaacs, Richard Lee, Alexis Te, Steven Kaplan, and Art Sedrakyan Bilal ChughtaiBilal Chughtai More articles by this author , Adrien BernsteinAdrien Bernstein More articles by this author , Jessica BuckJessica Buck More articles by this author , Jialin MaoJialin Mao More articles by this author , Abby IsaacsAbby Isaacs More articles by this author , Richard LeeRichard Lee More articles by this author , Alexis TeAlexis Te More articles by this author , Steven KaplanSteven Kaplan More articles by this author , and Art SedrakyanArt Sedrakyan More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.2898AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Stress urinary incontinence (SUI) can greatly decrease a women's quality of life, and prevalence reports vary greatly indicating that up to 35% of women suffer from this condition. We determined short-term safety and long-term re-interventions following surgical treatment of stress urinary incontinence among female Medicare beneficiaries. METHODS We analyzed a 5% national random sample of Medicare claims from 2000 to 2011 of female beneficiaries who underwent sling or bulking procedures, based on CPT-4 and ICD-9 procedure codes. Individual patient's first sling or bulking procedure in the claim was identified. 90-day adverse events and re-interventions during the follow-up period were captured using ICD-9 diagnosis, procedure and CPT-4 codes. Statistical analysis for categorical data was performed to determine differences in distribution of patient demographics and comorbidities. Outcomes including 90-day adverse events and re-interventions were compared between treatment groups. Time to event was used to determine freedom from re-intervention after therapy. RESULTS We identified 21,134 and 3,475 patients undergoing sling and bulking procedures between 2000 and 2011. There was a 29.7% increase in sling procedures and 59.5% decrease in bulking procedures from 2000 to 2011. 90-day adverse events of both procedures were rare, with exception of mild risk of urinary retention (Sling 11.3%, Bulk 8.4%). Smaller proportion of patients receiving slings had re-interventions compared to those who had bulking therapy. 53.2% sling patients and 76.3% bulking patients who had subsequent procedures received same procedure at first re-intervention. CONCLUSIONS Both sling and bulking procedures are safe in terms of short-term performance. Patients who received initial treatment of bulking agent injection are more likely to have re-interventions. Patients who had re-interventions tend to repeat the therapy instead of converting to another procedure. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e1036 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Bilal Chughtai More articles by this author Adrien Bernstein More articles by this author Jessica Buck More articles by this author Jialin Mao More articles by this author Abby Isaacs More articles by this author Richard Lee More articles by this author Alexis Te More articles by this author Steven Kaplan More articles by this author Art Sedrakyan More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Treatment of the patulous Eustachian tube with soft-tissue bulking agent injections.

A patulous Eustachian tube ([ET] tuba aperta) may cause symptoms as autophony, breath synchronous tinnitus, pressure sensation, and conductive hearing loss and thus lead to an enormous cutback in quality of life. In combination with "sniffing," it can trigger the development of cholesteatoma. Because of the ambiguous symptoms, the diagnosis can be challenging. A patulous ET can only be diagnosed through a well-structured examination, including patient history, physical examination with thorough observation of the movements of the tympanic membrane, and tympanometry with reflex-decay. Transnasal endoscopic injection of injectable soft-tissue bulking agent into the torus tubarius was performed in 20 patients as a new treatment option for patulous ET. All patients were followed up 6 weeks and 6 and 12 months after treatment. For each intervention, 0.8 to 2 mL of injectable soft-tissue bulking agent was used. In nine patients, more than one procedure was necessary. On follow-up, 10 out of 15 patients were satisfied with the result. Only three out of 15 patients reported no improvement of their symptoms. The procedure was minimally invasive, fast, and easy to perform. There is no gold standard for the therapy of patulous ET. The injection of soft-tissue bulking agent in the torus tubarius is a new minimally invasive therapeutic approach, but much more clinical experience is needed.

Significance of an endoscopically injected nodule detected on ultrasound as a predictive factor for the resolution of vesicoureteral reflux.

Endoscopic treatment of vesicoureteral reflux (VUR) is feasible in pediatric patients. As endoscopic injection has a lower success rate than ureteral reimplantation, a postoperative voiding cystourethrogram (VCUG) is usually performed. The present study evaluated whether the presence of a nodule on noninvasive ultrasound could predict the resolution of VUR and replace invasive VCUG. Patients who received an injection of endoscopic bulking agent for VUR from January 2005 to December 2010 were evaluated retrospectively. It was evaluated whether a nodule, an echogenic mass lesion distinguished from the bladder at the ureteral orifice, was present on the ultrasound one month postoperatively. The success of the injection in the group with nodules was compared with that of the group without nodules by VCUG 3 months postoperatively. A total of 149 patients (220 ureters) met the inclusion criteria. The mean age at surgery was 3.5 years (range, 0.6–18 years). The overall success rate was 73.2%. A nodule was present in 152 cases (69.1%). The group with nodules had a higher success rate than the group without nodules (84.2%, 128/152 vs. 48.5%, 33/68, respectively; P<0.001). According to multivariate analysis, injection nodules were a predictive factor for the success of the endoscopic injection (odds ratio, 6.050; P<0.001). The failure rate increased with increasing injection volume. The sensitivity of sonographic injection nodules for predicting success was 79.5% and the specificity was 59.3%. To conclude, the presence of a postoperative nodule can predict the resolution of VUR.

Advances in the Treatment of Urinary Incontinence in Women

Urinary incontinence in women is quite prevalent today and management can be costly. Urinary incontinence can be minimal or quite bothersome, limiting activities of daily living. It is subdivided into urgency urinary incontinence, stress urinary incontinence, and mixed urinary incontinence. As such, treatment can vary immensely depending on the clinical presentations, ranging from behavioral modification to medicinal therapies to surgical procedures. First-line management for all urinary incontinence includes lifestyle and behavioral modifications. Historically, treatment options for urgency urinary incontinence were predominantly antimuscarinics, while more recent therapies include oral beta-3 agonist administration, sacral neuromodulation, onabotulinumtoxinA injection, and posterior tibial nerve stimulation. Stress urinary incontinence can be treated with a variety of urethral bulking agent injections or sling-based procedures using mesh, autologous fascia, or cadaveric fascia, as well as urethral intrasphincteric injections of autologous muscle-derived cells in new clinical trials. These recent advances that have been developed to help better curb urinary incontinence are discussed in this review.

Bulking agents for urinary incontinence: what, when and where?

Stress urinary incontinence is a major problem at the field of female urology and urogynecology. Symptomatically, this is a losing of the urine on physical efforts, coughing or sneezing. Incompetency of the urethral closing mechanisms are causing urine loss. Mid-urethral synthetic slings are the gold standard of the treatment of the stress urinary incontinence. At the same time, different urethral bulking injections are creating an artificial cushioning at the area around the urethra [1]. Bulking agents may work by increasing the central filler volume and thereby increasing the power of sphincter. The timing of the procedures are rarely evidence approved, and mainly they are empirical, based on personal experience, availability of the injections and dedicated patients. So called “Bad urethra” patients are the main candidates for the injectables. While women with mixed incontinence, patients in childbearing age who are warned about uncertain outcome of synthetic slings during delivery or the patients with concomitant severe somatic pathology could get benefit from the bulking agents. According to the Cochrane Review “the available evidence base remains insufficient to guide practice” [2]. Comparative studies found that the placebo saline injection was followed by a similar symptomatic improvement to bulking agent injection. This fact pointed questions about the possibility of any beneficial effects. One multicenter, prospective, randomized, double-blind trial of the composed of pyrolytic carbon-coated beads suspended in a water-based gel showed 80.3% improvement within 1 year [3]. Indeed some treatments caused high levels of the retention and discomfort [4]. The place and the volume of the injections are tremendously different – from the bladder neck the urethra. There is no evidence to prove the superiority of mid-urethral or bladder neck techniques. There is no plain conclusions from the trials comparing alternative agents, although dextranomer hyaluronic acid was associated with more local side effects [5]. It is obvious that the ideal injectable materials are something still to be developed. In spite of the different characteristics of the bulking agents there is a modest difference in duration of effects between agents. We could summarize that paraurethral injections of the bulking agents might be an option for the limited number of patients [6].

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Current and Emerging Treatment Options for Fecal Incontinence

Fecal incontinence (FI) is a multifactorial disorder that imposes considerable social and economic burdens. The aim of this article is to provide an overview of current and emerging treatment options for FI. A MEDLINE search was conducted for English-language articles related to FI prevalence, etiology, diagnosis, and treatment published from January 1, 1990 through June 1, 2013. The search was extended to unpublished trials on ClinicalTrials.gov and relevant publications cited in included articles. Conservative approaches, including dietary modifications, medications, muscle-strengthening exercises, and biofeedback, have been shown to provide short-term benefits. Transcutaneous electrical stimulation was considered ineffective in a randomized clinical trial. Unlike initial studies, sacral nerve stimulation has shown reasonable short-term effectiveness and some complications. Dynamic graciloplasty and artificial sphincter and bowel devices lack randomized controlled trials and have shown inconsistent results and high rates of explantation. Of injectable bulking agents, dextranomer microspheres in non-animal stabilized hyaluronic acid (NASHA Dx) has shown significant improvement in incontinence scores and frequency of incontinence episodes, with generally mild adverse effects. For the treatment of FI, conservative measures and biofeedback therapy are modestly effective. When conservative therapies are ineffective, invasive procedures, including sacral nerve stimulation, may be considered, but they are associated with complications and lack randomized, controlled trials. Bulking agents may be an appropriate alternative therapy to consider before more aggressive therapies in patients who fail conservative therapies.

Myoblast differentiation on growth factor-immobilized polycaprolactone microparticles: a potential bioactive bulking agent for fecal incontinence

AbstractFecal incontinence (FI), caused by damage or weakness of the anal sphincter, is a devastating problem for patients experiencing the symptom. Although injectable bulking agents are accepted as a minimally invasive therapeutic technique to treat FI, their short-term efficacy and inability to enhance the anal sphincter function are considered as challenges in clinical practices. In this study, growth factor [nerve growth factor (NGF) and/or basic fibroblast growth factor (bFGF)]-immobilized polycaprolactone (PCL) microparticles were prepared as an injectable bioactive bulking agent that can provide a bulking effect (by microparticles) and stimulate myoblast differentiation or injured muscles around the anus (by the sustained release of growth factors) to enhance the sphincter function for the effective treatment of FI. Pluronic F127-entrapped PCL microparticles were prepared by an isolated particle-melting method. Two different growth factors (NGF and bFGF) were incorporated on the surfaces of the Pluronic F127-entrapped PCL microparticles via heparin binding. The growth factors immobilized on the microparticles were released in a sustained manner over 4 weeks. From cell cultures on the growth factor-immobilized microparticles, it was observed that the myoblasts adhered on the microparticle surfaces showed differences in differentiation into myotubes depending on the growth factor type. In particular, the dual NGF/bFGF-immobilized microparticle group was effective for myogenic differentiation in comparison with the single growth factor (NGF or bFGF)-immobilized groups. The dual NGF/bFGF-immobilized microparticles are suitable to be applied as an injectable bulking agent for the treatment of FI.