Periurethral Collagen Injection Research Articles

Long-Term Results of Bulking Agent Injection for Persistent Incontinence in Cases of Neurogenic Bladder Dysfunction

We evaluated the effectiveness of bladder neck injection as a supplementary treatment for persistent low pressure incontinence after unsatisfactory fascial sling procedures in patients with neurogenic lower urinary tract dysfunction. A total of 89 patients with neurogenic lower urinary tract dysfunction underwent fascial sling procedures between 1992 and 2005. Because of unsatisfactory results, 27 patients received endoscopic injection of a bulking agent. All patients included in the study underwent urodynamic examination after the sling procedure, which revealed persistent low pressure transurethral leakage of urine. We retrospectively analyzed the endoscopic approach used to administer the bladder neck injection, method of postoperative catheterization and number of injections given. Efficacy of bladder neck injection was graded by the patient and the urologist. After a median followup of 8 years (range 2.5 to 14) only 2 patients (7%) were continent after having received a single injection of bulking agent. A total of 12 patients (44%) were given a second injection and 8 (30%) were given a third injection but these subsequent injections did not result in continence. Of the patients 16 (59%) eventually underwent bladder neck surgery, 2 (7%) were dry and 8 (30%) accepted the inconvenience. Two patients underwent ileocystoplasty and 1 patient underwent botulinum A toxin (Botox(R)) injection due to decreased bladder capacity and poor bladder compliance. Neither the endoscopic approach nor the method of postoperative catheterization affected the success rate. Bladder neck injection after failure of primary sling procedures has limited value in patients with neurogenic lower urinary tract dysfunction. Repeat bladder neck injection yields no additional benefits.

Recruitment of Bone Marrow Derived Cells to the Bladder After Bladder Outlet Obstruction

Bladder fibrosis is an undesired end point of partial bladder outlet obstruction. In fibrotic disease of the lung, kidney, skin and heart chemokines recruit bone marrow derived cells to injured tissue. Blockade of chemokines like CCL2 results in decreased fibrosis in other organs. To our knowledge we present the first report of bone marrow derived cell recruitment to the bladder in a murine bladder outlet obstruction model. We lethally irradiated WT female mice and reconstituted their bone marrow using fetal liver cells from transgenic mice ubiquitously expressing green fluorescent protein. Periurethral collagen injection was used for bladder outlet obstruction. Obstruction was assessed by urodynamics, and bladder and kidney histological changes. Bladders were harvested 1 to 12 weeks after bladder outlet obstruction and compared to those in nonobstructed controls. The chemokine CCL2 was compared between obstructed and nonobstructed mice with reverse transcriptase-polymerase chain reaction. Green fluorescent protein expressing bone marrow derived cells were identified with immunohistochemistry and fluorescence activated cell sorting. Bladders showed histological and urodynamic changes consistent with obstruction. CCL2 induction increased after obstruction compared to that in controls. After obstruction bone marrow derived cells were present in the urothelial and stromal layers. Activated epidermal growth factor receptor was found in cells associated with bone marrow derived cells. Bone marrow derived cells are recruited to the bladder by bladder outlet obstruction and are present in the urothelial and stromal layers. Stromal bone marrow derived cells may have a role in hypertrophy and fibrosis. Further study of the recruitment and function of bone marrow derived cells in the bladder may provide potential targets for antifibrotic therapy.

Collagen Injection for Female Urinary Incontinence After Urethral or Periurethral Surgery

We evaluated the result of periurethral collagen injection in incontinent patients after prior urethral surgery. We reviewed the charts of patients who underwent periurethral collagen injection between January 2000 and December 2006 for persistent stress urinary incontinence after a failed suspension procedure or urethral repair. Preoperative assessment included the validated Urogenital Distress Inventory-6 symptom questionnaire, a single global quality of life score, history and physical examination, cystogram while standing and multichannel urodynamics. All patients had a well supported urethra and intrinsic sphincteric deficiency. Outcome measures included questionnaires and 3-dimensional urethral ultrasound at 6 weeks, 6 to 12 months and yearly thereafter. In patients who were still symptomatic after the first injection a repeat injection was considered when there was asymmetrical or low collagen volume on ultrasound, and another therapy was considered when ultrasound findings were adequate. In 31 consecutive patients Urogenital Distress Inventory-6 question 3 and quality of life scores decreased after collagen injection (mean volume 5.5 cc). Baseline postoperative collagen volume on ultrasound was 2.6 cc (range 0.8 of 4.8). Of the patients 93% considered themselves clinically improved or cured, 17 of 31 required only 1 injection with a symmetrical configuration in 83%, while 8 received 1 or 2 more injections because of an asymmetrical configuration (75%) and/or low volume. Despite a mean collagen volume of 3.2 cc (range 2 to 4.3) 6 women with persistent stress urinary incontinence underwent a pubovaginal sling procedure. Eight of 25 patients requiring only collagen had stable collagen volume for 2 years without repeat injection. Collagen injection is a viable option with satisfactory results in this complex population.

Clinical and urodynamic evaluation in women with stress urinary incontinence treated by periurethral collagen injection

To evaluate the success of treatment with periurethral collagen injections in patients suffering from stress urinary incontinence (SUI) with bladder neck hypermobility and intrinsic sphincter deficiency. Forty women suffering from (SUI) were selected and divided into GI (consisting of 13 women with SUI and bladder neck hypermobility) and GII (consisting of 27 women with SUI and intrinsic sphincter deficiency). Periurethral collagen was injected followed by a subjective evaluation (the need for urinary protectors) and an objective evaluation through urodynamic study before and after the treatment. It was noticed that after 9 months there was a decrease in the need of urinary protectors in the two groups. It was observed through the urodynamic study that either cure or improvement was achieved in 46% in GI and 40.7% in GII. There was a significant increase in the leak pressure in GII. Moreover, there was a decrease in the volume of urine leak in the two groups, being the results in GII statistically significant. It was concluded that the periurethral collagen injection is useful for the treatment of the SUI. The results in hypermobility are similar to those in intrinsic sphincter deficiency. In fact, it is a very simple out patient's procedure, with little side effects.

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

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

Calcification of Glutaraldehyde Cross-Linked Collagen in Bladder Neck Injections in Children With Incontinence: A Long-Term Complication

We report the incidence of calcifications developing at the bladder neck/urethra in pediatric patients treated with glutaraldehyde cross-linked collagen for urinary incontinence. We reviewed charts of patients treated with glutaraldehyde cross-linked collagen injections for urinary incontinence between 1994 and 1999. Etiology of incontinence, pertinent medical history, operative details and postoperative imaging were examined. Of 31 patients 4 (13%) had development of submucosal calcifications in the bladder neck/urethra. All 4 patients had received multiple injections of glutaraldehyde cross-linked collagen for incontinence secondary to neurogenic bladder. The calcifications were confirmed surgically. Pathology reports available for 2 of 4 patients showed chronic inflammation without dysplasia or malignant changes. Mean followup was significantly different between calcified and noncalcified cases (10.3 vs 7.2 years, p = 0.009), as was total volume of collagen injected (21 vs 12 cc, p = 0.012). Mean time to diagnosis of calcifications was 8.8 years (range 7 to 11) after first injection. A total of 24 patients without calcification underwent bladder imaging at a mean of 6.8 years (+/-2.2) after glutaraldehyde cross-linked collagen injection, which was not significantly different than the time to diagnosis (p = 0.089). The number of injections was not significantly different between the 2 groups (p = 0.426). Of our patients 13% had development of calcifications at the site of prior glutaraldehyde cross-linked collagen injections for incontinence. These calcifications were surrounded by chronic inflammation. Patients who have undergone glutaraldehyde cross-linked collagen injections may benefit from long-term followup with bladder imaging to detect and follow calcifications at prior injection sites.

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 H 2O (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 cm 3 (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.

Long-Term Effects of Dextranomer Endoscopic Injections for Treatment of Urinary Incontinence: An Update of a Prospective Study of 31 Patients

A prospective study was initiated 7 years previously to assess the efficacy of endoscopic dextranomer based implants for pediatric structural incontinence. Preliminary results revealed that at 3 years 50% of the patients were either dry or significantly improved. We report long-term results in the same cohort of patients. A total of 33 children and adolescents 5 to 18 years old with severe incontinence due to sphincteric incompetence (exstrophy-epispadias complex in 13, neuropathic bladder in 16, bilateral ectopic ureter in 4) were enrolled. Of the patients 13 underwent 2 and 4 underwent 3 treatment sessions to achieve a definitive result. Mean injected volume was 3.9 ml (range 1.6 to 12) per session. At each evaluation patients were considered cured (dryness interval 4 hours), significantly improved (minimal incontinence requiring no more than 1 pad daily and no further treatment required) or treatment failures (no significant improvement). Videourodynamics were used to study the evolution of the bladder capacity, activity and compliance. A total of 31 patients were followed 3 to 7 years after the last injection. At 3 years after treatment 15 of 30 patients (50%) were dry or improved. One patient who had leakage after 3 years of dryness due to bladder deterioration subsequently underwent ileocystoplasty. At 4 years 12 of 25 patients (48%) were dry or improved. At 5 years 9 of 21 patients (43%) were dry, as were 4 of 11 (36%) at 6 years and 2 of 5 (40%) at 7 years of followup. The success rate according to pathological evaluation was comparable in neuropathic bladders (7 of 14, or 50%), exstrophy (3 of 6, or 50%) and epispadias (3 of 7, or 43%). Of 12 patients who underwent bladder neck plasty before the injection of bulking agent 7 (58%) were either dry or improved. The success rate was higher in males (13 of 23, or 57%) than in females (3 of 8, or 38%). Also, at puberty 2 males who were improved became dry. Bladder capacity increased in 12 of 18 initially small bladders and remained normal and stable in 9, while 4 initially dry patients had development of recurrent leakage secondary to bladder deterioration and underwent augmentation. Otherwise, there were no long-term side effects observed related to the injection of the bulking agent. Endoscopic treatment of severe organic urinary incontinence with dextranomer is durable for up to 7 years of followup in 40% of the patients.

Periurethral Mass Formations Following Bulking Agent Injection for the Treatment of Urinary Incontinence

Durasphere is gaining popularity as a bulking agent for treating women with stress urinary incontinence. We present a series of patients with periurethral mass formation following Durasphere injection. The charts of 135 women with a mean age of 69.4 years (range 46 to 83) who underwent Durasphere periurethral injections were retrospectively reviewed. Patients who had a periurethral mass were identified and their clinical data were collected and analyzed. Four patients (2.9%) were diagnosed with periurethral mass formation 12 to 18 months (average 14.7) following a Durasphere injection. Clinical presentation varied, including irritative voiding symptoms, pelvic pain and urinary incontinence. All patients were found to have a tender and tense periurethral mass. A radiopaque mass was revealed during videourodynamic study in 1 patient. Incision, and transvaginal and endoscopic drainage or transvaginal excision were used to treat these masses. Intraoperative and pathological findings as well as operative outcomes are presented. Irritative or obstructing voiding symptoms, pelvic pain or a periurethral mass in patients with a history of Durasphere or other periurethral bulking agent injection should alert the physician to the possibility of periurethral mass formation. The true incidence of this late complication remains to be determined.

Long-term efficacy of periurethral collagen injection for the treatment of urinary incontinence secondary to myelomeningocele.

The reports of efficacy of periurethral collagen injection (Contigen, Bard, Covington, Georgia) for treatment of urinary incontinence in the myelomeningocele population are limited and variable. We reviewed the efficacy of periurethral collagen in patients with myelomeningocele to provide long-term followup data. From 1994 to 1999, 19 children and 6 adults with myelomeningocele underwent periurethral injections of collagen with an average of 2 treatments per patient. Mean followup +/- SD from last injection in the pediatric and adult groups was 2.9 +/- 1.5 years and 4.7 +/- 2.6 years, respectively. Postoperative continence was defined as dry, improved or unchanged. No pediatric patients became dry, 7 (37%) improved and 12 (63%) were unchanged. A single adult was dry (17%), 4 (67%) improved and 1 remained unchanged. Transient improvement was noted in 8 of the 13 patients who reverted to an unchanged status. Response rate was 66% in nonambulatory patients versus 42% in ambulatory patients (p = 0.38). Of 12 patients who responded and 13 who did not 8 in each group required 2 or more treatments. The responding group percentage of predicted bladder capacity was 97.6% versus 89.5% in those who remained unchanged (p = 0.66). The initial transient improvement following collagen injection and the long-term improvement following repeat injections suggest that degradation of collagen decreased its efficacy. The long-term results of this minimally invasive technique are poor.

Factors influencing the long-term success of periurethral collagen therapy in the office

Glutaraldehyde crosslinked bovine collagen has been used for periurethral bulking for the treatment of urodynamic stress incontinence since 1989 with variable success. A retrospective study was undertaken to evaluate the factors involved in the long-term success of glutaraldehyde crosslinked bovine collagen used for periurethral bulking in the office. Patients were followed objectively with stress testing after receiving periurethral collagen injection in the office under local anesthesia. Repeat injections were done as necessary during their follow-up appointments. The "success" group was defined as those women who demonstrated negative stress tests for over 1 year following their first injection. Nineteen of 184 women (10.3%) demonstrated negative stress tests for over 1 year following only one initial injection of glutaraldehyde crosslinked collagen. Their success lasted a mean of 829 days up to the time of follow-up. Prior anti-incontinence surgery was the one factor analyzed that showed a trend toward this long lasting success. No other factors were predictive of negative stress tests for over 1 year. Prior anti-incontinence surgery seems to represent a factor involved in the long-term success of periurethral bulking in the office with glutaraldehyde crosslinked bovine collagen for the treatment of urodynamic stress incontinence.

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

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. 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. 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. 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.

オリーブ油に起因したTVT手術後の膀胱結石

Tension-free vaginal tape (TVT), a less-invasive variation of the suburethral sling, has been rapidly gaining popularity worldwide in the treatment of female stress urinary incontinence. We report on two cases of bladder stones composed of fatty acid calcium following TVT operations. Case 1: A 76-year-old woman with a history of hysterectomy due to cervical cancer was suffering from vault prolapse. The insertion of a ring pessary lead to the development of stress urinary incontinence, and she was referred to our hospital. As she was frail, sexually inactive, and elderly, she underwent partial colpocleisis (Le Fort operation) combined with a TVT operation. One-month postoperative videourodynamics and chain cystourethrography (CUG) using olive oil as the lubricant showed cure of incontinence and mild support of the urethra. Her maximum flow rate was 18.8 ml/s and no residual urine was observed. Six months postoperatively she developed postmiction pain and pyuria that were not improved by antibiotics. Cystoscopy showed a small bladder stone, whose removal cured cystitis. Case 2: A 49-year-old woman, with a history of abdominal hysterectomy due to myoma uteri, visited our hospital complaining of stress urinary incontinence. A periurethral collagen injection was only temporarily effective, and she underwent a TVT operation. A 1-month postoperative evaluation including chain CUG using olive oil as the lubricant showed cure of incontinence, mild support of the urethra, a maximum flow rate of 28.8 ml/s, and no residual urine. Two months postoperatively she developed miction pain and pyuria that were solved by removing a small bladder stone. Anti-incontinence surgery increases the risk of developing bladder stones due to either foreign bodies (bladder erosion) or obstruction. However, neither of our cases had these conditions; instead, both bladder stones were composed of fatty acid calcium that appeared to be related to the olive oil used as the lubricant in chain CUG. Only four cases (including ours) of bladder stones composed of fatty acid calcium have been documented, but they may indicate that care is necessary when using olive oil as a contrast medium or lubricant in the urinary tract. When a woman with a history of anti-incontinence surgery has persisting or recurrent cystitis, cystoscopy should be performed to exclude bladder erosion and stones.

EROSION OF A MALE POLYPROPYLENE SLING

No AccessJournal of UrologyAdult Urology: Voiding Dysfunction1 Nov 2004EROSION OF A MALE POLYPROPYLENE SLING J. HAKIM and M. GIGNAC J. HAKIMJ. HAKIM More articles by this author and M. GIGNACM. GIGNAC More articles by this author View All Author Informationhttps://doi.org/10.1097/01.ju.0000142106.38139.e2AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "EROSION OF A MALE POLYPROPYLENE SLING." The Journal of Urology, 172(5), p. 1925 References 1 : Management of vaginal erosion of polypropylene mesh slings. J Urol2003; 169: 2242. Link, Google Scholar 2 : Polypropylene sling of the bulbar urethra for post-radical prostatectomy incontinence. Eur Urol2003; 43: 152. Google Scholar 3 : The male sling for stress urinary incontinence: a prospective study. J Urol2002; 167: 597. Link, Google Scholar From the Triangle Urology Group, Pittsburgh, Pennsylvania© 2004 by American Urological Association, Inc.FiguresReferencesRelatedDetails Volume 172Issue 5November 2004Page: 1925 Advertisement Copyright & Permissions© 2004 by American Urological Association, Inc.Keywordssurgical meshurinary incontinence, stresspolypropylenesMetricsAuthor Information J. HAKIM More articles by this author M. GIGNAC More articles by this author Expand All Advertisement PDF downloadLoading ...

Three-dimensional ultrasonography: an objective outcome tool to assess collagen distribution in women with stress urinary incontinence

Objectives To examine the distribution of periurethral collagen by three-dimensional ultrasonography (3D US) and to incorporate this technology into a practical treatment decision tree for women with stress urinary incontinence desiring collagen injection. Methods Forty-six women who received periurethral collagen injection were assessed with 3D US to document the position and volume of collagen around the urethra. Patients with a good clinical response were observed with serial 3D US scans. Women with no persistent improvement who showed a low volume or asymmetric distribution of collagen were offered repeat injections. When the patient had no improvement despite symmetric or circumferential distribution of collagen with good volume retention, another anti-incontinence treatment was recommended. Group 1 was composed of women who had a good clinical outcome and group 2 of those who did not. A statistical comparison between the two outcome groups was done to determine whether any particular distribution pattern was associated with an increased likelihood of clinical success. Results Of the 46 patients, 21 (46%) were satisfied with their continence after their last periurethral collagen injection, with a median follow-up of 14.0 months (range 2 months to 4.25 years). A significantly greater proportion of patients in group 1 had circumferentially distributed collagen on 3D US compared with those in group 2 (62% versus 20%, P = 0.006). Conclusions Circumferential distribution of collagen around the urethra is associated with a higher likelihood of clinical success. The assessment of periurethral collagen by 3D US provides an affordable, noninvasive, objective outcome measure that may aid in treatment planning.

Long-Term Efficacy of Periurethral Collagen Injection for the Treatment of Urinary Incontinence Secondary to Myelomeningocele

Long-Term Efficacy of Periurethral Collagen Injection for the Treatment of Urinary Incontinence Secondary to Myelomeningocele

Long-Term Efficacy of Periurethral Collagen Injection for the Treatment of Urinary Incontinence Secondary to Myelomeningocele

The reports of efficacy of periurethral collagen injection (Contigen, Bard, Covington, Georgia) for treatment of urinary incontinence in the myelomeningocele population are limited and variable. We reviewed the efficacy of periurethral collagen in patients with myelomeningocele to provide long-term followup data. From 1994 to 1999, 19 children and 6 adults with myelomeningocele underwent periurethral injections of collagen with an average of 2 treatments per patient. Mean followup +/- SD from last injection in the pediatric and adult groups was 2.9 +/- 1.5 years and 4.7 +/- 2.6 years, respectively. Postoperative continence was defined as dry, improved or unchanged. No pediatric patients became dry, 7 (37%) improved and 12 (63%) were unchanged. A single adult was dry (17%), 4 (67%) improved and 1 remained unchanged. Transient improvement was noted in 8 of the 13 patients who reverted to an unchanged status. Response rate was 66% in nonambulatory patients versus 42% in ambulatory patients (p = 0.38). Of 12 patients who responded and 13 who did not 8 in each group required 2 or more treatments. The responding group percentage of predicted bladder capacity was 97.6% versus 89.5% in those who remained unchanged (p = 0.66). The initial transient improvement following collagen injection and the long-term improvement following repeat injections suggest that degradation of collagen decreased its efficacy. The long-term results of this minimally invasive technique are poor.

The safety of reusing injectable collagen: a multicenter microbiological study.

We have previously reported pilot data regarding the safety of saving partially used syringes of a glutaraldehyde cross-linked collagen for use in subsequent treatment sessions with the same individual. That single institution study involved 56 partially used syringes cultured for aerobic bacteria. Only one weakly positive culture was detected among these 56 samples, which prompted us to carry out this expanded study involving multiple centers and different injection techniques. Samples were collected from four centers. Following periurethral injection in an office setting, 166 partially used syringes of glutaraldehyde cross-linked collagen were refrigerated for between 1 and 104 weeks (average 58). Material from all 166 syringes was then cultured qualitatively and quantitatively for both aerobic and anaerobic organisms. Collagen from one syringe grew >100,000 colonies of Escherichia coli. All other cultures were negative. In the pilot study, one culture of 56 syringes was weakly positive for coagulase-negative staphylococcus. When the results from both studies were considered together, only two of 222 partially used syringes (0.9%) were contaminated. The background risk of local infection associated with periurethral collagen injection is approximately 0.29%. Using the statistical equation 'number needed to harm', we found that a clinician would have to reuse 111 syringes at a saving of $34,965 before he or she would cause a single local injection by so doing. Therefore, we feel that it may be cost-effective and safe to reinject material from a partially used syringe of glutaraldehyde cross-linked collagen during a subsequent treatment session on an individual.

COLLAGEN INJECTION FOR TREATMENT OF URINARY INCONTINENCE IN CHILDREN

We assess the success rate of periurethral collagen injection in children with neurogenic bladder dysfunction secondary to myelomeningocele. From 1992 to 1998, 15 male and 5 female patients with spina bifida (age 13.3 +/- 3.8 years) underwent endoscopic collagen injection for the treatment of urinary incontinence secondary to sphincter deficiency. Mean followup was 4.2 years. Pretreatment urodynamic study showed a stable compliant bladder with an average leak point pressure of 52 cm. H2O (range 23 to 100). Concurrent medical management included anticholinergics in 15 cases, agonists in 3, and clean intermittent catheterization in 16. Five patients had undergone previous ileocystoplasty. Collagen injections were given with the patient under general anesthesia. The number of injections was 1 in 5 cases, 2 in 11, 3 in 3, and 4 in 1. Average collagen volume injected per treatment was 6.6 cc (range 2 to 13). All patients were evaluated on a subjective continence scale of no change (wet), improved or completely dry at the time of assessment. Of the 20 patients, 16 had no change, 3 showed improvement and 1 was dry. Initial improvement in the first 2 months after injection deteriorated thereafter in 16 cases. The previously reported high success rate of collagen injection is not supported by this study. With long-term followup collagen injection is rarely effective for treating urinary incontinence in children with neurogenic sphincter deficiency.

Periurethral Collagen Injection for Stress Incontinence With and Without Urethral Hypermobility

Obstet Gynecol 2000;95:327–331 Forty women were treated with periurethral collagen (Contingen, CR Bard Inc., Covington, GA) injection for urinary stress incontinence. Nine had urethral hypermobility and 31 did not. Other than the hypermobility, the groups were similar, including the amount of collagen injected at the procedure. A total of 60 injections were given. The mean follow-up was 8 months. The subjective cure rate at 6 months was 71% in the hypermobility group and 32% in the group without hypermobility. The subjective “satisfaction” rating was the same in the 2 groups. Fifty percent of each group experienced post-procedure bladder hyperactivity. Comment: Ever since this procedure was introduced several years ago, it has been unclear as to what criteria constitute the most appropriate candidate for this therapy. Studies generally have recommended that patients with an immobile, low-pressure urethra might be the best candidate, but this could be because a fixed urethra is unlikely to benefit from other surgical procedures. Even so, in my experience, the procedure does maintain continence for more than a year in most patients. (TMJ)