Urethral bulking agents for the treatment of stress urinary incontinence in women: A systematic review
Venetia Hoe1,2, Britt Haller1,2, Henry Yao1,2, Helen O'Connell1,2.
1Urology, Western Health, Melbourne, Australia; 2Surgery, University of Melbourne, Melbourne, Australia
Stress urinary incontinence (SUI) is a common and debilitating condition predominantly affecting women. The use of urethral bulking agents (UBAs) is a well-established treatment for SUI. Glutaraldehyde cross-linked bovine collagen (Contigen®) has now been superseded by new synthetic non-absorbable bulking agents. Currently marketed UBAs include polyacrylamide hydrogel (Bulkamid®), polydimethylsiloxane (Macroplastique®), carbon-coated zirconium oxide (Durasphere®), calcium hydroxylapatite (Coaptite®), with the latest product being a polydimethylsiloxane silicone gel that polymerises when injected (Urolastic®). Despite the common use of UBAs, clinical data comparing its outcomes are limited. The aim of this study is to perform a systematic review to assess and compare the efficacy and safety of all urethral bulking agents available for the treatment of SUI in women.
This systematic review was conducted in accordance to the PRISMA guideline. A systematic search was conducted using the Ovid Medline, Embase and PubMed databases. Studies were included if they involved women who underwent either Bulkamid®, Macroplastique®, Durasphere®, Coaptite® or Urolastic® injections for the treatment of SUI. 583 articles were screened with 56 articles included. A qualitative analysis was performed.
The newer synthetic urethral bulking agents are not inferior to Contigen®, with variable mean success rates of 30% to 80% in the short-term (<24 months). Better long-term (>24 months) success rates were found with Bulkamid® (44% to <80%), Coaptite® (68.5% to 70%), and Macroplastique® (21% to 60%) on qualitative review. Urinary tract infection rates were similar between bulking agents (1.9% to 5.6%) although temporary acute urinary retention was more commonly associated with Coaptite® (32.8%), and de novo urgency in Durasphere® (16.9%). Significant complications such as migration into lymph nodes was reported with Durasphere®. Erosion was reported with Macroplastique®, Coaptite® and Urolastic®, with a rate as high as 24.6% in one study of Urolastic®.
There is most data available to support the use of Bulkamid® and Macroplastique®, which has shown a short-term efficacy of 29.8% to 89.7% and 40% to 85% respectively and long-term efficacy of 42% to <80% and 21% to 60% respectively. Bulkamid® appears to have a more favourable safety profile, with no cases of erosion or migration of product associated with its use.
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