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THE
JOURNAL OF FEMALE Commented Abstracts |
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METHODS: A retrospective review was performed of 60 periurethral collagen injections performed on 40 consecutive women from January 1996 to December 1997. A review of the office chart and operative notes was performed to obtain demographic, urodynamic, and procedural data. Outcome data were obtained by personal or telephone interview, using patients' subjective assessments including an analog satisfaction scale. RESULTS: Nine of 40 patients (23%) had urethral hypermobility. Compared with patients without hypermobility, patients with hypermobility required a similar number of procedures (a mean of 1.9 compared with 1.4, P = .13) and required similar amounts of collagen on the first injection (5.6 ml compared with 5.3 ml, P = .69). Preoperative urodynamic parameters were similar in both groups. Rates of subjective dryness were equivalent in patients with , and without hypermobility at 1 month (76% and 46%, P = .24) and at 6 months (71% and 32%, P = .09) following initial injection. A post hoc power analysis was performed to evaluate the primary study measures of continence at 1 and 6 months, and number of collagen injections. This revealed that a sample size of 40 patients would be sufficient to detect a 2.5-fold difference in number of injections and a 3-fold difference in subjective dryness. CONCLUSION: Coexisting urethral hypermobility should not preclude the use of collagen injections in women with stress urinary incontinence. COMMENTARIES Stress Urinary Incontinence, in general, in women less than 60 years old occurs when the bladder cannot retain urine when there is an enlargement of intravesicle pressure during exercise, coughing or sneezing.Among the many surgical approach, collagen injection is one of the simpler procedures and one of the least invasive. Meanwhile, the authors of this work refer that in the United States, this technique has been recommended just in cases where there is no urethral hypermobility, therefore limiting the indications of this technique. This limitation originated itself in part from the observation done by Kreder and Austin in 1996, that in cases of women with stress Urinary Incontinence with urethral hypermobility and intrinsic sphincter deficiency, they obtained a rate of success of 81% when they used the sub urethral sling, and only 25% when the used one only collagen injection. This work of Kreder and Austin does not consider that the success of the procedure with collagen may be related with the number of applications and the quantity of the material injected. In fact, in several papers where the results of the collagen injections are presented, as much in female Urinary Incontinence as in male, these two successful requisites are evident: number of applications and quantity of injected collagen. Considering these requisites and the fact that the collagen injection is an outpatient procedure and it presents a lower morbidity than the vaginal sling, Steele et al proposed to compare, in women with intrinsic sphincter deficiency with or without urethral hypermobility, the obtained results in both groups with one or more collagen applications, done consecutively in the dependence of the evolution presented by the patients. In both groups were done, in average, 2 sessions of injections (variation of 1 to 4) with a variable quantity of collagen of 5.3 to 5.6 ml, not having registered any serious complication after the procedure. The post operatory time of observation was short (segment of one and six months) and the number of patients studied was small (9 patients with urethral hypermobility and 31 without hypermobility), even though this fact did not hinder and efficient statistic analysis. The authors, in observation done 6 months after the execution of the treatment, verified 67% of good results in the group of patients with urethral hypermobility and 63% in the group without hypermobility. It is evident that these results are a little inferior to the ones obtained by the suburethral sling, but we must consider that in no case prolongued urine retention occurred, in Kreder and Austin’s work it was of 7% , a hematoma did not develop. In the question that refers to the indication or not of a collagen injection in women with urethral hypermobility we must consider that there is no simple parameter, or a set of them, that defines an intrinsic sphincter deficiency. By the urodynamic exam made by the authors it showed that there was no correlation of urethral pressure registered at the moment when there was Urinary loss during the Valsalva maneouver and the maximum urethral pressure profil, and because of this, the obtained values by the exams were heterogeneous even for the same patient, which limits any inclusion of criteria of this patient in the study groups. Any way, the authors showed having similar results in both patient groups, seeming that there are no reasons to exclude, from this type of treatment, women that show stress Incontinence with urethral hypermobility. Meanwhile, more studies will be necessary, mainly with a longer observation (more than 6 months), to ensure efficacy of the treatment in women submitted to collagen injections. On the other side, more ample studies in a larger number of women could, eventually, show differences in the evolution between the group that presents urethral hypermobility and the one that does not. An answer to these questions is important because certainly there are women that do not wish in any way, even though they have a sufferable life quality because of Urinary Incontinence, to be submitted to invasive procedures or that present undesirable complications. Luiz Antonio Corrêa |
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