It involves a transurethral probe and 4 micro-needle electrodes which deliver RF to 4 submucosal sites at 3 levels within the bladder neck and proximal urethra. TURF indication is in women with SUI due to hypermobility, who have no significant POP. It is not indicated for ISD, UUI or mixed UI with primary urge component. He felt that this TURF technique provides a safe office-based treatment for patients with anatomic SUI. It has an excellent safety profile with minimal adverse events and no safety adverse events The procedure is short in duration (around 15 to 20 minutes), is well tolerated and recovery is rapid. It is a viable option for management of SUI due to hypermobility.
Dr. Deborah Lightner gave a thorough review of vaginal and urethral inserts for the “passive” management of SUI. These are indicated in women with SUI devices based on the patient’s choice, for short-term use, and if other LUTS or prolpase is present. Many women use vaginal inserts which are tampons or tampon-like devices. It has been shown that 75% of women who buy pads or tampons are using them for urinary leakage. The majority of women with SUI symptoms improve. A pessary is another vaginal device that is often used,. At least 36% of women who choose a pessary do so for bladder control and 75% of them attained their goal for use. The ATLAS study by Richter (2008) noted that 63% of women were satisfied with the pessary, 33% were w/o bothersome SUI and 50% had >75% reduction in symptoms. Pessaries do need refitting and many women give up their use early. She went on to discuss urethral devices which can be meatal occlusive devices (“patches”) or urethral inserts which can cause UTIs. The FemSoft is the urethral insert available in the US and she reviewed its use. Here conclusions where that vaginal and urethral inserts are very appropriate for select patients, but the provider can expect early discontinuation. But if well-tolerated, there is high long-term success. These will allow the urologist to provide a full complement of good pelvic floor care.
Dr. Cespedes presented on the use of injectables. Typical patients for injection therapy are:
- the elderly and medically unstable female who has significant UI symptoms but is not a good candidate for an open procedure,
- female who has failed surgical procedures,
- has SUI with hypermobility but refuses surgery,
- desires children but wants to be dry now,
- has exercise induced SUI.
He feels that the injection technique is a process of tissue expansion so it should be performed slowly. Generally he injects only 1 to 2 syringes per visit. He feels that the mucosa may rupture if too much is injected at one time or if injected too quickly or too superficially. If no “bulging” is seen after injecting 1 to 2 ml, then there may be excessive depth of injection. Submuscosal injection has shown to yield the best results. Injections to the bladder neck or mid-urethra have equivalent cure rates but there may be more pain with injection at the mid-urethra. Local sedation should be used if possible as spinal anesthesia can increase risk of urinary retention. Placement of catheters should be avoided after the procedure. He felt that calling the procedure a failure after one injection does not constitute an adequate trial. In the future, we will inject autologous or stem cells. He reviewed the current injectables noting that Contigen (Bard) is no longer available. That leaves Coaptite, whose injectability is similar to collagen, Macroplastique, which is easily injected using specialized equipment and Durashpere, which has a newer formulation. None of these injections require allergy testing or refrigeration and they have better long term durability than collagen.
He concluded that proper patient selection yields better results. Educating patients about the number of injections that may be needed, time required between re-injections and need for periodic re-injections will improve patient satisfaction. His technique is to inject small amounts slowly and to wait 4 to 6 weeks between injections. Repeat injections can occur over time. Costs are less if injections are performed in the office under local anesthesia.
References:
Komesu, et.al. Patient-selected goal attainment for pessary wearers: what is the clinical relevance? Am J Obstet Gynecol. 2008. 198(5):577.e1-5.
Sarma, et.al. Long-term vaginal ring pessary use: discontinuation rates and adverse events. BJOG. 2009. 116(13):1715-21.
Panelists:Saad Juma (Radio Frequency Ablation), Deborah Lightner (Pessaries, Plugs & Barrier Devices), and R. Duane Cespedes (Injectables)
Moderated by Gary Lemack at the American Urological Association (AUA) Annual Meeting - May 14 - 19, 2011 - Walter E. Washington Convention Center, Washington, DC USA
Reported for UroToday by Diane K. Newman, RNC, MSN, CRNP, FAAN and Continence Nurse Practitioner Specialist - University of Pennsylvania Medical Center.
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