Metro Urology, St. Paul, MN, USA
Urethral bulking agents (UBAs) have been used extensively to treat women with stress urinary incontinence due to intrinsic sphincter deficiency. This article presents the authors' experience with one of the currently approved urethral bulking agents, Macroplastique®, in a urology office setting.
Patient Assessment - Proper patient selection is the key to success with a UBA and establishing patient expectations prior to the procedure is important for a satisfactory outcome.
Patient Education Pre-Procedure - The patient is asked to stop any anticoagulant medications. An oral broad spectrum prophylactic antibiotic is prescribed. For some patients, an oral anti-anxiety medication may occasionally be needed. Occasionally, transient urinary retention may occur following a urethral bulking procedure; therefore, all patients are instructed in intermittent self-catheterization technique.
Patient Preparation on the Day of Procedure - A voided urine sample is collected to check for any signs of a urinary tract infection. Ensure the patient has discontinued anticoagulants and that the prescribed antibiotics and/or anti-anxiety medications have been taken. The patient undresses from the waist down, covers with a sheet, and lies on the procedure table with her feet in stirrups. The nurse drapes the patient using four sterile towels to delineate the surgical field with the perineal area exposed. The perineal area is prepped with iodine solution with additional attention to the urethral area. Next, the nurse inserts lidocaine gel into the urethra to provide local anesthesia. The gel is left in place for a few minutes before the procedure is started to allow the anesthetic to take effect.
Procedure Preparation - Using a 25-gauge, 1.5-inch needle, 10 cc of 1% lidocaine and 1 cc of 8.4% sodium bicarbonate(NaHC03) are drawn up together into a 12 cc syringe. The physician identifies two injection sites on each side near the urethral meatus, at the three and nine o'clock positions, for the peri-urethral block. Inserting the needle toward the bladder neck, approximately 5.5 cc of the lidocaine/NaHC03 solution is injected into each of these sites while slowly withdrawing the needle from the tissue. Irrigation fluid will be used for irrigation intermittently throughout the procedure to provide an optimal view of the urethra and bladder neck. The physician also attaches the video camera and light source cords to the cystoscope. The cystoscope is lubricated with water-soluble lubricant and gently inserted into the patient’s urethra. With the needle bevel facing into the urethral lumen, the first injection site is identified at the six o'clock position. Using a tunneling technique, the physician angles the scope and needle to a 30° angle, punctures the urethra, and then flattens the scope to 0° while advancing the needle, slowly injecting up to 2.5 cc over one to two minutes. The two o'clock and ten o'clock positions are identified, irrigation fluid flow is stopped, and up to 1.25 cc of Macroplastique is injected into each site. The exact injection locations of six, two, and 10 o’clock are not as important as placing the material in a circumferential plane to allow for coaptation of the urethra.
Post-Op Patient Care and Follow Up
Before the patient leaves the clinic, the nurse discusses the potential side effects and warning signs and instructs the patient to continue with post-procedure antibiotics as prescribed and to drink six to eight glasses of water during the next 24 hours to help prevent a urinary tract infection. The patient is instructed to use over-the-counter drugs for any urinary discomfort or burning. A follow-up appointment with the physician is scheduled for one month and the patient is advised to avoid sexual activity during this period of time. A follow-up treatment anytime after three or four months may be necessary if the first procedure has not fully resolved the patient's SUI.
With the current focus on control of health care costs and patient preference for less invasive treatment, in-office Macroplastique injection is a practical treatment option for patients with SUI. This procedure can be performed under local anesthesia as part of a community-based urology practice. In the authors' experience, excellent patient tolerance and provider experience make this office-based procedure easy to incorporate into a busy schedule. At the time of this article's publication, 65 procedures have been performed in the authors' office without any unanticipated adverse events. The procedure is well tolerated by patients, can be done as part of the normal clinical schedule, and is convenient for both the patient and staff. The role of the nurse is pivotal in making this procedure successful for all participants. Use of UBAs, such as Marcroplastique, is a viable option for select women with SUI.
Source: Summary of publication
Written by:
Ramsden M, Williams E, Siegel S. Are you the author?
Reference: Urol Nurs. 2010 Sep-Oct;30(5):297-305.
PubMed Abstract
PMID: 21067095
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UroToday.com Stress Urinary Incontinence Section
