JOURNAL OF ENDOUROLOGYVolume 9, Number 6, December 1995Mary Ann Liebert, Ine.

Surgeon's Workshop: Antegrade Collagen Injection: NewTechnique for Postprostatectomy Stress Incontinence

CARL G. KLUTKE, M.D., ROBERT B. NADLER, M.D., and GERALD L. ANDRIOLE, M.D.

ABSTRACT

Intraurethral collagen injection has become a recognized modality to treat stress urinary incontinence. Theresults of this procedure using the traditional retrograde endoscopie approach have generally been disap¬pointing for men with sphincteric incontinence after radical prostatectomy. We describe a new technique ofantegrade collagen injection utilizing suprapubic percutaneous bladder access to achieve simultaneous ante-grade and retrograde endoscopie views of the bladder neck. This new injection technique is a promising andsimple method of correcting postprostatectomy stress urinary incontinence.

INTRODUCTION

INTRAURETHRAL INJECTION OF COLLAGEN is a rela¬tively new form of therapy for stress incontinence that poten¬tially allows correction of the problem in an outpatient settingwith minimal morbidity. The procedure has an excellent rate ofsuccess for carefully selected female patients: incontinence hasbeen significantly improved in more than 90%. '-2 Unfor¬tunately, the results in male patients with sphincteric inconti¬nence after radical prostatectomy have been disappointing.1-3The reasons for the inability of collagen injections to correctthis form of stress incontinence are not known. One possibleexplanation is that standard retrograde injection procedures arecumbersome to perform and difficult to monitor accurately.Moreover, such an approach often results in the injection of col¬lagen into noncompliant tissues of the vesicourethral anasto¬mosis. To circumvent some of these difficulties, we have de¬veloped an alternative method of collagen administration thataffords better closure of the open bladder neck and proximalurethral segment by the material. This report describes the pro¬cedure of antegrade injection of collagen into the bladder neckof men with postprostatectomy stress incontinence.

TECHNIQUE

Adequate intravenous sedation or regional or general anes¬

thesia is administered. The patient is placed in the dorsal litho¬tomy position with the head down. Retrograde flexible cys¬toscopy is performed to assess the urethra and bladder neck.

The bladder is distended by instilling irrigating fluid throughthe flexible cystoscope. An 18-gauge splenic needle is placedpercutaneously from a site 3 to 4 cm above the symphysis pu¬bis into the bladder. Placement of the needle at this point is im¬portant, as a vesicle puncture lower—closer to symphysis pu¬bis—leads to difficulty accessing the bladder neck, and one thatis higher—closer to umbilicus—runs the risk of traversing theperitoneal cavity. Needle placement is monitored cystoscopi-cally; a 0.035-inch Benson guidewire is passed through the nee¬

dle and curled in the bladder. The tract is dilated using suc¬

cessive Amplatz dilators (Cook Urological, Spencer, IN) toachieve placement of a 24F sheath. A 2IF to 23F rigid cysto¬scope is inserted through the sheath, and antegrade cystoscopyis performed.

Collagen (Contigen; CR. Bard, Inc., Covington, GA) is theninjected through a 5F 23-gauge needle (Williams cystoscopicinjection needle; Cook Urological) at several sites around thebladder neck until visual coaptation occurs (Fig. 1). Video mon¬

itoring of the bladder neck through both the antegrade (i.e.,rigid) and retrograde (i.e., flexible) cystoscopes is performed tobe certain the collagen is occluding the bladder outlet withoutextravasating into the urethra. The endoscopie needle is insertedtangentially into the submucosa of the bladder neck and prox¬imal urethra with the needle bevel facing the urethral mucosallining. On completion of the collagen injection, the cystoscopeis removed, and a 20F suprapubic catheter is inserted into thebladder.

The patient is released to home on oral antibiotics on the dayof surgery. The suprapubic catheter is occluded by the patienton the second postoperative day for a voiding trial. If satisfac-

Division of Urologie Surgery, Washington University School of Medicine, St. Louis, MO

513

514 KLUTKE ET AL.

FIG. 1. Antegrade injection of collagen via suprapubic ac¬cess with endoscopie monitor view (inset).

tory voiding occurs, the suprapubic tube is removed in the of¬fice on the third or fourth postoperative day. Later office fol¬low-up is performed at 2, 3, and 6 weeks and 12 months post-operatively.

DISCUSSION

The minimally invasive technique of periurethral collageninjection in female patients with stress incontinence secondaryto intrinsic sphincter deficiency without hypermobility has beenwell accepted by the urologie community in the United States.Unfortunately, in men with incontinence after radical prosta¬tectomy, treatment with any injectable material has generallymet with poor results, and many patients eventually require anartificial sphincter to become completely dry. Politano5 reportedthe best results using periurethral polytetrafluoroethylene in¬jection; he observed improvement in 88% of patients aftertransurethral resection and 67% after radical prostatectomy.However, other investigators have not been able to duplicatethese results with either polytetrafluoroethylene paste or thenewer glutaraldehyde cross-linked collagen. Deane et al6 re¬

ported a 17% improvement rate in postprostatectomy inconti¬nence, with no patients being totally dry. Similarly, Kabelin7reported a 23% improvement rate, with no patients becomingcompletely dry. The results of periurethral fat injections in theman with postprostatectomy sphincteric insufficiency have like¬wise been disappointing.8 Kageyama and associates9 utilizedtransperineal collagen injection under transrectal ultrasoundguidance in an attempt to place the needle and collagen more

precisely. Although those investigators did deliver less colla¬gen, their 10% continence rate is similar to that reported withtransurethral placement.4

Why injection therapy meets with such limited success in themale patient who has undergone radical prostatectomy is opento debate. One hypothesis considers that the significant post-

surgical scarring in the urethra proximal to the external sphinc¬ter limits the ability of an injectable material to bring about tis¬sue coaptation. In our experience, this scarring severely limitsthe areas of mucosa suitable for injection. Moreover, from a

retrograde approach, the angle of needle introduction into themucosa is suboptimal. Thus, with only limited patches of suit¬ably distensible mucosa, complete circumferential mucosalbulking and coaptation is often impossible. Furthermore, ex¬

trusion is often a problem when collagen is injected in nondis-tensible submucosal tissue.

The antegrade collagen injection technique described hereinhas several theoretical advantages over perineal andtransurethral delivery techniques. First, it affords a direct viewof the unscarred bladder neck. This facilitates submucosal nee¬

dle placement into easily distensible submucosa. Second, theangle of delivery is gentle, and circumferential needle place¬ment is easily achieved. Third, antegrade observation of thebladder neck and urethra allows a direct view of tissue coapta¬tion from above without distending the urethral lumen with thecystoscope. This allows the surgeon to better judge the com¬

pleteness of the procedure and avoids trauma to the newly in¬jected tissue, as occurs with the retrograde approach. Fourth,retrograde viewing with a flexible cystoscope confirms com¬

plete coaptation. Finally, the suprapubic tube allows bladderdrainage without catheterization, which can mold the collagenaround the catheter, if postprocedure urinary retention occurs.

Although there are many benefits to the suprapubic antegradeapproach, it does have some at least theoretical drawbacks.While minimally invasive, it requires suprapubic vesical access,a suprapubic tube, and the associated complications. As seen

in our series, urinary or fluid extravasation from the cystotomymay complicate the procedure. We have altered our techniqueto avoid this potential complication by limiting the suprapubictract to 24F, keeping bladder volumes low throughout the pro¬cedure, and maintaining complete bladder drainage with a largesuprapubic tube postoperatively. With a suprapubic approach,the risk of bleeding and bowel injury exist. Furthermore, dila¬tion of the tract through the scarred anterior fascia and retro-

pubic space is at times difficult in this patient population.In conclusion, the suprapubic antegrade approach to colla¬

gen delivery is a technically feasible surgical procedure for malepatients with postprostatectomy stress urinary incontinence.Although more invasive than the transurethral retrograde ap¬proach, the suprapubic percutaneous approach still is minimallyinvasive and uses principles familiar to all urologists. The short-term success rate of the procedure appears to be better than thatof the standard retrograde urethral approach. Longer follow-upof a larger number of patients is necessary.

REFERENCES

Herschorn S, Radomski SB, Steele DJ: Early experience with in-traurethral collagen injections for urinary incontinence. J Urol1992;148:1797McGuire EJ, Wang SC, Appel R, Webster G, DeRidder P, BennettA: Treatment of urethral incontinence by collagen injection—oneyear follow up (abstract). J Urol 1990;143:224AShortliffe LMD, Freiha FS, Kessler R, Stamey TA, ConstantinouCE: Treatment of urinary incontinence by the periurethral implan¬tation of glutaraldehyde cross-linked collagen. J Urol 1989;141:538

ANTEGRADE COLLAGEN INJECTION 515

4. McGuire EJ, Appell RA: Transurethral collagen injection for uri¬nary incontinence. Urology 1994;43:413

5. Politano VA: Transurethral Polytef injection for post-prostatectomyurinary incontinence. Br J Urol 1992;69:26

6. Deane AM, English P, Hehir M, Williams JP, Worth PHL: Tefloninjection in stress incontinence. Br J Urol 1985;57:78

7. Kabelin JN: Treatment of post-prostatectomy stress urinary incon¬tinence with periurethral polytetrafluoroethylene paste injection. JUrol 1994;152.T463

8. Santarosa RP, Blaivas JG: Periurethral injection of autologous fatfor the treatment of sphincteric incontinence. J Urol 1994;151:607

9. Kageyama S, Kazuki K, Kazuo S, Tomomi U, Toshihide S, YushioA: Collagen implantation for post-prostatectomy incontinence: earlyexperience with a transrectal ultrasonographically guided method. JUrol 1994;152:1473

Address reprint requests to:Carl G. Klutke, M.D.

4960 Childrens Place, Box 8242St. Louis, MO 63110