Periurethral Approach

The bent-needle technique for a periurethral approach for injectable bulking agents is a simplified, reproducible technique with a one-case learning curve. In comparison to traditional transurethral and periurethral approaches using long, straight needles for various implant materials, the bent-needle technique produces superior results in terms of needle localization and tissue acceptance of bulking under lower pressure without the need of regional or general anesthesia. With cystoscopic confirmation of localizing the needle tip, there is less potential for injecting into vascular spaces or into the deeper muscle layers of the urethra. The bent-needle technique of a periurethral approach produces a longer tract of tissue resistance to the implant material exuding from the injection site that is typical of transurethral procedures.

Preparation of the patient and anesthesia used are the same as for the transurethral route. Additionally, 2mL of 1% plain lidocaine solution may be injected with a 1.5-inch 30-gauge needle at the 3- and 9-o'clock periurethral positions.

As depicted in Figure 6-4.2, we have opted to use a preformed, approximately 15-degree bent needle that does not

Figure 6-4.2. The bent-needle technique for the submucosal/periurethral approach.

(Reprinted with the permission of The Cleveland Clinic Foundation.)

needle is placed at the urethral/vaginal wall crease. With the needle positioned with the bend toward the urethral lumen, the needle is advanced to the proximal urethra and bladder neck. The length and the bend of the needle allow the needle to transverse the urethral musculature and to arrive at the distensible plane between the lamina propria and muscularis muscle at the proximal urethra and bladder neck area. Using a bent needle instead of the traditional straight needle allows for a consistent, reproducible placement of the needle tip within the proper plane of the proximal urethra with minimal manipulation. Depending on the material chosen for injection, hydro dissection of the distensible pocket for implant injection between the lamina propria and the muscularis muscle may be achieved first by injecting 0.5 mL of saline or 1% lidocaine before introducing the injectable implant material.

To assess for immediate cure in cases performed under local anesthesia, the surgeon may perform a cough/stress test on the patient. If stress incontinence persists, additional material should be injected during the same session. The bent needle may also be inserted on the opposite side at the 9-o'clock position and the bulking agent injected with the same technique if further coaptation is required based on clinical judgment or using the cough/stress test maneuver as a guide for achieving a satisfactory treatment endpoint.

The merits reported by physicians for adopting the bent-needle technique for a periurethral approach include the following highlights. First, the technique is reproducible and has a one-case learning curve compared with other methods for this therapy. Second, superior needle-tip localization at the level of the proximal urethra is achieved compared with traditional periurethral and transurethral techniques. Third, cystoscopic confirmation of the needle tip, as well as lateral to medial movement of the needle prevents vascular or deep urethral muscle injection of the bulking agent. Fourth, the formation of a longer periurethral needle track for the injection procedure prevents costly implant extrusion, decompression of the bulking achieved, and better management of patients with a hypocoagulable condition. Fifth, less implant material is needed for the injection procedure compared with other less consistent techniques. Finally, the technique is widely applicable for any implant material chosen without new techniques to be learned by the physician and supporting staff for every implant introduced into the market.

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