„Bulking Agents” zur Behandlung der männlichen und weiblichen Stressinkontinenz - Eine Standortbestimmung

Zusammenfassung

Die submuköse Injektion von Substanzen zur Einengung des Urethralumens und Verbesserung einer Stressinkontinenz wird seit 1918 durchgeführt. Während anfänglich die Einengung durch narbige Veränderungen als Folge der Injektion von z. B. Paraffin erfolgte, wurde später die Einengung durch Ausbildung eines submukösen Polsters angestrebt. Als erstes „Bulking Agent” wurde Polytetrafluoroethylen (Teflon®) eingesetzt [4]. Die Langzeitresultate mit einer Erfolgsrate von 13 - 38 % bei der Stressinkontinenz der Frau sowie 23 - 80 % beim Mann sind jedoch enttäuschend. Die Migration der Partikel durch Phagozytose und Transport (z. B. in Haut, Lunge) hat dazu geführt, dass andere Substanzen erprobt wurden: autologes Fett, Kollagen und Silikon. Der Effektverlust durch den Abbau von Kollagen und Fett konnte durch den Einsatz von Silikon überwunden werden. Dennoch haben alle diese Substanzen nicht zu zufrieden stellenden Langzeitresultaten geführt. Gute Kurzzeiterfolge durch den Einsatz von Silikon bei der postoperativen Stressinkontinenz des Mannes werden beschrieben. Neuere Substanzen befinden sich in der klinischen Erprobung. Derzeit ist die Therapie mit „Bulking Agents” bei der Frau eine Option bei Hochrisiko-Patientinnen, die einer konventionellen operativen Therapie nicht zuzuführen sind. Bei Patientinnen, die operative Verfahren ablehnen oder aber bei der persistierenden Stressinkontinenz aufgrund einer intrinsischen Sphinkterinsuffizienz z. B. nach frustraner konventioneller operativer Therapie kann der Einsatz von „Bulking Agents” erwogen werden. Anatomische Veränderungen wie z. B. eine Zystozele können nicht korrigiert werden. Bei der postoperativen Sphinkterschwäche des Mannes kann die Unterspritzung zu einer Besserung der Frühkontinenz führen. Die Therapie mit „Bulking Agents” kann komplikations- und schmerzarm durchgeführt werden und führt bei einem eng umschriebenen Patientengut zu guten Ergebnissen.

Abstract

Injection therapy for the treatment of stress urinary incontinence has been in use since 1918. In the early years, narrowing of the urethral lumen was achieved by injection of substances like paraffin that resulted in scarring of the urethra. Later, bulking agents were developed, that formed a submucosal cushion in the urethra. The first substance used for this purpose was polytetrafluoroethylene (Teflon®), reported by Berg in 1973. The initially good results were soon followed by disappointing long-term results with success rates of 13 - 38 % in the treatment of females and 23 - 80 % in the treatment of males. Migration of Teflon®-particles (e. g. to the lung or brain) due to phagocytosis occurred and led to severe complications. Therefore other bulking agents, such as autologous fat, collagen and silicone, were tested. The quick degradation of fat and collagen could be overcome by the use of silicone, which remains at the injecition site due to its particle size. Nevertheless, none of these substances have led to sufficient long term results, although short-term success rates of 100 % in the treatment of male incontinence have been reported. A wide variety of new substances are currently being tested in animal experiments and clinical studies. At present, treatment with bulking agents should be restricted to female high-risk-patients unable to undergo conventional operative procedures. It should be considered for females who reject conventional treatment or have an intrinsic sphincteric deficiency in whom such procedures have failed. Anatomic pathologies like cystoceles cannot be cured. Only males with reduced sphincteric function (e. g. isolated lesion of the external sphincter) after operative treatment of the prostate may benefit from transurethral injection therapy. Patients with complete destruction of the external sphincter will not have any benefit over a longer period of time. Therefore only careful patient selection can achieve good results in the use of bulking agents.

Schlüsselwörter:

Inkontinenz - Kollagen - Silikon - Autologes Fett - Bulking Agents

Key words:

Incontinence - Collagen - Silicone - Autologous fat - Bulking agents

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