Case
A 56 years old multiparous female was referred to the clinic with complaint of mixed urinary incontinence for 7 years back. She had 6 normal vaginal delivery and history of disc surgery and Burch colposuspension. She suffered from nocturia and terminal dribbling. She had the history of 6 natural vaginal delivery, spinal surgery on L4 and L5 vertebrae after several years suffering from lumbar discopathy and she had history of surgery on her gallbladder two years before. Oxybutynin and vesicare(Solifenacin Succinate) and amitriptiline were prescribed which no improvement was seen. Pelvic muscle training and biofeedback method were performed followed by anti-incontinence surgery Burch Colposuspension for patient three years ago. These treatments had not any effect on improvement. The patient did not have burning sensation indicative of urinary tract infection, also no flank or supra-pubic pain. Voiding diary showed frequent episodes of incontinence during day and night. In the physical examination, no vaginal prolapse was detected due to previous Burch Colposuspension. kidney Ultrasound evaluation was normal. Urodynamic study showed high pressure intravesical pressure and episodes of urge incontinence and UPP (Urethral pressure profile) exposed sphincter deficiency.Abdominal leak point pressure (ALPP) was 62 cm H2O. In cystoscopy, fixed open internal sphincter with normal capacity and moderate trabeculation in the bladder were exposed.
Informed consent was obtained from patient. At the baseline, 1 and 3 months after intervention, the patient were assessed according to cough test, pad test, urodynamic study, upper tract ultrasonography (UTU), uroflowmetry (UFL), post voiding residue (PVR), International Consultation on Incontinence Questionnaire-Urinary incontinence (ICIQ-UI), and International Consultation on Incontinence Modular Questionnaire-Quality of Life (ICIQ-QOL).
For patient, platelet rich plasma-fibrin glue-stem cells injection, butolonium toxins injection and TVT were applied in one session of surgery under general anesthesia and lithotomy position which took 64 minutes.
Preparation of autologous platelets rich plasma-fibrin glue-stem cell :
Sixty milliliters of peripheral blood were taken in 9mL of citrate phosphate dextrose buffer. PRP: blood was centrifugated at 2000 g for 2 minutes, RBC and plasma was separated and plasma was centrifuged at 4000 g for 8 minutes, and the supernatant plasma was separated and 4mL PRP was separated. Fibrin glue (cryoprecipitation method): the supernatant plasma was freeze at -80°C, thawed and centrifuged at 4000 g for 8 minutes. The supernatant plasma was separated to a final volume of 4 mL. Stem cell: hydroxyethyl starch was added to RBC and left for 45 minutes RBC sedimentation. Supernatant was separated, centrifuged 400g about 10 minutes, and supernatant was removed to final 4 ml volume. (3)
Platelets rich plasma-fibrin glue-stem cell and botulinum injection
In operation room, the patient was under general anesthesia and lithotomy position. PRP, Fibrin glue and stem cell were mixed (12 ml) before injection. The transurethral endoscopic injection of PRP-Fibrin glue-stem cell was carried out by a 21-Fr rigid cystoscope. Under endoscopic vision, a puncture needle was passed through the cystoscope into the urethra at the region of the external urethral sphincter and submucosal injections of PRP-Fibrin glue-stem cell was performed. Initially, 8 ml was injected at a depth of 5 mm into the rhabdosphincter. Subsequently, 4 ml was equally injected into the submucosal spaces at 3 and 9 O’clock positions. Hundred unit of botulinium toxin was injected via cystoscope into vesical detrusor.
Tension free Vaginal Tape
Sixty milliliters of Citanest-Adrenalin (0.25%) were injected in the abdominal skin just above the pubis symphysis and retzius space. After 2 cm long transverse skin incision, 40 ml of 0.25% Citanest-Adrenalin was injected into the vaginal wall sub- and paraurethrally. 1.5 cm long incision in the midline starting approximately 0.5 cm from the outer urethral meatus in the vaginal wall. Laterally a blunt dissection 1.0 cm long each side of the urethra. By needle the sling was placed around the urethra: it was inserted into the prepared paraurethral incision on the right side of the urethra. The urogenital diaphragm was perforated and the tip of the needle was brought up to the abdominal incision by ’shaving’ the back of the pubic bone. The procedure was then repeated on the left side. When the sling had been placed in a U shape around the midurethra, owing to the strong adhesive forces (friction) around the sling no fixation is necessary. The vaginal incision is then closed. A folly catheter was inserted. One-gram cephazoline was injected intravenously.