The cystoscopic reconstruction of the external urethral sphincter technique

Objectives: Stress urinary incontinence (SUI) is estimated to affect more than 20 million women in the United States. Despite negatively impacting physical, psychological, social, and economic health, less than 2% of women with SUI undergo treatment. Concern for surgical complications and recovery time have been suggested as causes of this disparity. Polyacrylamid hydrogel (PAHG) is a periurethral bulking agent that was FDA approved in 2020. Previous studies report a range of 40 -60% satisfaction rate and 15-67% objective cure rates using a standard injection site at the bladder neck. Cystoscopic Reconstruction of the External Sphincter Technique (CREST) is a novel technique for injecting PAHG into the structures of the mid to distal urethra to realign and reconstruct the seal of the EUS in women with MUI and SUI. We seek to describe CREST efficacy and complication data.

Methods: This is a retrospective chart review of women > 18 years old who underwent CREST with PAHG bulking for management of SUI between January to October 2022 at a single tertiary care center with a single surgeon. 3 month follow up data was obtained. Women with either hypermobile or non-hypermobile urethra were included as well as those with stress and mixed urinary incontinence. Women were excluded who had prior treatment for SUI, pelvic organ prolapse greater than stage I, underlying neurologic condition or history of radiation therapy to the pelvis. Subjective improvement was defined as self-reporting of improvement in SUI symptoms. Subjective cure was defined as > 70% improvement in SUI symptoms and objective cure was defined as negative cough stress test.

Results: One hundred thirteen patients underwent CREST. 85 percent (96/113) reported subjective improvement. 69 percent (78/113) reported > 70% improvement in SUI symptoms and 67% (76/113) had negative cough stress test. The mean number of injections was 1.3 (SD 0.5) and median follow-up 102 days (IQR 32). Complications included: 8% (9/113) acute urinary retention managed with short term indwelling catheter, 7% (8/113) with acute urinary tract infection and 4% (5/113) with denovo urgency incontinence.

Conclusions: CREST is a novel technique for injecting PAHG into the structures of the distal urinary sphincter to realign and reconstruct the natural mechanism that prevents stress urinary incontinence in women with all degrees of urethral hypermobility, Our data suggest this technique is efficacious with minimal complications supporting further evaluation of this technique.