**4. Periurethral bulking agents**

While the majority of patients that have failed surgical repair for SUI will opt for a more aggressive intervention, periurethral bulking agents offer a potential adjunct for the insufficient sling, especially if the patient or surgeon are hesitant to be more invasive given the history of prior urethral surgery. Periurethral bulking agents include biodegradable and nonbiodegradable agents that are injected endoscopically in the perurethral tissue to presumably further coapt the urethral mucosa. While the availability of these agents has recently changed, the primary injectable bulking agents in the United States include Contigen (Bard Inc., Murry Hill, NJ) which has recently been discontinued, Durasphere (Coloplast Inc, Minneapolis, MN), Macroplastique (Uroplasty Inc, Minneapolis, MN) and Coaptite (Bioform Inc., Franksville, WI).

incontinence. Recurrent stress urinary incontinence after urethral sling surgery (transvaginal tape and transobturator tape) and common complications such as urinary tract infection and de novo urge urinary incontinence need to be fully evaluated. It is also important when determining the etiology of surgical failure to identify whether the patient has refractory SUI by determining whether there was any period of cure or improvement. Recurrent stress urinary incontinence warrants at a minimum: complete history and physical examination and urinalysis. Most physicians would advocate urodynamic testing in cases of failed previous surgery for incontinence. (Houwert et al. 2010; Walsh & Moore 2010) Cystoscopic evaluation is easy to perform in the clinic and should be utilized to determine if there is evidence of sling erosion or misplacement. Ultimately, the determination must be made

If there is evidence of flank or pelvic pain, a retroperitoneal ultrasound with evaluation of the bladder is necessary to evaluation for obstruction and or injury to the ureteral orifices. Urodynamics with or without fluoroscopy is useful to further characterize the physiology of the bladder. While there is no published data regarding routine use, most practices use routine urodynamic evaluation of failed anti-incontinence patients prior to a repeat

Some urologists routinely use dynamic T2-weighted MRI to look at the anatomic defects seen in pelvic floor dysfunction. A vaginal examination might demonstrate a change in the patient's pelvic floor anatomy, such as evidence of prolapse. Many researchers have used dynamic MRI to evaluate the female pelvis and delineate the possible components of pelvic floor dysfunction. This requires experience using this modality and a radiologist that can interpret the test in a useful way. In the cost-saving climate of health care today, dynamic T2 MRI can likely only be used in the setting of severe refractory incontinence or neurologic

There is a paucity of literature for the nonsurgical management of recurrent SUI following prior surgical repair. Most treatments are based on primary SUI studies, namely pelvic floor muscle training, weight loss, incontinence pessary and medications. These options have

While the majority of patients that have failed surgical repair for SUI will opt for a more aggressive intervention, periurethral bulking agents offer a potential adjunct for the insufficient sling, especially if the patient or surgeon are hesitant to be more invasive given the history of prior urethral surgery. Periurethral bulking agents include biodegradable and nonbiodegradable agents that are injected endoscopically in the perurethral tissue to presumably further coapt the urethral mucosa. While the availability of these agents has recently changed, the primary injectable bulking agents in the United States include Contigen (Bard Inc., Murry Hill, NJ) which has recently been discontinued, Durasphere (Coloplast Inc, Minneapolis, MN), Macroplastique (Uroplasty Inc, Minneapolis, MN) and

whether this leakage is due to bladder or outlet dysfunction.

been systematically reviewed elsewhere. (Shamliyan et al. 2008)

conditions.

**3. Nonsurgical management** 

**4. Periurethral bulking agents** 

Coaptite (Bioform Inc., Franksville, WI).

procedure. (Rutman et al. 2006; Rodriguez et al. 2010; Walsh & Moore 2010)

Investigators have reported the use of periurethral bulking agents after failed sling procedures for SUI, but no randomized studies have been reported. However, a recent report looking at intermediate follow up has reported some success. Macroplastique and Durasphere were used as periurethral bulking agents in 23 women following a failed midurethral sling procedure. (Lee et al. 2010) Macroplastique was used in 21 patients and Durasphere was used in 2 patients with a median interval between sling placement and periurethral bulking agent injection of 12 months (range 3-65). With intermediate follow up at a median of 10 months (range 6-34 months), 8 of 23 patients (35%) of all patients reported "cure" whereas 92% reported they had benefited from the procedure. Notably, 77% of the women reported satisfaction from the procedure, perhaps noting the relative simplicity and ease of placement.
