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Urethral Pseudolipoma: A Complication of Periurethral Lipo-Injection for Stress Urinary Incontinence in a Woman
Vol. 155,646, February 1996 Printed in U S A .
URETHRAL PSEUDOLIPOMA: A COMPLICATION OF PERIURETHRAL LIPO-INJECTION FOR STRESS URINARY INCONTINENCE IN A WOMAN PAUL0 C R. PALMA, CASSIO L. Z. RICCETTO AND NELSON R. NETTO, JR From the Divlston of Urologv, UnlLerslty of Campcnas Medical Center, U N I C M P , Scio Paulo, Brazd
KEY WORD^ urethra, unnary incontinence, stress, Injections, intramuscular
The use of fat in the treatment of sphincteric insufficiency has several advantages: i t is readily available and biocompatible, and it involves a minimally invasive procedure.] The mechanism of achieving continence is based on increasing urethral coaptation, which increases leak point pressure.2 We report on a patient in whom a urethral pseudolipoma developed. To our knowledge pseudolipoma as a complication of lipo-injection for sphincteric insufficiency has not been reported previously. CASE REPORT
H. X. S., a 65-year-old woman, underwent bilateral oophorectomy with total hysterectomy and vaginal apex excision for cystic adenocarcinoma o f the ovary. Stress urinary incontinence developed in the early postoperative period. Physical examination revealed a diminished urethral length in addition to a fibrous periurethral reaction. Urodynamic evaluation 3 months postoperatively demonstrated a leak point pressure of less than 30 cm. water.3 The patient underwent 2 sessions of periurethral autologous lipo-injection at %month intervals. Injections were given with a 20 gauge needle via a periurethral route under cystoscopic guidance to achieve the correct position into the urethral muscular envelope. The proper placement of the needle was confirmed by coaptation all around the urethra induced by fat injection at a single point. The amount of fat injected vaned from 6 to 10 ml. until maximal mucosal coaptation resulted. A 14F Foley catheter was left in place overnight. Although continence significantly improved, the patient presented 3 months postoperatively when a 2 cm. fatty tissue nodule prolapsed through the urethral meatus during voiding (fig. 1). The prolapsed tissue was excised by a n incision around the nodule base and borders were approximated with Accepted for publication June 2, 1995.
FIG. 2. Adipose cells are mixed with fibroblast stroma with poor lymphocytic inflammatory reaction and well established graft neovascularization. H & E, reduced from X 100.
h e r o chromic catgut sutures. To avoid fat leakage though the suture repeat lipo-injection was performed a month later. The patient was completely dry during 10 months of folIowup. Pathological analysis of the excised tissue revealed adipose cells mixed with fibroblast stroma and a poor lymphocytic inflammatory reaction with some lipogranuloma formation (fig. 2). DISCUSSION
Lipo-injection was originally performed by injecting 40 ml. fatty tissue outside of the urethral muscular envelope. However, this approach may not increase the sealing effect. When injected within the urethral muscular envelope, in addition to proper coaptation, the submucosal vascular plexus may contribute to graft integration. Ln our case the complication developed because lipo-injection was performed from the bladder neck toward the urethral meatus in a n attempt to increase the fimctional length of the urethra. We now believe that the proper technique is to inject the fatty tissue from the bladder neck to the mid urethra to avoid prolapse of the fatty tissue. Although further investigation and longer followup are required before a definitive statement can be made as to the clinical application of this technique, our experience shows that lipo-injection may be useful in the management of select cases of urinary incontinence. REFERENCES
1. Appel, R. A.: Injectables for urinary incontinence. World J. Urol.,
8 208, 1992.
2. Palma, P.C. R. and Netto, N. R., Jr.:Injeqso periuretral de tecido adiposo autologo no tratamento da incontinhcia urinaria de esforqo. J. Bras. Urol., 1 6 49, 1990. 3. McGuire, E. J., Fitzpatrick, C. C., Wan, J., Bloom, D.. Sanvordenker. J., Ritchey, M. and Gormley, E. A,: Clinical assessment of urethral sphincter function. J. Urol., 1 5 0 14.52, 1993.
FIG.1. Intraoperatively urethral pseudolipoma prolapses during Valsalva maneuver. 646
URETHRAL PSEUDOLIPOMA: A COMPLICATION OF PERIURETHRAL LIPO-INJECTION FOR STRESS URINARY INCONTINENCE IN A WOMAN PAUL0 C R. PALMA, CASSIO L. Z. RICCETTO AND NELSON R. NETTO, JR From the Divlston of Urologv, UnlLerslty of Campcnas Medical Center, U N I C M P , Scio Paulo, Brazd
KEY WORD^ urethra, unnary incontinence, stress, Injections, intramuscular
The use of fat in the treatment of sphincteric insufficiency has several advantages: i t is readily available and biocompatible, and it involves a minimally invasive procedure.] The mechanism of achieving continence is based on increasing urethral coaptation, which increases leak point pressure.2 We report on a patient in whom a urethral pseudolipoma developed. To our knowledge pseudolipoma as a complication of lipo-injection for sphincteric insufficiency has not been reported previously. CASE REPORT
H. X. S., a 65-year-old woman, underwent bilateral oophorectomy with total hysterectomy and vaginal apex excision for cystic adenocarcinoma o f the ovary. Stress urinary incontinence developed in the early postoperative period. Physical examination revealed a diminished urethral length in addition to a fibrous periurethral reaction. Urodynamic evaluation 3 months postoperatively demonstrated a leak point pressure of less than 30 cm. water.3 The patient underwent 2 sessions of periurethral autologous lipo-injection at %month intervals. Injections were given with a 20 gauge needle via a periurethral route under cystoscopic guidance to achieve the correct position into the urethral muscular envelope. The proper placement of the needle was confirmed by coaptation all around the urethra induced by fat injection at a single point. The amount of fat injected vaned from 6 to 10 ml. until maximal mucosal coaptation resulted. A 14F Foley catheter was left in place overnight. Although continence significantly improved, the patient presented 3 months postoperatively when a 2 cm. fatty tissue nodule prolapsed through the urethral meatus during voiding (fig. 1). The prolapsed tissue was excised by a n incision around the nodule base and borders were approximated with Accepted for publication June 2, 1995.
FIG. 2. Adipose cells are mixed with fibroblast stroma with poor lymphocytic inflammatory reaction and well established graft neovascularization. H & E, reduced from X 100.
h e r o chromic catgut sutures. To avoid fat leakage though the suture repeat lipo-injection was performed a month later. The patient was completely dry during 10 months of folIowup. Pathological analysis of the excised tissue revealed adipose cells mixed with fibroblast stroma and a poor lymphocytic inflammatory reaction with some lipogranuloma formation (fig. 2). DISCUSSION
Lipo-injection was originally performed by injecting 40 ml. fatty tissue outside of the urethral muscular envelope. However, this approach may not increase the sealing effect. When injected within the urethral muscular envelope, in addition to proper coaptation, the submucosal vascular plexus may contribute to graft integration. Ln our case the complication developed because lipo-injection was performed from the bladder neck toward the urethral meatus in a n attempt to increase the fimctional length of the urethra. We now believe that the proper technique is to inject the fatty tissue from the bladder neck to the mid urethra to avoid prolapse of the fatty tissue. Although further investigation and longer followup are required before a definitive statement can be made as to the clinical application of this technique, our experience shows that lipo-injection may be useful in the management of select cases of urinary incontinence. REFERENCES
1. Appel, R. A.: Injectables for urinary incontinence. World J. Urol.,
8 208, 1992.
2. Palma, P.C. R. and Netto, N. R., Jr.:Injeqso periuretral de tecido adiposo autologo no tratamento da incontinhcia urinaria de esforqo. J. Bras. Urol., 1 6 49, 1990. 3. McGuire, E. J., Fitzpatrick, C. C., Wan, J., Bloom, D.. Sanvordenker. J., Ritchey, M. and Gormley, E. A,: Clinical assessment of urethral sphincter function. J. Urol., 1 5 0 14.52, 1993.
FIG.1. Intraoperatively urethral pseudolipoma prolapses during Valsalva maneuver. 646