Contemporary trends for urological training and management of stress urinary incontinence in Ireland

Introduction and hypothesis The aim of this study is to evaluate the trends in stress urinary incontinence (SUI) surgery since the 2018 pause on use of the polypropylene (PP) mid-urethral sling (MUS) and to quantify the effect this has had on surgical training. Methods Two anonymous surveys were sent to all current urology trainees and to all consultant surgeons who specialise in stress urinary incontinence surgery. Results Prior to the pause, 86% (6 out of 7) of consultant urologists and 73% (11 out of 15) of consultant gynaecologists would “always”/“often” perform MUS for SUI. After that, 100% (22 out of 22) of consultants reported that they “never” perform MUS. There has been a modest increase in the use of urethral bulking agent (UBA) procedures among urologists, with 43% (3 out of 7) now “often” performing this, compared with 71% (5 out of 7) “never” performing it pre-2018. Trainee exposure to SUI surgery reduced by 75% between 2016 and 2020. Despite a ten-fold increase in UBA procedures logged by trainees, the decline in MUS has resulted in a major reduction in total SUI surgeries. Coinciding with this decrease in surgeries, there was a 56% reduction in trainees’ self-assessed competence at SUI surgery. Thirteen percent of trainees are interested in specialising in Female Urology and those trainees had significantly greater exposure to SUI procedures during their training than those who did not (p = 0.0072). Conclusions This study has identified a downward trend in SUI surgery, which is concerning for the undertreatment of females with SUI. A decline in SUI surgery training has resulted in reduced trainee confidence and interest in this subspecialty.

Migrated Macroplastique in bladder wall – ‘Mickey Mouse’ sign in MRI

Macroplastique is an injectable urethral bulking agent used in stress incontinence. There is a paucity of studies beyond five years of follow-up looking into the long-term side effects of injecting this material. Here we present a female patient, who had Macroplastique injected multiple times 20 years ago for stress incontinence, and who presented with significant storage symptoms and non-visible haematuria. The symptoms were due to migration of Macroplastique and erosions, which looked like bladder tumour. Magnetic resonance imaging (MRI) scan showed circumferential migration of the Macroplastique material, mimicking the appearance of a ‘Mickey Mouse’.