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The the temporarily positioned superior abdominal flap about posterior thigh skin is undermined deep to the fasciae latae 2 cm superior to the deeply situated the cutout umbilicus generic bactrim 480mg online. The patient is then sutured to the 3 buy 960 mg bactrim, 6 purchase bactrim 960mg with mastercard, and 9 O’clock positions in the rectus fascia turned supine for correction of the remaining laxity of the around the retained island umbilicus purchase bactrim 480mg amex. The roughly parallel inferior gluteal and upper sion is transmitted through the dermal flaps of the abdominal posterior thigh incisions are continued along the labia majora wall flap to the rectus fascia with some relaxation of the high to within the groin crease at the junction of the thigh and tension between the umbilicus and pubis. There is no tension pubic area and across the upper inner thigh to remove a band along the skin closure of the island umbilicus cutout to the of excess tissue from the medial thigh. If an upper body lift is planned, then residual lifted and secured at a higher position to the underlying pubic paramedian epigastric and mid-torso skin rolls along with a periosteum and Colles’ fascia as in the Lockwood anchor descended breasts will be corrected by reverse abdomino- medial thighplasty [36]. The groin crease is then recon- plasty, superior repositioning of the inframammary folds, and structed where the scars are often undetectable under cloth- breast reshaping. A thigh-long ellipse of skin of flanks may still be full and will need liposuction. When the the medial thigh is removed through a vertical excision that mons pubic ptosis is severe, we prefer the three-sided pic- starts at the groin crease and extends to the inner knee. The superior an isolated procedure it offers circumferential reduction side of the mons is pulled tight by abdominoplasty. In addition there is a three-sided picture frame pubic monsplasty to correct the dome shape of the region after a suture suspension during her prior abdominoplasty. The spiral excision is drawn between the buttocks and upper thigh and spirals around the medial thighs to end along side of the labia majora to meet the abdominoplasty scar. The upper c d portion of the vertical excision is seen anteriorly and the lower portion is seen posteriorly to end medial to the popliteal fossa. Despite her girth, her thigh tissues were very lax, indicating combined liposuction and excision 5. Type 2 is used for mild to moderate mid-torso laxity Upper body lift is an excision of mid-torso back rolls that or when the patient refuses a back scar. The proper width of resection is achieved when all verti- chest to the inframammary fold, a brachioplasty is often cal redundancy is removed by gathering the skin. Type 2 is a vertical J-shaped exci- line, that is the case in only the most severe mid-torso skin Plastic Surgery in Massive Weight Loss Patients 425 Fig. Appropriate thigh contours and skin turgor as well as mons pubis shaping are established with inconspicuous scars c d sagging. Since the skin is always adherent to the sue can be used to augment the inferior pole of the breasts, posterior spinous region, it is only the chasing of dog ears then it is planned as an inferior deepithelialized continuation that forces the midline crossover of the excision. However, often they heal as well as the other boomerang pattern correction of gynecomastia. Once the abdominoplasty excision in vesting of the transverse tissue over the latissimus dorsi 426 D. The implants remain in good position with no expansion dashed lines of the pectoralis muscles, and midline and meridian lines of the lower poles as seen in Fig. After mastopexy, 325 cc gel implant augmentation and fascia and either discarded or retained as a laterally based deepithelialized intercostal perforator flap for breast reshap- ing. There will be some scalloping of the longer advanced side that tends to smooth out over time. Otherwise an unsecured advancement expose the Strattice sewn to the pectoralis muscle over the gel implant back flap may recede to lateralize the breast. Unlike the standard Wise pattern breast reduction part of overall torso skin laxity. Usually, we use a Wise pattern dermal bra suspension aims to restore breast shape through a in order to remove excess, poorly elastic skin. It also suspends the superior dermal pedicle of The markings of the Wise pattern mastopexy, spiral the breast to the second rib periosteum. If there is inadequate breast volume, a breast ratus fascia and lateral border of the central breast mound. When the base or footprint of the the rotated and advanced lateral thoracic flap to the second breast has lowered, it should be raised. L brachioplasty involves excisions of a longitudinal hemi- The spiral flap uses upper abdominal and lateral thoracic ellipse of the medial arm and crescentic lateral chest skin excess tissue not only to add volume but also to suspend. The excisions connected by an inverted V excision across the deepithelialized lateral thoracic flap is placed in a tunnel to axilla [23, 44]. This brachioplasty is designed for correction establish long-lasting superior pole fullness and a smooth of severe arm laxity, axillary ptosis, and upper chest laxity transition from the lateral breast to the axilla. Then an anchoring deep suture Plastic Surgery in Massive Weight Loss Patients 429 suspends the proximal posterior flap to the deltopectoral fascia. The width of the vertical chest limb can only be deter- Pearls and Pitfalls mined after breast reshaping has been completed. L • Total body lift surgery is an approach, not a tech- brachioplasty completes the total body lift. Banked blood transfu- • Optimal nutritional and medical preparation is sions for single stage were 1. Fifteen of the 50 single-stage patients (25 %) suffered Informed Consent for Abdominoplasty/Lower Body major complications (2-month delay or an unscheduled Lift/Thighplasty return to the hospital). These major complica- Instructions tions included multiple, infected, and recurrent seromas, but- This is an informed consent document that has been prepared tock adipose flap necrosis, prolonged edema, chest hematoma to help Dr. Hurwitz and his staff inform you on that required drainage, thigh abscesses, spiral flap tip necro- the combination operations of abdominoplasty, lower sis, pulmonary embolism, and Clostridium difficile pseudo- body lift, and medial thighplasty and their risks, as well as membranous colitis resulting in total colectomy. Residual and recurrent skin laxities as well as unwanted It is important that you read this information carefully and retained adipose are common problems of body contouring completely. While major but localized excisions with lipo- indicating that you have read and understand the page suction have been our usual approach to correct these prob- and sign the consent for surgery as proposed by lems, recently we have successfully applied the contraction Dr. With aging, following pregnancies, or massive weight loss, there are a set of body contouring procedures that remove unwanted loose skin and fat from the lower torso and 7 Informed Consents thighs and then reshape them. After that region is addressed, the surgical rehabilitation is commonly com- Obtaining an informed consent for multiple interrelated pleted on the mid-torso, breasts, and arms. That second operations is a complex process that has been aided by my session is an upper body lift, which consists of a reverse patient education book, Total Body Lift. An informed consent abdominoplasty, removal of mid-back rolls, establishing a document for the first stage of total body lift surgery, abdom- higher fold under the breast, and reshaping of the breasts. In Although that scenario is our most common approach, its usual format the patient initials each page. Agha-Mohammadi This consent form deals with surgery of the lower body and lift, and upper medial thighplasty are covered by under- thighs, which is often the first part of what Dr. Hurwitz wear, the vertical medial thighplasty scar will be seen calls a total body lift. Hurwitz has gained consider- individuals who intend to lose weight should postpone body able experience in body contouring surgery and is an contouring surgery until they have been able to adequately innovator and an internationally recognized teacher in reduce and maintain their weight loss. Furthermore, significant for Plastic Surgery with offices in Pittsburgh and weight loss after body contouring surgery could result in Philadelphia (Chadds Ford), Pennsylvania, and in undesirable contours and sagging of skin. Hurwitz will offer the procedures Women’s Hospital, because that is a nearby well-equipped and staging that address your body contour concerns, facility with my experienced team of anesthesiologists, your resources, and your level of acceptance of risk. We strongly recommend reading his book, Total Alternative treatments Body Lift, available from the office at no charge, for in- Alternative forms of management consist of not treating the depth discussions of this surgery and presentation of areas of loose skin and fatty deposits.

Poor results using sacral nerve stimulation (Interstim) for treating pelvic pain patients cheap 480 mg bactrim amex. A prospective single-blind buy bactrim 480 mg mastercard, randomized crossover trial of sacral vs pudendal nerve stimulation for interstitial cystitis purchase bactrim 960mg otc. Sacral nerve neuromodulation in the treatment of patients with refractory motor urge incontinence: Long-term results of a prospective longitudinal study purchase bactrim 960mg mastercard. Efficacy and safety of sacral nerve stimulation for urinary urge incontinence: A systematic review. Re-operation rates after permanent sacral nerve stimulation for refractory voiding dysfunction in women. Buttock placement of the implantable pulse generator: A new implantation technique for sacral neuromodulation—A multicenter study. For many patients choosing bulking agents, a desire for a simple in-office injection technique with immediate, albeit not permanent, result may be paramount. Others, based on realistic goals, choose urethral bulking having undergone one or more prior procedures with less than a satisfactory outcome and are not interested in enjoining more invasive procedures. Some patients may not be candidates for other procedures due to fragility or medical comorbidities. As such, complex urodynamic-derived criteria are generally not required prior to the use of bulking agents. The determination of the postvoid residual volume, however, is recommended prior to the use and reinjection of bulking agents [9], both diagnostically and to reduce adverse events, as the application of bulking agents in the setting of an elevated postvoid residual may lead to outlet obstruction and overflow incontinence [10]. Bulking agents may be used as primary treatment and, importantly, do not hamper the subsequent use of surgical procedures when and if necessary to complement sphincteric competence [11]. In addition to use as a primary treatment, several reports support injection of bulking agents as an effective adjunct for many difficult clinical scenarios, including secondary application following failed surgical procedures [32–34] and following radical pelvic surgery in both men and women [35,36], in patients with spinal cord injuries [37,38], or for continent stomas [39] that lack the desired level of continence due to insufficient closure pressures. As with use in a primary setting, large high-quality studies of bulking agents in the aforementioned challenging situations are lacking. Additionally, effective soft-tissue bulking has been reported in pediatric vesicoureteric reflux [40–43], fecal 776 incontinence [44–49], cosmetic procedures [50,51], and gastroesophageal reflux [52]. Coaptation of the urethral lumen allowing for a watertight seal involves the physical properties of the intrinsic softness of the mucosa [5], supportive connective tissue, normal vascularity [53,54], neural integrity, and adequate function of surrounding smooth and striated muscle to provide resistance to these variable intra-abdominal forces. The voluntary sphincters are necessary for active continence; hence, strength training these voluntary muscles with pelvic floor muscle contractions [55,56] allows for heightened closure pressures during momentary and nonsustained increases in abdominal pressure, as occurs with coughing, sneezing, and other Valsalva activities. Bulking agents work by increasing resistance to intra-abdominal forces via the soft-tissue filler properties of the injectable agent [57]. Hence, improvement of continence may be limited if the degree of incontinence is severe. Poor tissue compliance may not accommodate sufficient soft-tissue fill for complete continence. Though only case reports exist, poorly coapting soft tissues due to neural damage, in postprostatectomy incontinence [36,58–61] or stomas, may achieve effective soft-tissue fill with a bulking agent. Several comparative trials have measured the efficacy using the Stamey Urinary Incontinence Scale [62], which is likely associated with a poor discrimination index [63] to detect changes in continence (i. More recent trials have included more sensitive and appropriate measures of change in continence, including pad tests, validated questionnaires, and patient perception of effectiveness [64]. Current literature does not demonstrate any significant difference in efficacy or complications between currently accepted bulking agents [3]. Anticipated efficacy for patients treated with collagen without concomitant prolapse treatment has been reported to decline over time, from 48% at 12–23 months to 32% at 24–47 months [66]. A recent systematic review of response rates at 12 months with experienced surgeons approached 30%–40% dry, with twice that percentage dry/improved. Using all measures, bulking agents are less effective and less durable than other procedures but remain less invasive with lower complication rates [67]. For most agents, the published prospective randomized trials have been industry sponsored and therefore limited to one or two randomized trials. However, the technique of bulking agent injection requires a measured degree of expertise. Given that each bulking agent has characteristics specific to its application, most centers choose a bulking agent and become facile with that agent. Impaired durability of the bulking agents is a greater challenge than current safety issues. Requiring a pressurized injection system, 247 females with intrinsic sphincter deficiency in a ® multicenter study were randomized 1:1 and treated with Macroplastique versus Contigen serving as a control. In a rare study following a study group out to 24 months, 33 of 38 of the patients achieving dry/continence at 12 months remained dry at 24 months. An additional 12 of 29 patients, who were judged improved at 12 months, were dry at 24 months [69]. The Macroplastique Implantation Device, a specialized pressured syringe and applicator, allows for outpatient transurethral cystoscopic injection under direct vision. Sterilization of the reusable injector system requires enzymatic cleaning, disinfection, and autoclaving, which may not be available within the outpatient or clinic setting. The material is injected with a disposable 21-gauge needle under cystoscopic guidance and readily adapted to the outpatient or clinic setting. Furthermore, the product is immunogenic requiring a negative skin testing 30 days prior to bulking agent injection. A fatal pulmonary embolism [74] and a fat embolism syndrome [75] argue strongly against its use; of note, the fat embolism syndrome was associated with an injection with 14G needle using a periurethral approach. Of note, autologous fat remains widely used in cosmetic procedures and purportedly retains 60% of its bulk over time. This result has not been translatable to safe or efficacious use in urinary incontinence. Achieving higher “maximum squeezing” opening pressure correlates with improved continence after bulking agents. It has therefore been suggested that agents should be injected on the luminal side from the sphincter and at the high-pressure region of the sphincter [57]. Increasing volume of the injected bulking agent would subsequently result in decrease in luminal closure pressure if the bulking agent either overbulked the region [47] or conversely extravasated. Notably, success rates have been reported to decrease with an increased number of injection sites, likely due to extravasation [87]. Injection of the material, therefore, should be slow and deliberate in order to maximize fill and reduce disruption of the fragile soft tissue. Sequential injections are preferable to bursting the soft-tissue envelope created by the bulking agent. Therefore, it may be useful to think of reaching a “sweet spot” with the volume injected: too little is ineffective at raising the intraluminal closure pressures, and too much will burst the envelope containing the bulking agent. Transurethral injections directed nearer to the bladder neck may be associated with less urinary retention compared with periurethral injections as is reported in some studies comparing methods. It has been theorized that the greater volume reported in most comparative trials of the periurethral injection may be an associated cause [88]. Others have suggested that a luminally placed bulking agent might allow for higher degrees of soft-tissue creep (i.

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The pathophysiologic substrate in disease states other than coronary artery disease is less clear bactrim 960mg without a prescription. Electrophysiologic Substrate The clinically measurable electrophysiologic consequences of infarction that are potentially arrhythmogenic include abnormalities of conduction and refractoriness discount 480 mg bactrim fast delivery, heterogeneity of conduction and refractoriness generic bactrim 960 mg, enhanced automaticity cheap 480mg bactrim overnight delivery, and areas of inexcitability. Unipolar (top) and bipolar (bottom) signals recorded with the Rhythmia mapping system. The bipolar signal removes the large farfield signal recorded in the two unipolar electrograms from which the bipolar signal is derived. We developed criteria for normal, abnormal, and fractionated electrograms using bipolar signals recorded with a Bard Josephson catheter (see Fig. Normal electrograms had sharp, biphasic, or triphasic spikes with amplitudes of ≥3 mV, durations of ≤70 msec, and/or an amplitude/duration ratio of ≥0. We defined fractionated electrograms as abnormal electrograms that fell outside the 95% confidence limits of amplitude and duration of all abnormal electrograms. The most common abnormalities were low voltage and increase in electrogram duration, both of which appear to be nonspecific markers of infarction or even poor contact. Multicomponent and fractionated electrograms, isolated late potentials and late electrograms were more closely related to 31 arrhythmogenic sites; but the positive predictive value was only ∼30%. Only 14% of “sites of origin” came from sites that demonstrated normal electrograms. It should be obvious that since mapping catheters have different size electrode (tip and ring), normal and abnormal electrogram characteristics need to be defined for each catheter. Subsequent intraoperative studies using a 20 pole plaque electrode showed that successful surgery was associated with elimination of isolated late potentials and split potentials suggesting mechanistic significance 37 (Fig. The first two complexes are sinus in origin and the left ventricular recordings show markedly abnormal electrograms. Multiple components are present, and the electrogram exceeds 160 msec in duration. We defined total endocardial activation as the time from the earliest local activation to the time of the latest local activation. We used the total endocardial activation time, the duration of the longest electrogram recorded, the presence of late electrograms (including late potentials), and the extent of abnormal P. These abnormalities of activation, whether recorded endocardially in the catheterization laboratory or intraoperatively, occur only in areas of prior infarction and 35 36 38 39 significant wall motion abnormalities. Sites 2, 3, and 4 are the septum, 1 is the apex, 5 and 6 are the mid- and basal inferior wall, 8 is the inferoposterior wall, 9 is the apical anterolateral wall, 10 is the basal lateral wall, 11 is the midanterior wall, and 12 is the basal anterior wall. Endocardial catheter mapping in patients in sinus rhythm: relationship to underlying heart disease and ventricular arrhythmias. Three surface recordings accompanied by three local bipolar electrograms (normal, abnormal, and fractionated and late) recorded from different left ventricular endocardial sites are shown. The arrows show the onset and offset (characterized by the amplification signal decay artifact) of local electrical activity. Endocardial catheter mapping in patients in sinus rhythm: relationship to underlying heart disease and ventricular arrhythmias. Normal values and abnormal electrograms recorded with this plaque are shown on the left. The value of catheter mapping during sinus rhythm to localize site of origin of ventricular tachycardia. In this instance, the pattern of activation is normal but the electrograms are of broader duration and several have multiple components. Rate of tachycardia, and not the location of prior infarction, ejection fraction, or extent of coronary disease is the only factor that determines clinical outcome. Clearly, these fragmented or fractionated electrograms are not an artifact of filtering or motion, because such electrograms can neither be created nor abolished by changing the filtering and can be recorded with uni- or bipolar recordings in fixed pieces of tissue or in nonmoving and infarcted regions during intraoperative 39 40 43 mapping. The extent and location of fibrosis is a critical determinant of the electrogram amplitude, duration, complexity, and timing because of its effect on fiber orientation, curvature, connectivity, and anisotropy, all of which influence conduction. The peak-to-peak bipolar amplitude in mV is plotted 2 against the interelectrode activation time. When the bipolar pair of electrodes are more perpendicular to the tissue, the voltage is lower than when the electrodes are parallel to the surface with rapid activation between electrodes. When the wavefront is transverse to the bipoles, activation is slower and the amplitude of the bipolar electrogram is markedly reduced. Detailed mapping studies with microelectrodes in human tissue and in tissue from experimental canine 29 43 44 46 47 48 50 51 52 53 tachycardia models , , , , , , , , , demonstrate that slow propagation of an impulse through areas from which fractionated electrograms are recorded is associated with relatively normal action potentials of the muscle fibers. Response of these local electrograms to antiarrhythmic agents is also compatible with relatively 54 55 normal action potential characteristics. Thus, anatomic abnormalities can produce functional abnormalities (poor cellular coupling, impedance mismatch, altered curvature, etc. Slow conduction produced by ischemia (low pH), hyperkalemia, or uniform depression of Na channels reduces the peak-to-peak unipolar voltage and duration. It has a similar effect on bipolar signals but duration is less affected because far field activity, a contributor of unipolar duration, is markedly reduced in bipolar, especially filtered bipolar, recordings. Thus the peak-to-peak voltage is a direct reflection of conduction velocity and not of tissue mass. We have shown that most of the cause of low-amplitude and fractionated electrograms and late 37 potentials secondary to infarction is produced by ≈2 mm of endocardial scar. Loss of tissue alone, without fibrosis induced changes in activation due to separation of myocytes would not produce fractionated, low-voltage electrograms or late potentials. The unipolar and bipolar signals would show low-voltage, broad electrograms without fractionation. These abnormalities of the electrograms are most closely related to fibrosis-dependent effects on conduction, not loss of tissue. The use of sinus rhythm mapping in localizing the arrhythmogenic substrate for ablation of untolerated ventricular arrhythmias is discussed in Chapter 13. The development of three-dimensional (3D) mapping systems has allowed more detailed characterization of the electrophysiologic substrate of healed infarction, as a greater number of sites can be collected and the spatial relationships of these sites can be understood. Importantly, the use of different recording systems and catheter types requires standardization, particularly the establishment of a new set of normal values. Unfortunately, no duration standards are available because of the lack of “fixed” gain recordings. The newer Carto 3 system has bipolar filters preset at 16 to 240 Hz; this filtering gives slightly different normal. In order to make meaningful comparisons among published data filter settings and catheter tip and ring electrode size and interelectrode distance must be comparable. Unfortunately while most laboratories use preset filter settings regardless of the system they use, other laboratories try to be systematic like us. Thus it is hard to interpret differences in data, particularly when those recordings are used to guide ablation (see Chapter 13). The high-pass filter markedly influence unipolar signals while the low pass setting influences the degree of fractionation in bipolar signals.

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Requiring a pressurized injection system 960 mg bactrim, 247 females with intrinsic sphincter deficiency in a ® multicenter study were randomized 1:1 and treated with Macroplastique versus Contigen serving as a control generic 480 mg bactrim fast delivery. In a rare study following a study group out to 24 months generic bactrim 960mg mastercard, 33 of 38 of the patients achieving dry/continence at 12 months remained dry at 24 months cheap bactrim 480mg on-line. An additional 12 of 29 patients, who were judged improved at 12 months, were dry at 24 months [69]. The Macroplastique Implantation Device, a specialized pressured syringe and applicator, allows for outpatient transurethral cystoscopic injection under direct vision. Sterilization of the reusable injector system requires enzymatic cleaning, disinfection, and autoclaving, which may not be available within the outpatient or clinic setting. The material is injected with a disposable 21-gauge needle under cystoscopic guidance and readily adapted to the outpatient or clinic setting. Furthermore, the product is immunogenic requiring a negative skin testing 30 days prior to bulking agent injection. A fatal pulmonary embolism [74] and a fat embolism syndrome [75] argue strongly against its use; of note, the fat embolism syndrome was associated with an injection with 14G needle using a periurethral approach. Of note, autologous fat remains widely used in cosmetic procedures and purportedly retains 60% of its bulk over time. This result has not been translatable to safe or efficacious use in urinary incontinence. Achieving higher “maximum squeezing” opening pressure correlates with improved continence after bulking agents. It has therefore been suggested that agents should be injected on the luminal side from the sphincter and at the high-pressure region of the sphincter [57]. Increasing volume of the injected bulking agent would subsequently result in decrease in luminal closure pressure if the bulking agent either overbulked the region [47] or conversely extravasated. Notably, success rates have been reported to decrease with an increased number of injection sites, likely due to extravasation [87]. Injection of the material, therefore, should be slow and deliberate in order to maximize fill and reduce disruption of the fragile soft tissue. Sequential injections are preferable to bursting the soft-tissue envelope created by the bulking agent. Therefore, it may be useful to think of reaching a “sweet spot” with the volume injected: too little is ineffective at raising the intraluminal closure pressures, and too much will burst the envelope containing the bulking agent. Transurethral injections directed nearer to the bladder neck may be associated with less urinary retention compared with periurethral injections as is reported in some studies comparing methods. It has been theorized that the greater volume reported in most comparative trials of the periurethral injection may be an associated cause [88]. Others have suggested that a luminally placed bulking agent might allow for higher degrees of soft-tissue creep (i. Others report no statistical difference between the effectiveness of the periurethral versus transurethral approach to injection [88,89]. In the transurethral technique, the bulking agent may be injected at the bladder neck or the midurethra under cystoscopic guidance. There is insufficient comparative data to support bladder neck versus midurethral injection. In the transurethral cystoscopic approach, the urethral mucosa is punctured distal to the chosen injection locale in the urethra. Prior to the puncture, the urethra and bladder are inspected and the scope is then withdrawn to the distal urethra. The middistal portion of the urethra is punctured with the bevel of the needle toward the lumen at a 30°–45° angle. The needle is transluminally advanced into the submucosa, but not to the muscularis. The angle is subsequently dropped parallel to the path of the urethra, and the needle is advanced approximately 1 cm within the submucosal layer with slow deliberate injection of the material aided by visual deformation of the tissues and halting further injection particularly if blanching of the mucosal vessels is observed. Submucosal 779 hydrodissection with lidocaine may be performed prior to injection [91] to reduce discomfort and to prepare the envelope for the agent. Once the injection is completed, the needle is held in position for several seconds prior to withdrawal, in order to allow for equilibration of pressures within the receiving soft-tissue envelope and to reduce extravasation from the needle site [91]. While failure rates have been reported to increase with the number of puncture sites [83], presumably due to the loss of the bulking agents through these punctures, several industry-recommended techniques include three-site injections (e. Contraindications to the use of a bulking agent in an appropriately selected patient include an active urinary tract infection or known hypersensitivity to the agent or any of its components. Bulking agents have been successfully and safely injected in fully anticoagulated patients, albeit with a theoretical concern for an increased risk of ongoing hematuria or urinary retention in the setting of a periurethral hematoma (personal experience). The most common adverse event is temporary urinary retention with major adverse events being rare [62,63,84]. Acute urinary retention has been reported in up to 24% of patients in a study of Durasphere and thus deserves mention during patient counseling. Additionally, it should be noted that retention in this setting is transient, for instance, lasting 7 days or less in most series [24,63]. Other adverse events that may be commonly encountered include postoperative dysuria, hematuria, uncomplicated urinary tract infection, and de novo urinary urgency, which typically resolve with conservative management [62,63,92,93]. Aspiration or incision and drainage of the injected agent is associated with 100% return of the patients prior sphincteric incontinence [94]. A few specific long-term complications that are quite rare, typically reported as single cases or small series, merit consideration as well. Urethral prolapse, potentially from disruption of support between the urethral mucosal and muscle wall with urethral bulking, has been reported [95–99]. Periurethral masses, variously described as periurethral pseudocyst [100] or sterile pseudoabscess [48,75,76,100–105], may be large and symptomatic and are associated with outlet obstruction [106] and/or pain [75]. Treatment of these lesions with aspiration [94] is associated with symptomatic pseudoabscess reoccurrence and thereby may require definitive transurethral, transvaginal, or retropubic incision and drainage [76]. These masses, if draining spontaneously into the urethral lumen, might progress to a de novo urethral diverticulum [107,108]. As several agents require high-pressure injector systems, particle migration into local and distant lymph nodes may occur [109] and be visibly confirmed if the bulking agent is able to be imaged. Embolization may also occur, though only autologous fat has been reported to result in pulmonary embolism [75] and death [74]. All bulking agents could be erosive, resulting either from a property of the injected agent [110] or of the surrounding tissue [111,112] and may result in the extremely rare complication of fistula formation. Transvaginal incision and drainage of a pseudoabscess carries this theoretical risk. Adverse events have also been reported outside of the urologic and gynecological literature, such as in plastic surgery series, but are likewise rare [113,114].

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