Continence Mechanism Research Articles

The long-term post-surgical outcome of intermediate anorectal malformation in our department.

Posterior sagittal anorectoplasty and laparoscopic-assisted anorectal pull-through are preferred for anorectal malformation (ARM) today, while careful pull-through procedures with sacroperineal approach yield excellent outcomes. This study focuses on a pull-through procedure emphasizing continence mechanism preservation and compares outcomes with historical studies with various procedures. Bowel function of patients with intermediate ARM followed up for over 10years post-surgically was assessed. Data collected included ARM type with the Krickenbeck classification, comorbidities, complications, post-surgical examinations, follow-up, and bowel function at the latest clinic visit. The literature review collected original articles including more than 10 post-anorectoplasty cases which were followed for over 10years. Eleven cases were identified, with a median age at anorectoplasty and follow-up length of 6.9months and 14.4years. Two fistula recurrences required surgical treatment. Long-term incontinence and constipation were observed in 9% and 45% of the cohort, respectively. Good rectal angulation and a positive rectoanal inhibitory reflex were confirmed in most cases examined. A literature review identified eight studies with various outcome-measuring instruments. Outcomes of the introduced pull-through procedure were favorable, while the literature review highlights the variation in outcomes of various anorectoplasty. Level IV.

Effect of neoadjuvant chemoradiation on anorectal function assessed with anorectal manometry: A systematic review and meta-analysis.

Improvement in oncological survival for rectal cancer increases attention to anorectal dysfunction. Diagnostic questionnaires can evaluate quality of life but are subjective and dependent on patients' compliance. Anorectal manometry can objectively assess the continence mechanism and identify functional sphincter weakness and rectal compliance. Neoadjuvant chemoradiotherapy is presumed to affect anorectal function. We aim to assess anorectal function in rectal cancer patients who undergo total mesorectal excision, with or without neoadjuvant chemoradiation, using anorectal manometry measurements. MEDLINE, Embase, and Cochrane databases were searched for studies comparing perioperative anorectal manometry between neoadjuvant chemoradiation and upfront surgery for rectal cancers. Primary outcomes were resting pressure, squeeze pressure, sensory threshold volume and maximal tolerable volume. Eight studies were included in the systematic review, of which seven were included for metanalysis. 155 patients (45.3%) had neoadjuvant chemoradiation before definitive surgery, and 187 (54.6%) underwent upfront surgery. Most patients were male (238 vs. 118). The standardized mean difference of mean resting pressure, mean and maximum squeeze pressure, maximum resting pressure, sensory threshold volume, and maximal tolerable volume favored the upfront surgery group but without statistical significance. Currently available evidence on anorectal manometry protocols failed to show any statistically significant differences in functional outcomes between neoadjuvant chemoradiation and upfront surgery. Further large-scale prospective studies with standardized neoadjuvant chemoradiation and anorectal manometry protocols are needed to validate these findings.

The use of urodynamic to assess the mechanism of incontinence in patients with Yang-Monti based catheterizable cutaneous stomas.

To analyze the static and dynamic urodynamic parameters of reservoirs and continent conduits in continent cutaneous urinary diversion with catheterizable stoma. 76 patients had augmented ileocystoplasty or continent urinary diversion with catheterizable urinary stoma based on Mitrofanoff principle and Yang-Monti procedure using subserous tunnel as continence mechanism. They were followed up for at least 6 months post-operatively for continence through stoma and divided into two groups (continents vs non-continent) according to stomal continence. Both groups had urodynamic assessment performed via the stoma to assess reservoir capacity, pressure and contractions, efferent limb functional length, reservoir overactivity, static and dynamic maximal closure pressures and leak point pressure. Continence rate was 87%. Continent group included 66 patients and incontinent group included 10 patients. In both groups at rest, the reservoir pressure after filling did not exceed 25 cm H2O. During peristaltic contraction, the pressure did not exceed 30 cm H2O and the duct remained continent. After Valsalva maneuver, the reservoir pressure increased up to 34 (+ 7.4) cm H2O and leakage occur in 10 patients (13%). Reservoir (wall) overactivity was recorded in 54 patients, with insignificant rise in intraluminal pressure during the contractions. In both groups, the efferent tract closing pressure was always higher than the reservoir pressure. The mean of maximal closing pressure at Valsalva was 82.5 (+ 4.18) cm H2O in the continent group and 61.66 (+ 8.16) cm H2O in the incontinent group. The mean functional length of the conduit was 4.95 + 1.62 in the continent group and 2.80 + 1.50 cm in the incontinent group. Urodynamic evaluation of continent catheterizable cutaneous stoma after Yang-Monti procedure has a practical significance. Functional length of the conduit seems to be the most influential factor for continence reflecting static & dynamic maximal closure pressure. Higher conduit closing pressure is associated with better continence. Contractions of the pouch and peristaltic contraction of the conduit has no effect on continence mechanism.

Isolated Male Epispadias with Continence in a 40 Year Old: A Case Report

Epispadias is part of the bladder exstrophy-epispadias complex; it has a defective dorsal wall of the urethra with potential incompetence of the urinary continence mechanism. Isolated male epispadias is due to failure of the urethral plate to tubularize on the dorsum of the penis. It is rare with an incidence rate of 1 in 117,000 live births in males. The severity depends on the position of the urethral opening and ranges from peno-pubic to penile and glandular. Epispadias is usually repaired within the first year of life though some patients have presented in their second decade. Epispadias is classically associated with bladder exstrophy in over 90% of the cases while isolated epispadias with continence is very rare constituting less than 10% of cases. Separation of pelvic bones is seen in 70% of peno-pubic epispadias affecting the bladder neck and external sphincter leading to incontinence and stress urinary dribbling. The goals of repair include; achieving a cosmetically acceptable and functional penis, which is straight and adequate in length, enabling penetrative sexual intercourse and urinary continence. There have been reports of isolated epispadias in adults but none was as old as 40 years. This patient has been married for 20 years and has been unable to impregnate his spouse. He had modified Cantwell-Ransley procedure after a detailed clinical and psychological evaluation to achieve the goals of repair. Adults presenting with isolated continent peno-pubic epispadias are rare. Presenting at this age and after having been married for two decades could have a derogatory effect on body image, self-confidence, psycho-sexual and reproductive life. Surgical correction of this anomaly as we did has the potential to lead to acceptable outcomes as demonstrated in this index case.

Role of Magnetic Resonance Imaging in Pelvic Organ Prolapse Evaluation.

Background and Objectives: The primary method for assessing pelvic floor defects is through physical examination. Magnetic resonance imaging (MRI) is a radiological technique that is useful for identifying the underlying defects of pelvic floor structures that require surgery. The primary aim of this study was to find correspondence between the clinical and radiological staging of pelvic organ prolapse (POP) before and after vaginal surgery. A secondary endpoint was to investigate, through clinical and MRI findings, whether surgery influences continence mechanisms. Finally, we reported changes in the quality of life of women who underwent surgery for prolapse. Materials and Methods: Twenty-five women with prolapse stage ≥ 2 POP-Q were recruited in this prospective study. They underwent preoperative clinical examination, MRI at rest and under the Valsalva maneuver, and quality of life questionnaires. Three months after vaginal surgery, they repeated clinical and radiological evaluation. Results: Twenty women completed the study. Both clinical and MRI evaluations showed an improvement in prolapse and symptoms after surgery. There were some discrepancies between clinical and radiological staging. MRI parameters did not show differences between pre- and postoperative values at rest; under the Valsalva maneuver, instead, the measurements changed after surgery. Continence was not worsened by the widening of the vesicourethral angle. Patients reported an improvement in quality of life. Conclusions: MRI is an accurate and objective method for defining the stage of prolapse, but clinical evaluation alone is sufficient for staging prolapse before surgery and evaluating the result at follow-up. It is an accurate method for visualizing some pelvic structures that can be compromised because of pelvic organ prolapse. MRI showed that vaginal surgery does not affect continence mechanisms.

Surgical techniques to preserve continence after robot-assisted radical prostatectomy.

Radical prostatectomy significantly impacts the inherent anatomy of the male pelvis and the functional mechanisms of urinary continence. Incontinence has a considerable negative influence on the quality of life of patients, as well as their social and psychological wellbeing. Numerous surgical techniques have been demonstrated to support the preservation of continence during robot-assisted radical prostatectomy (RARP). In this in-depth analysis, we give a general summary of the surgical techniques used in RARP and their impact on incontinence rates.

Initial Experience of Cutaneous Continent Urinary Diversion by Modified Penn Pouch Technique: Is It More Expedient than Ileal Conduit?

Introduction: In the current clinical practice, following cystectomy, either due to malignant or benign pathologies, the most common urinary diversion is in the form of ileal conduit. Quality of life is markedly decreased in patients with ileal conduit as they have to carry an external appliance with the poorest self-images that significantly reduce the desires of all forms of physical contact (sexual and non-sexual). Here we describe the initial experience of cutaneous continent urinary diversion following cystectomy that provides the patients with an external appliance-free life with good functional outcomes of the reservoir. Methods : The hospital records of 6(six) patients during a period of 5 months were reviewed retrospectively who underwent cutaneous continent urinary diversion in Dhaka Medical College Hospital, Dhaka and Center for Kidney Diseases & Urology Hospital, Dhaka. Out of 6 (six) patients, 5(five) underwent radical cystectomy for muscle-invasive bladder cancer, and 1(one) patient underwent simple cystectomy for exstrophy bladder. For the creation of the reservoir modified Penn pouch technique was applied, and the appendix was used as a catheterizable cutaneous stoma for the continent mechanism. A peri-operative and short periods of postoperative outcomes, including complications, quality of life assessment, continence and ability to empty the reservoir by selfcatheterization, was recorded. Results : Among the 6 (six) patients, 5 (five) cases were following radical cystectomy for muscle-invasive bladder cancer, and 1 (one) was following simple cystectomy for exstrophy bladder. After a median follow-up of 6 weeks, the continence rate was 100%. All patients (100%) could empty the neo-bladder by self-catheterization every 4-8 hours. Patients were highly satisfied with this stoma as they could avoid external appliances. Conclusion : Cutaneous continent urinary diversion is a successful method of neobladder construction following cystectomy for urinary bladder malignancy or severe functional and anatomical urinary bladder abnormalities with excellent functional outcomes. It needs skilled surgical techniques, and the decision on this method used should depend upon the indications and contraindications of surgery like renal functional status, patient anatomy, the physical and physiological condition of the patients and personal choice. Bangladesh J. Urol. 2022; 25(1): 7-13

Urinary Continence Recovery after Retzius-Sparing Robot Assisted Radical Prostatectomy and Adjuvant Radiation Therapy.

Retzius-sparing robot-assisted radical prostatectomy (RS-RARP) allows the preservation of the structures advocated to play a crucial role in the continence mechanism. This study aims to evaluate the association between adjuvant radiation therapy (aRT) and urinary continence (UC) recovery after RS-RARP. For the purpose of the current study, all patients submitted to RS-RARP for prostate cancer (PCa) at a single high-volume European institution between January 2010 and December 2021 were identified. Only patients that harbored pT2 stage with positive surgical margins or pT3/pN1 stage with or without positive surgical margins were included in the analyses. Two groups of patients were identified as follows: patients who had undergone aRT and patients submitted to observation (no-aRT patients). As per definition, aRT was delivered within 1-6 months after surgery. After 1:1 propensity score matching, 124 aRT patients were compared with 124 no-aRT patients who continued standard follow-up protocol after surgery. UC recovery was 81 vs. 84% in aRT vs. no-aRT patients (p = 0.7). In multivariable Cox regression analyses, aRT did not reach the independent predictor status for UC recovery at 12 months. In the subgroup analysis including only aRT patients, only the nerve-sparing technique was independently associated with UC recovery at 12 months. Conversely, the type of aRT (IMRT/VMAT vs. 3D-CRT) did not reach the independent predictor status for UC recovery at 12 months. The current study is the first to address the association between aRT and UC recovery in patients treated with RS-RARP for PCa. Based on our data, aRT is not associated with worse UC recovery. In the cohort of patients treated with aRT, the nerve-sparing technique independently predicted UC recovery.

MP60-20 ROLE OF SHH PATHWAY IN URINARY CONTINENCE AND ITS IMPACT ON CELLULAR FATE IN MOUSE URETHRA

You have accessJournal of UrologyCME1 Apr 2023MP60-20 ROLE OF SHH PATHWAY IN URINARY CONTINENCE AND ITS IMPACT ON CELLULAR FATE IN MOUSE URETHRA Walid Farhat, Priyank Yadav, Marcela Ambrogi, Audrey Spiegelhoff, Chad Vezina, and Kimberly Keil Stietz Walid FarhatWalid Farhat More articles by this author , Priyank YadavPriyank Yadav More articles by this author , Marcela AmbrogiMarcela Ambrogi More articles by this author , Audrey SpiegelhoffAudrey Spiegelhoff More articles by this author , Chad VezinaChad Vezina More articles by this author , and Kimberly Keil StietzKimberly Keil Stietz More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003318.20AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Sonic hedgehog (Shh) signaling is critical in many developing organs and subject to disruption through gene-environment interactions. Urinary continence is dependent on appropriate development of bladder neck and urethra driven by epithelial-mesenchymal interactions mediated in part by SHH. To further understand the impact of Shh pathway disruption on lower urinary tract and continence, we examined voiding physiology and histology in compound mutant GLI family zinc finger Gli2+/−; Gli3Δ699/+ mice, which have hypomorphic hedgehog signaling. METHODS: Voiding physiology was tested in young adult female mice (n=5-8/genotype) using void spot assay, uroflowmetry and ex vivo bladder bath assays. Urethra and bladder (n=3/genotype) were collected for immunostaining using antibodies against smooth muscle alpha actin to visualize urethral smooth muscle thickness, or uroplakin, transformation related protein 63, and keratin 5 (combinatorial staining resolves basal, intermediate and luminal epithelial cells). RESULTS: Gli2+/−; Gli3Δ699/+ female mice void more urine spots, void more spots of smaller diameter and void a greater percentage of urine in the cage center than wild type mice. Voids from Gli2+/−; Gli3Δ699/+ mice, measured by uroflowmetry, weigh less (indicating smaller volume) and are shorter in duration than wild type mice. Gli2+/−; Gli3Δ699/+ female mouse bladders, isolated in ex vivo bath preparations, are less responsive to electrical field stimulation and potassium chloride than bladders from wild type mice. Our results are consistent with detrusor under activity and potential stress incontinence in Gli2+/−; Gli3Δ699/+ female mice. In search for a physiological mechanism, we conducted histological analysis to reveal a clear anatomic boundary between wild type mouse bladder neck and urethra. Umbrella shaped uroplakin+ cells populate the bladder neck and cuboidal shaped uroplakin- superficial cells populate the urethra. The bladder neck epithelium of Gli2+/−; Gli3Δ699/+ mice does not appreciably differ from wild type, but urethral epithelial cells are uroplakin+, suggesting possible segmental deficits during urethral development that may account in part for incontinence in Gli2+/−; Gli3Δ699/+ mice. CONCLUSIONS: Our data suggest that establishing continent voiding function in mice is dependent on appropriate urethra epithelial cell fate. Future work to understand mechanisms underlying decreased bladder contractile properties, and urethral cell fate will enhance understanding of the continence mechanism. Source of Funding: DK104310 © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e851 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Walid Farhat More articles by this author Priyank Yadav More articles by this author Marcela Ambrogi More articles by this author Audrey Spiegelhoff More articles by this author Chad Vezina More articles by this author Kimberly Keil Stietz More articles by this author Expand All Advertisement PDF downloadLoading ...

Post-Operative Anorectal Manometry in Children following Anorectal Malformation Repair: A Systematic Review.

Despite surgical correction, children with anorectal malformations may experience long-term bowel dysfunction, including fecal incontinence and/or disorders of evacuation. Anorectal manometry is the most widely used test of anorectal function. Although considerable attention has been devoted to its application in the anorectal malformation cohort, there have been few attempts to consolidate the findings obtained. This systematic review aimed to (1) synthesize and evaluate the existing data regarding anorectal manometry results in children following anorectal malformation repair, and (2) evaluate the manometry protocols utilized, including equipment, assessment approach, and interpretation. We reviewed four databases (Embase, MEDLINE, the Cochrane Library, and PubMed) for relevant articles published between 1 January 1985 and 10 March 2022. Studies reporting post-operative anorectal manometry in children (<18 years) following anorectal malformation repair were evaluated for eligibility. Sixty-three studies were eligible for inclusion. Of the combined total cohort of 2155 patients, anorectal manometry results were reported for 1755 children following repair of anorectal malformations. Reduced resting pressure was consistently identified in children with anorectal malformations, particularly in those with more complex malformation types and/or fecal incontinence. Significant variability was identified in relation to manometry equipment, protocols, and interpretation. Few studies provided adequate cohort medical characteristics to facilitate interpretation of anorectal manometry findings within the context of the broader continence mechanism. This review highlights a widespread lack of standardization in the anorectal manometry procedure used to assess anorectal function in children following anorectal malformation repair. Consequently, interpretation and comparison of findings, both within and between institutions, is exceedingly challenging, if not impossible. Standardized manometry protocols, accompanied by a consistent approach to analysis, including definitions of normality and abnormality, are essential to enhance the comparability and clinical relevance of results.

Complete bladder duplication presenting in adulthood: A case report on reconstructive technique and reflections on translational urology in refugees

Introduction and aim of studyThe bladder-Exstrophy-Epispadias (BEEC) complex is a spectrum of congenital malformations with many variations. A never operated political refugee with BEEC was referred to our center for management upon arrival in Europe. Our aim is to report the technique and outcomes on a never operated on BEEC adult, highlighting the importance of transitional urologic care for congenital malformations in adult patients.Materials and methodsA 27-year old female patient was referred to our center for complete incontinence since birth by the General practitioner from the refugee center who suspected BEEC. Upon further investigation, an exstrophic bladder with blind ending ureteral orifices and a urethral meatus caudal to the exstrophic bladder plate were highlighted. A second non-exstrophic bladder with two orthotopic ureters was demonstrated, thereby a bladder duplication in the sagittal plane was diagnosed, presenting a wide-open bladder neck and a 7 cm pubic diastasis, causing the incontinence she was initially referred for. With the patient in a supine position, laparotomy incision was done with excision of the umbilical scar. The exstrophic bladder plate is dissected caudally. As it presents good detrusor quality, decision is taken to use it as a ventral inlay to augment the non-exstrophic bladder. A Mitchell-type bladder neck reconstruction is performed with a classical fascia sling wrapped around the bladder neck to increase the continence mechanism given the very wide pubic diastasis. Given the risk for hyper-continence, interposition of a continent Mitrofanoff-type vesicostomy is additionally realized. Genital reconstruction is achieved.ResultsOver 1 year post operatively, the patient is completely dry, can holp up to 250ml between catheterization she performs five times per day and once at night. No post-operative complications were observed.ConclusionThe case of one adult patient with a rare urological condition like bladder exstrophy with duplication is presented, illustrating challenges political refugees referred to Europe implicates in terms of surgery regarding congenital malformations in adult patients. A multidisciplinary approach is highly important, demonstrating the importance of transitional care.

Contribution of Retzius-sparing robot-assisted radical prostatectomy to the mechanism of urinary continence as demonstrated by dynamic MRI

Retzius-sparing robot-assisted radical prostatectomy (RARP) has been reported to exhibit better postoperative urinary continence, but the reasons behind this are unknown. This study included 254 cases who underwent RARP and underwent postoperative dynamic MRI. We measured the urine loss ratio (ULR) immediately after postoperative urethral catheter removal and investigated its affecting factors and the mechanisms. Nerve-sparing (NS) techniques was performed in 175 (69%) unilateral and 34 (13%) bilateral cases, whereas Retzius-sparing in 58 (23%) cases. The median ULR early after indwelling catheter removal in all patients was 4.0%. The multivariate analysis was performed on factors that reduce ULR and found that the following factors were associated with ULR: younger age, NS and Retzius-sparing, which were significant. Additionally, dynamic MRI findings showed that membranous urethral length and the anterior rectal wall movement toward the pubic bone during abdominal pressure were significant factors. The movement observed on the dynamic MRI during abdominal pressure was thought to reflect an effective urethral sphincter closure mechanism. Long membranous urethral length and an effective urethral sphincter closure mechanism during abdominal pressure were considered effective for favorable urinary continence after RARP. NS and Retzius-sparing were clearly shown to have an additive effect in preventing urinary incontinence.

Novel insights into physiological mechanisms underlying fecal continence.

The machinery maintaining fecal continence prevents involuntary loss of stool and is based on the synchronized interplay of multiple voluntary and involuntary mechanisms, dependent on cooperation between motor responses of the musculature of the colon, pelvic floor, and anorectum, and sensory and motor neural pathways. Knowledge of the physiology of fecal continence is key toward understanding the pathophysiology of fecal incontinence. The idea that involuntary contraction of the internal anal sphincter is the primary mechanism of continence and that the external anal sphincter supports continence only by voluntary contraction is outdated. Other mechanisms have come to the forefront, and they have significantly changed viewpoints on the mechanisms of continence and incontinence. For instance, involuntary contractions of the external anal sphincter, the puborectal muscle, and the sphincter of O'Beirne have been proven to play a role in fecal continence. Also, retrograde propagating cyclic motor patterns in the sigmoid and rectum promote retrograde transit to prevent the continuous flow of content into the anal canal. With this review, we aim to give an overview of primary and secondary mechanisms controlling fecal continence and evaluate the strength of evidence.

Central perforated VRAM flap and neurostimulated levator augmentation for functional and aesthetical reconstruction after abdominoperineal excision in cancer.

Preservation of quality of life regarding fecal continence after abdominoperineal excision (APE) in cancer is challenging. Simultaneous soft tissue coverage and restoration of continence mechanism can be provided through an interdisciplinary collaboration of colorectal and plastic reconstructive surgery. Evaluation of surgical procedure and outcome combining soft tissue reconstruction using a central perforated vertical rectus abdominis myocutaneous flap (VRAM), implementing a perineostoma and restoring anorectal angle augmenting the levator ani by neurostimulated graciloplasty. 14 Patients underwent APE due to cancer. In all patients coverage was achieved by pedicled VRAM and simultaneous pull-through descendostomy (perineostoma). 10 of those patients received a levator augmentation additionally. Postoperative complications, functional measures of continence as well as quality of life were obtained. Perineal minor complication rate was 43% without need of surgical intervention. All but one VRAM survived. Continence measures and disease specific life quality showed a good preservation of continence in most patients. The results present a complex therapy option accomplished by a collaboration of two highly specialized partners (visceral and plastic surgery) after total loss of the sphincter function and consecutive fecal insufficiency after APE.

Comparison between recent sphincter-sparing procedures for complex anal fistulas-ligation of intersphincteric tract vs transanal opening of intersphincteric space.

Complex anal fistulas are difficult to treat. The main reasons for this are a higher recurrence rate and the risk of disrupting the continence mechanism because of sphincter involvement. Due to this, several sphincter-sparing procedures have been developed in the last two decades. Though moderately successful in simple fistulas (50%-75% healing rate), the healing rates in complex fistulas for most of these procedures has been dismal. Only two procedures, ligation of intersphincteric fistula tract and transanal opening of intersphincteric space have been shown to have good success rates in complex fistulas (60%-95%). Both of these procedures preserve continence while achieving high success rates. In this opinion review, I shall outline the history, compare the pros and cons, indications and contraindications and future application of both these procedures for the management of complex anal fistulas.

Evaluating post radical prostatectomy mechanisms of early continence.

To identify the periprostatic structures associated with early return of urinary continence after radical prostatectomy (RP). We compared total continence results between four different techniques of robot-assisted radical prostatectomy (RARP). Specifically, we studied 1-week and 1-month zero-pad continence rates of anterior (n = 60), posterior (n = 59), a novel hybrid posterior-anterior (n = 12), and transvesical (n = 12) approaches of RARP. Each technique preserved a unique set of periprostatic anatomic structures, thereby, allowing evaluation of the individual impact of preservation of nerves, bladder neck, and space of Retzius with associated anterior support structures on early continence. Urethral length was preserved in all approaches. The space of Retzius was preserved in posterior and transvesical approaches, while the bladder neck was preserved in posterior and hybrid approaches. Nerve sparing was done per preoperative oncological risk. For all patients, 24-h pad usage rates and 24-h pad weights were noted at 1 week and 1 month after catheter removal. Multivariable logistic regression analysis was performed to identify predictors of early continence. Data were obtained from prospective studies conducted between 2015 and 2021. At 1 week, 15%, 42%, 45%, and 8% of patients undergoing anterior, posterior, hybrid, and transvesical RARP approaches, respectively, were totally continent (p = 0.003). These rates at 1 month were 35%, 66%, 64%, and 25% (p = 0.002), respectively. The transvesical approach, which preserved the space of Retzius but not the bladder neck, was associated with the poorest continence rates, while the posterior and hybrid approaches in which the bladder neck was preserved with or without space of Retzius preservation were associated with quickest urinary continence recovery. Bladder neck preservation was the only significant predictor of 1-week and 1-month total continence recovery in adjusted analysis, Odds ratios 9.06 (p = 0.001) and 5.18 (p = 0.004), respectively. The beneficial effect of the Retzius-sparing approach on early continence recovery maybe associated with bladder neck preservation rather than space of Retzius preservation.

Improving the Technique of Pelvic Floor Muscle Contraction in Active Nulliparous Women Attending a Structured High-Low Impact Aerobics Program-A Randomized Control Trial.

Learning the correct technique of performing pelvic floor muscle (PFM) exercises is a very important factor influencing the effectiveness of this muscle group training. Correctly performed PFM contractions are involved in the urinary continence mechanism. In this study, we tested the hypothesis that a six-week high-low impact aerobics program, supported by one EMG biofeedback session and pelvic floor muscle training, improves the technique of PFM contraction. Participants were 42 active nulliparous women (age 22 ± 2 years, mean ± SD), randomly allocated into intervention (n = 18) and control (n = 24) groups. We analyzed the technique of PFM contractions, taking into account the order in which selected muscle groups were activated, so called ‘firing order’. In both groups, we assessed the PFM contraction technique using surface electromyography (sEMG) and intravaginal probes, before and after six weeks of intervention. The intervention group received one biofeedback session on how to properly contract PFM and afterwards participated in a high-low impact aerobics program supplemented by PFM training. The control group did not receive any intervention. In the pre-test, 67% of the intervention group activated PFM first in order in short, quick contractions. After six weeks of training, this task was correctly performed by 100% of this group (p = 0.04). The proper performance of PFM short contraction in the control group was 75% and 67%, before and after intervention, respectively. In the intervention group we also observed statistically significant improvement in the PFM contraction technique in 10-s contractions. The presented intervention was beneficial for the improvement of PFM contraction. High–low impact aerobics, supplemented by one EMG biofeedback session and pelvic floor muscle training can be recommended for active nulliparous women.

Outcome of different surgical procedures for fistula-in-ano: a single centre-based study

Background: Fistula-in-ano is an abnormal communication between anal canal/rectum and perianal skin. It is considered to be chronic sequelae of cryptoglandular perianal abscess. Surgical treatment is the standard of care. However, the surgical techniques have evolved over time in order to give a satisfactory non-recurring result without jeopardising continence mechanism. Our aim was to study the feasibility and outcome of various surgical procedures done for fistula-in-ano.Methods: This study was conducted in colorectal division of department of general surgery SKIMS Srinagar, from 2017-2019. All patients underwent a surgical procedure which was deemed feasible for a particular case. Pre-operative data and post-operative outcome/complications were studied over a mean follow up of 12 months. Final inferences were drawn after analysing the data using various statistical tools.Results: Fistula-in-ano has male predominance (8:1), with intersphincteric fistula being the commonest type (48%) in our study. Majority of our patients underwent fistulectomy (72.5%) with or without Seton placement. Over a mean follow up of 12 months, only 19 patients (15.32%) developed recurrence. Incontinence was observed in 15 patients (12.09%). The risk of recurrence was observed to be directly related to the complexity of fistula.Conclusions: Fistulectomy is safe and effective for low intersphincteric and trans-sphincteric fistulas with acceptable rates of recurrence. Benefit of radical excision in high fistulas with multiple secondary tracts should be carefully weighed against risk of post-operative incontinence.

Review of the indications, methods, and clinical utility of anorectal manometry and the rectal balloon expulsion test.

Anorectal manometry (ARM) comprehensively assesses anorectal sensorimotor functions. This review examines the indications, techniques, interpretation, strengths, and weaknesses of high-resolution ARM (HR-ARM), 3-dimensional high-resolution anorectal manometry (3D-HR-ARM), and portable ARM, and other assessments (i.e., rectal sensation and rectal balloon expulsion test) that are performed alongside manometry. It is based on a literature search of articles related to ARM in adults. HR-ARM and 3D-HR-ARM are useful for diagnosing defecatory disorders (DD), to identify anorectal sensorimotor dysfunction and guide management in patients with fecal incontinence (FI), constipation, megacolon, and megarectum; and to screen for anorectal structural (e.g., rectal intussusception) abnormalities. The rectal balloon expulsion test is a useful, low-cost, radiation-free, outpatient assessment tool for impaired evacuation that is performed and interpreted in conjunction with ARM. The anorectal function tests should be interpreted with reference to age- and sex-matched normal values, clinical features, and results of other tests. A larger database of technique-specific normal values and newer paradigms of analyzing anorectal pressure profiles will increase the precision and diagnostic utility of HR-ARM for identifying abnormal mechanisms of defecation and continence.

The Clinical Features and Predictive Factors of Nocturnal Enuresis in Adult Women.

ObjectiveOur current knowledge on nocturnal enuresis (NE) in adults is scarce due to its uncommon nature. The present study was designed to investigate symptom characteristics and risk factors of NE in adult women to improve the current clinical understanding and management of this rare disease.MethodsOver a 3-year period, we enrolled 70 adult women who complained of bedwetting, with a frequency of at least once per week and a symptom duration of 3 months or longer. Patients were excluded if they had known pregnancy, current urinary tract infection, untreated malignancies, anatomical abnormalities, and irregular sleep cycle. The International Consultation on Incontinence Modular Questionnaire—female lower urinary tract symptoms and bladder diary were employed to appraise lower urinary tract symptoms and voiding behavior. Urodynamics was performed to assess the bladder function. A linear regression analysis was applied to determine potential risk factors for NE frequency.ResultsAmong the recruited subjects, comorbidities and lower urinary tract symptoms were frequently reported. On bladder diary, patients commonly presented with nocturnal polyuria (NP), reduced nocturnal voided volumes (RNVVs), or both. Urodynamics revealed multiple dysfunctions, namely, detrusor overactivity (DO), urodynamic stress incontinence (USI), reduced compliance, bladder outlet obstruction, detrusor underactivity (DU), and simultaneous DO and DU. Patients with more frequent NE (≥4/week) demonstrated markedly increased body mass index, more comorbid conditions, worse incontinence symptoms, NP or NP plus RNVVs, reduced compliance, and poorer voiding possibly owing to DU. Whereas, RNVVs alone and worse overactive bladder-related parameters were associated with milder NE. Multivariate analysis indicated that frequency/urgency quality of life, incontinence symptom, NP + RNVVs, poor flow, increased bladder sensation, USI, and simultaneous detrusor overactivity plus DU were independent risk factors for NE severity.ConclusionNE in adult women may have both urological and non-urological pathophysiology. Imbalanced circadian urine production, jeopardized continence mechanisms, overactive bladder, and DU-induced poor voiding are major factors that contribute to the pathogenesis of NE in adult women. Focused treatments on restoring these functions should be individually considered.