External Urinary Sphincter Research Articles

Sexual Dimorphism of Spinal Neural Circuits Controlling the Mouse External Urethral Sphincter With and Without Spinal Cord Injury.

Spinal cord injury (SCI) disrupts coordination between the bladder and the external urinary sphincter (EUS), leading to transient or permanent voiding impairment, which is more severe in males. Male versus female differences in spinal circuits related to the EUS as well as post-SCI rewiring are essential for understanding of sex-/gender-specific impairments and possible recovery mechanisms. To quantitatively assess differences between EUS circuits in males versus females and in spinal intact (SI) versus SCI animals, we retrogradely traced and counted EUS-related neurons. In transgenic ChAT-GFP mice, motoneurons (MNs), interneurons (INs), and propriospinal neurons (PPNs) were retrogradely trans-synaptically traced with PRV614-red fluorescent protein (RFP) injected into EUS. EUS-MNs in dorsolateral nucleus (DLN) were separated from other GFP+ MNs by tracing them with FluoroGold (FG). We found two morphologically distinct cell types in DLN: FG+ spindle-shaped bipolar (SB-MNs) and FG- rounded multipolar (RM-MNs) cholinergic cells. Number of MNs of both types in males was twice as large as in females. SCI caused a partial loss of MNs in all spinal nuclei. After SCI, males showed a fourfold rise in the number of RFP-labeled cells in retro-DLN (RDLN) innervating hind limbs. This suggests (a) an existence of direct synaptic interactions between spinal nuclei and (b) a post-SCI increase of non-specific inputs to EUS-MNs from other motor nuclei. Number of INs and PPNs deferred between males and females: In SI males, the numbers of INs and PPNs were ∼10 times larger than in SI females. SCI caused a twofold decrease of INs and PPNs in males but not in females.

HUBUNGAN ANTARA KESIAPAN DAN KEBERHASILAN TOILET TRAINING PADA ANAK USIA TODDLER DI TEMPAT PENITIPAN ANAK (TPA) WILAYAH KECAMATAN GUNUNG ANYAR SURABAYA

The success of toilet training for toddlers can be identified when a child cancontrol the external urinary sphincter. It can be achieved by physical readiness, mentaland child’s psychological, and parental readiness to begin the toilet training practice. Thisstudy aims to analyze the correlation between the readiness and success of toilet trainingfor toddlers in one of the daycare services in Gunung Anyar. Methods : In this research,the population was 78, with 66 respondents using a simple random sampling technique. Across-sectional technique design was applied, and The researcher collected the data usinga questionnaire. In addition, the data were analyzed with Spearman Rho. Results : Theanalysis showed that there was a relationship between physical readiness and the successof toilet training (? = 0.001). The relationship between mental readiness and toilet trainingsuccess (? = 0.001). The relationship between psychological readiness and toilet trainingsuccess (? = 0.001). Relationship between parental readiness and toilet training success(? = 0.001). It can be concluded that there is a relationship between the readiness andsuccess of toilet training for toddlers. Conclusions : This research implies that childrenwill have physical, mental, and psychological readiness, and parents can support thesuccess of toilet training in toddlers

Preliminary results of the external urinary sphincter Uroflex® on the quality of life of patients with male urinary incontinence after prostate surgery: tolerance, severity of incontinence, and quality of life.

This study aims to establish the ability of the Uroflex® external artificial sphincter to reduce the severity of male urinary incontinence and improve the quality of life of patients with male urinary incontinence. A pre-post pilot study was carried out on a sample of 30 patients with male urinary incontinence. Tolerability and satisfaction were assessed by comparing the results of the Pad test, and EQ-5D and KHQ questionnaires before and after 3months of using Uroflex®. At 3months, 76.6% of patients continued using Uroflex®. The median score for overall satisfaction with the device was 8 out of 10. Pad test showed a significant reduction in the severity of male urinary incontinence at 3months (p < 0.001), with resolution of all symptoms in 31% of patients. The KHQ showed a significant improvement in global quality of life (p = 0.003). This was also significant for five of the nine specific dimensions assessed. There was also an improvement in self-rated health using the EQ-5D questionnaire, although not significant (p = 0.075). The Uroflex® external urinary sphincter seems to improve the severity of urinary incontinence and quality of life of patients with male urinary incontinence after prostate surgery. These encouraging results will need to be confirmed in larger controlled studies.

Reconstruction of Urethral Sphincter With Polyacrylamide Hydrogel.

Urethral bulking is an alternative to synthetic midurethral sling for the treatment of stress urinary incontinence (SUI) in women. Urethral bulking agents, which are injected in the submucosal tissues of the proximal urethra/bladder neck, have demonstrated less adverse effects with similar satisfaction rates but lower subjective and objective cure rates when compared with midurethral sling. Cystoscopic Reconstruction of External Sphincter Technique (CREST) is a novel technique, which reinforces the natural closure mechanism of the external urinary sphincter (EUS). The aim of the study was to provide safety and efficacy data for injecting polyacrylamide hydrogel (PAHG) in the components of the female EUS. This was a retrospective chart review of patients using CREST with PAHG as initial treatment for SUI by a single surgeon from January 2022 to October 2022. Exclusion criteria are as follows: younger than 18 years, prior SUI surgery, concomitant pelvic organ prolapse or reconstructive procedure, neurological conditions, or history of radiation. Subjective and objective cure rates were measured by patient-reported symptoms and cough stress test. Urinary retention, postoperative urinary infection, and de novo urinary urgency were assessed. One hundred and thirteen consecutive patients met inclusion criteria with median follow-up of 3 months. Eighty-five percent of participants reported subjective improvement, 69% reported subjective cure, and 69% demonstrated objective cure. Nine patients reported transient postoperative retention, 8 reported postoperative urinary tract infections, and 5 reported de novo urgency. There were no serious adverse events. CREST is a novel technique for injection of PAHG, into the EUS to treat SUI. Our data suggest that this technique could improve urethral injection outcomes with minimal complications.

External Urethral Sphincter Botulinum Toxin Injection to Treat Pseudodysynergia in Patients With Cerebral Palsy

To evaluate urinary outcomes following cystoscopic external urinary sphincter onabotulinumtoxinA (BTX) injections in patients with cerebral palsy (CP). Adults with CP can suffer from bladder outlet obstruction and urinary retention due to a spastic external urethral sphincter ("pseudodysynergia"). We have used BTX injections into the sphincter to relieve the obstruction and allow patients to maintain spontaneous voiding rather than intermittent catheterization. Patients were included in this retrospective cohort study if they had a diagnosis of CP, were at least 18 years of age, and underwent a urethral external sphincter BTX injection between 2016-2023. The procedure included 100u or 200u of BTX mixed in 4cc of saline. Primary outcomes were subjective, patient or caregiver reported changes in retention, lower urinary tract symptoms (LUTS), frequency of recurrent urinary tract infections (UTIs), and hydronephrosis or bladder stones/debris on ultrasound. Fifty patients were included; the majority were male (60%), lived at home with assistance (58%), and had a Gross Motor Function Classification System level of V (50%; ie, severe CP). The most common indications for BTX were retention (96%), LUTS (48%), hydronephrosis (18%), and recurrent UTIs (22%). Post-BTX improvement was seen in 67% of those with LUTS, 65% with retention, 67% with hydronephrosis, and 73% with recurrent UTIs. Most patients underwent repeat injections (60%). There were no significant complications associated with injections. External urethral sphincter BTX is a safe, effective option for treating pseudodysynergia in adults with CP.

Uncertainty in magnetic resonance imaging-based prostate postimplant dosimetry: Results of a 10-person human observer study, and comparisons with automatic postimplant dosimetry

Uncertainties in postimplant quality assessment (QA) for low-dose-rate prostate brachytherapy (LDRPBT) are introduced at two steps: seed localization and contouring. We quantified how interobserver variability (IoV) introduced in both steps impacts dose-volume-histogram (DVH) parameters for MRI-based LDRPBT, and compared it with automatically derived DVH parameters. Twenty-five patients received MRI-based LDRPBT. Seven clinical observers contoured the prostate and four organs at risk, and 4 dosimetrists performed seed localization, on each MRI. Twenty-eight unique manual postimplant QAs were created for each patient from unique observer pairs. Reference QA and automatic QA were also performed for each patient. IoV of prostate, rectum, and external urinary sphincter (EUS) DVH parameters owing to seed localization and contouring was quantified with coefficients of variation. Automatically derived DVH parameters were compared with those of the reference plans. Coefficients of variation (CoVs) owing to contouring variability (CoVcontours) were significantly higher than those due to seed localization variability (CoVseeds) (median CoVcontours vs. median CoVseeds: prostate D90-15.12% vs. 0.65%, p < 0.001; prostate V100-5.36% vs. 0.37%, p < 0.001; rectum V100-79.23% vs. 8.69%, p < 0.001; EUS V200-107.74% vs. 21.18%, p < 0.001). CoVcontours were lower when the contouring observers were restricted to the 3 radiation oncologists, but were still markedly higher than CoVseeds. Median differences in prostate D90, prostate V100, rectum V100, and EUS V200 between automatically computed and reference dosimetry parameters were 3.16%, 1.63%, -0.00 mL, and -0.00 mL, respectively. Seed localization introduces substantially less variability in postimplant QA than does contouring for MRI-based LDRPBT. While automatic seed localization may potentially help improve workflow efficiency, it has limited potential for improving the consistency and quality of postimplant dosimetry.

Transurethral injection of autologous muscle precursor cells for treatment of female stress urinary incontinence: a prospective phase I clinical trial

Introduction and hypothesisThe purpose was to investigate the safety and feasibility of transurethral injections of autologous muscle precursor cells (MPCs) into the external urinary sphincter (EUS) to treat stress urinary incontinence (SUI) in female patients.MethodsProspective and randomised phase I clinical trial. Standardised 1-h pad test, International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI-SF), urodynamic study, and MRI of the pelvis were performed at baseline and 6 months after treatment. MPCs gained through open muscle biopsy were transported to a GMP facility for processing and cell expansion. The final product was injected into the EUS via a transurethral ultrasound-guided route. Primary outcomes were defined as any adverse events (AEs) during follow-up. Secondary outcomes were functional, questionnaire, and radiological results.ResultsTen female patients with SUI grades I–II were included in the study and 9 received treatment. Out of 8 AEs, 3 (37.5%) were potentially related to treatment and treated conservatively: 1 urinary tract infection healed with antibiotics treatment, 1 dysuria and 1 discomfort at biopsy site. Functional urethral length under stress was 25 mm at baseline compared with 30 mm at 6 months’ follow-up (p=0.009). ICIQ-UI-SF scores improved from 7 points at baseline to 4 points at follow-up (p=0.035). MRI of the pelvis revealed no evidence of tumour or necrosis, whereas the diameter of the EUS muscle increased from 1.8 mm at baseline to 1.9 mm at follow-up (p=0.009).ConclusionTransurethral injections of autologous MPCs into the EUS for treatment of SUI in female patients can be regarded as safe and feasible. Only a minimal number of expected and easily treatable AEs were documented.

MP52-15 EXTERNAL URETHRAL SPHINCTER BOTULINUM TOXIN INJECTION TO TREAT PSEUDODYSSYNERGIA IN PATIENTS WITH CEREBRAL PALSY

You have accessJournal of UrologyCME1 Apr 2023MP52-15 EXTERNAL URETHRAL SPHINCTER BOTULINUM TOXIN INJECTION TO TREAT PSEUDODYSSYNERGIA IN PATIENTS WITH CEREBRAL PALSY Ryan Haggart, Christopher J Loftus, Molly DeWitt-Foy, Valencia Henry, Joseph Pariser, and Sean Elliott Ryan HaggartRyan Haggart More articles by this author , Christopher J LoftusChristopher J Loftus More articles by this author , Molly DeWitt-FoyMolly DeWitt-Foy More articles by this author , Valencia HenryValencia Henry More articles by this author , Joseph PariserJoseph Pariser More articles by this author , and Sean ElliottSean Elliott More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003300.15AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Cerebral palsy (CP) is an upper motor neuron disorder that typically results in spasticity of striated muscle, which can include the external urinary sphincter. Symptomatic urinary dysfunction in the form of intermittent retention and flooding may result from tonic spasticity of the external urinary sphincter (pseudodyssynergia). Botulinum toxin (BTX) may be injected to the external urinary sphincter to allow for more facile, regular voiding. In the only study examining the use of sphincter BTX injections, a reduction in chronic catheter dependence and urinary tract infection (UTI) rates in the 15 patients studied was reported. The objective of this study is to evaluate urinary outcomes following cystoscopic external urinary sphincter BTX injections in patients with CP. METHODS: In this retrospective cohort study, we reviewed patients with a diagnosis of CP seen in urology clinic from 2016-2022. Patients included were 18 years or older and had undergone a urethral external sphincter BTX injection. Injections were performed with either 100 units or 200 units in 4 cc of saline injected to the anterolateral external urethral sphincter. Data was collected via chart review and entered into a REDCap database. Outcomes included: retention, lower urinary tract symptoms (LUTS), hydronephrosis, and recurrent UTIs recorded as better, no change, or worse based on caregiver or patient feedback and repeat imaging. Urodynamics was performed pre-BTX but often not repeated as many patients are unable to void on command so a proper voiding phase could not be captured. RESULTS: 37 patients met inclusion criteria. The median age was 29 years (IQR 25-39), 57% were male, most (54%) lived at home with or without assistance, and 30% resided in a group home. Prior to BTX, most used a combination of a toilet (59%) and diapers (59%) for bladder management. The most common indication for BTX was retention (92%), followed by LUTS (38%), hydronephrosis (24%), and recurrent UTIs (22%). Post-BTX subjective improvement was seen in 71% (24/34) of patients with retention, 79% (11/14) with LUTS, 75% (6/8) with recurrent UTIs, and 78% (7/9) with hydronephrosis. The majority (68%) of patients underwent repeat injections, typically every 3-6 months. There were no significant complications associated with injections. CONCLUSIONS: External urethral sphincter BTX is a safe, effective option for treating urinary dysfunction in adults with CP. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e708 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ryan Haggart More articles by this author Christopher J Loftus More articles by this author Molly DeWitt-Foy More articles by this author Valencia Henry More articles by this author Joseph Pariser More articles by this author Sean Elliott More articles by this author Expand All Advertisement PDF downloadLoading ...

Male Incontinence - An Overview and its Relationship to Benign Prostatic Enlargement

Male Incontinence - An Overview and its Relationship to Benign Prostatic Enlargement Abstract: Male urinary incontinence is a common disease in elderly men and can lead to a significantly reduced quality of life. Reported prevalence of urinary incontinence increases up to 32% in men over 85 years. Risk factors for urinary incontinence are prostate surgery, advanced age, immobility, urinary tract infections, diabetes mellitus, cognitive disorders, and neurological disease. Urinary incontinence is divided into three subtypes: stress urinary incontinence, urge urinary incontinence, and mixed urinary incontinence. Benign prostatic obstruction can lead to a detrusor overactivity and a further urge incontinence. However, iatrogenic injury or a preexisting weakness of the external urinary sphincter are more common and can lead to stress urinary incontinence in men following prostate surgery. A correct treatment can significantly improve symptoms in men suffering from urinary incontinence. Though, every treatment plan must be tailored to the individual patient.

Prospective Evaluation of Prostate and Organs at Risk Segmentation Software for MRI-based Prostate Radiation Therapy.

The segmentation of the prostate and surrounding organs at risk (OARs) is a necessary workflow step for performing dose-volume histogram analyses of prostate radiation therapy procedures. Low-dose-rate prostate brachytherapy (LDRPBT) is a curative prostate radiation therapy treatment that delivers a single fraction of radiation over a period of days. Prior studies have demonstrated the feasibility of fully convolutional networks to segment the prostate and surrounding OARs for LDRPBT dose-volume histogram analyses. However, performance evaluations have been limited to measures of global similarity between algorithm predictions and a reference. To date, the clinical use of automatic segmentation algorithms for LDRPBT has not been evaluated, to the authors' knowledge. The purpose of this work was to assess the performance of fully convolutional networks for prostate and OAR delineation on a prospectively identified cohort of patients who underwent LDRPBT by using clinically relevant metrics. Thirty patients underwent LDRPBT and were imaged with fully balanced steady-state free precession MRI after implantation. Custom automatic segmentation software was used to segment the prostate and four OARs. Dose-volume histogram analyses were performed by using both the original automatically generated contours and the physician-refined contours. Dosimetry parameters of the prostate, external urinary sphincter, and rectum were compared without and with the physician refinements. This study observed that physician refinements to the automatic contours did not significantly affect dosimetry parameters. Keywords: MRI, Neural Networks, Radiation Therapy, Radiation Therapy/Oncology, Genital/Reproductive, Prostate, Segmentation, Dosimetry Supplemental material is available for this article. © RSNA, 2022.

Computer-aided segmentation on MRI for prostate radiotherapy, part II: Comparing human and computer observer populations and the influence of annotator variability on algorithm variability

Background and purposeComparing deep learning (DL) algorithms to human interobserver variability, one of the largest sources of noise in human-performed annotations, is necessary to inform the clinical application, use, and quality assurance of DL for prostate radiotherapy. Materials and methodsOne hundred fourteen DL algorithms were developed on 295 prostate MRIs to segment the prostate, external urinary sphincter (EUS), seminal vesicles (SV), rectum, and bladder. Fifty prostate MRIs of 25 patients undergoing MRI-based low-dose-rate prostate brachytherapy were acquired as an independent test set. Groups of DL algorithms were created based on the loss functions used to train them, and the spatial entropy (SE) of their predictions on the 50 test MRIs was computed. Five human observers contoured the 50 test MRIs, and SE maps of their contours were compared with those of the groups of the DL algorithms. Additionally, similarity metrics were computed between DL algorithm predictions and consensus annotations of the 5 human observers’ contours of the 50 test MRIs. ResultsA DL algorithm yielded statistically significantly higher similarity metrics for the prostate than did the human observers (H) (prostate Matthew’s correlation coefficient, DL vs. H: planning–0.931 vs. 0.903, p < 0.001; postimplant–0.925 vs. 0.892, p < 0.001); the same was true for the 4 organs at risk. The SE maps revealed that the DL algorithms and human annotators were most variable in similar anatomical regions: the prostate-EUS, prostate-SV, prostate-rectum, and prostate-bladder junctions. ConclusionsAnnotation quality is an important consideration when developing, evaluating, and using DL algorithms clinically.

Computer-aided segmentation on MRI for prostate radiotherapy, Part I: Quantifying human interobserver variability of the prostate and organs at risk and its impact on radiation dosimetry

Background and purposeQuantifying the interobserver variability (IoV) of prostate and periprostatic anatomy delineation on prostate MRI is necessary to inform its use for treatment planning, treatment delivery, and treatment quality assessment. Materials and methodsTwenty five prostate cancer patients underwent MRI-based low-dose-rate prostate brachytherapy (LDRPBT). The patients were scanned with a 3D T2-weighted sequence for treatment planning and a 3D T2/T1-weighted sequence for quality assessment. Seven observers involved with the LDRPBT workflow delineated the prostate, external urinary sphincter (EUS), seminal vesicles, rectum, and bladder on all 50 MRIs. IoV was assessed by measuring contour similarity metrics, differences in organ volumes, and differences in dosimetry parameters between unique observer pairs. Measurements from a group of 3 radiation oncologists (G1) were compared against those from a group consisting of the other 4 clinical observers (G2). ResultsIoV of the prostate was lower for G1 than G2 (Matthew’s correlation coefficient [MCC], G1 vs. G2: planning–0.906 vs. 0.870, p < 0.001; postimplant–0.899 vs. 0.861, p < 0.001). IoV of the EUS was highest of all the organs for both groups, but was lower for G1 (MCC, G1 vs. G2: planning–0.659 vs. 0.402, p < 0.001; postimplant–0.684 vs. 0.398, p < 0.001). Large differences in prostate dosimetry parameters were observed (G1 maximum absolute prostate ΔD90: planning–76.223 Gy, postimplant–36.545 Gy; G1 maximum absolute prostate ΔV100: planning–13.927%, postimplant–8.860%). ConclusionsWhile MRI is optimal in the management of prostate cancer with radiation therapy, significant interobserver variability of the prostate and external urinary sphincter still exist.

Benchmarking Automatic Segmentation Algorithms Against Human Interobserver Variability of Prostate and Organs at Risk Delineation on Prostate MRI

<h3>Purpose/Objective(s)</h3> The objective of this study was to benchmark custom automatic segmentation software against human interobserver variability of prostate and OAR segmentation on 3D MRIs for prostate radiotherapy. We hypothesized that automatic segmentation algorithms can exhibit consistency comparable to human readers, including radiation oncologists. <h3>Materials/Methods</h3> Twenty-five patients underwent MRI-based treatment planning and quality assessment for low-dose-rate prostate brachytherapy (LDRPBT). All 25 patients received both treatment planning MRIs and postimplant quality assessment MRIs. The MRIs were acquired on 3T scanners with flexible external array coils and no endorectal coil. The preimplant MRIs were acquired with a 3D T2-weighted TSE sequence. The postimplant MRIs were acquired with a 3D T2/T1-weighted fully balanced SSFP sequence. Five human observers involved in the LDRPBT workflow, including 2 radiation oncologists, delineated the prostate and 4 OARs on the 50 MRIs. The OARs included the external urinary sphincter (EUS), seminal vesicles (SV), rectum, and bladder. Human interobserver variability (IoV) amongst the 5 human readers was quantified in a human observer study. Similarity metrics, including precision (P), recall (R), Jaccard index (JI), and Matthew's correlation coefficient (MCC), were quantified between unique observer pairs for all 5 organ segmentation masks. A custom deep learning-based autosegmentation algorithm was used to segment the prostate and 4 OARs simultaneously on the same 50 MRIs that were annotated by the human readers. P, R, JI, and MCC were evaluated at different probability thresholds. The comparisons were made against reference segmentation masks of the 5 organs computed from the 5 human segmentation masks using the simultaneous truth and performance level estimation algorithm. The human IoV similarity metrics were compared to the computer similarity metrics at the point of maximum MCC using two-tailed nonparametric Wilcoxon rank sum tests. <h3>Results</h3> For the preimplant MRIs, the computer similarity metrics (C) were lower than the human IoV similarity metrics (H) for all organs except the EUS (MCC, C vs. H: prostate – 0.868 vs. 0.903, <i>P</i> < 0.0001; EUS – 0.610 vs. 0.552, <i>P</i> = 0.1690; SV – 0.678 vs. 0.750, <i>P</i> = 0.0094; rectum – 0.790 vs. 0.886, <i>P</i> < 0.0001; bladder – 0.879 vs. 0.941, <i>P</i> < 0.0001). However, the opposite was observed for the postimplant MRIs; C was significantly higher than H for all 5 organs (MCC, C vs. H: prostate – 0.925 vs. 0.892, <i>P</i> < 0.0001; EUS – 0.743 vs. 0.620, <i>P</i> = 0.0003; SV – 0.849 vs. 0.760, <i>P</i> < 0.0001; rectum – 0.925 vs. 0.876, <i>P</i> < 0.0001; bladder – 0.972 vs. 0.938, <i>P</i> < 0.0001). <h3>Conclusion</h3> The autosegmentation algorithm produced high quality segmentation masks for both the preimplant and postimplant MRIs. The human readers were more consistent than the autosegmentation algorithm on the T2-weighted preimplant MRIs, but the autosegmentation algorithm was more consistent than the human readers on the postimplant MRIs.

Multi-Institutional Study of Dorsal Onlay Urethroplasty of the Membranous Urethra after Endoscopic Prostate Procedures: Operative Results, Continence, Erectile Function and Patient Reported Outcomes

(1) Background: To critically evaluate dorsal onlay buccal mucosal graft urethroplasty (DOBMGU) for posterior urethral stenosis repair following transurethral resection and other endoscopic prostate procedures. (2) Methods: A retrospective multi-institutional review of patients with membranous or bulbomembranous urethral stenosis for whom treatment with DOBMGU was conducted after receipt of prostate endoscopic procedures. Baseline data, peri-operative care, post-operative care and patient-reported outcomes were analyzed. The primary outcomes were procedural failure and development of de novo stress urinary incontinence (SUI). The secondary outcomes were changes in voiding, sexual function and patient satisfaction. (3) Results: A total of 107 men with a mean age of 69 ± 9.5 years and stenosis length of 3.5 ± 1.8 cm were included. Prior endoscopic procedures among participants were 47 patients (44%) with monopolar TURP, 33 (30.8%) with bipolar TURP, 16 (15%) with Greenlight laser, 9 (8.4%) with Holmium laser enucleation and 2 (1.9%) with bladder neck incision. At a mean follow-up time of 59.3 ± 45.1 months, stenosis recurred in 10 patients (9.35%). Multivariate analysis confirmed that postoperative complications (OR 12.5; p = 0.009), history of radiation (OR 8.3; p = 0.016) and ≥2 dilatations before urethroplasty (OR 8.3; p = 0.032) were independent predictors of recurrence. Only one patient (0.9%) developed de novo SUI. Patients experienced significant improvement in PVR (128 to 60 cc; p = 0.001), Uroflow (6.2 to 16.8 cc/s; p = 0.001), SHIM (11.5 to 11.7; p = 0.028), IPSS (20 to 7.7; p < 0.001) and QoL (4.4 to 1.7; p < 0.001), and 87 cases (81.3%) reported a GRA of + 2 or better. (4) Conclusions: DOBMGU is an effective and safe option for patients with posterior urethral stenosis following TURP and other prostate endoscopic procedures. This non-transecting approach minimizes external urinary sphincter manipulation, thus limiting postoperative risk of SUI or erectile dysfunction.

MP15-04 THE EFFECT OF MICROPOROUS POLYSACCHARIDE HEMOSPHERES ON PATIENT OUTCOMES FOLLOWING ROBOT-ASSISTED RADICAL PROSTATECTOMY

You have accessJournal of UrologyProstate Cancer: Localized: Surgical Therapy I (MP15)1 Sep 2021MP15-04 THE EFFECT OF MICROPOROUS POLYSACCHARIDE HEMOSPHERES ON PATIENT OUTCOMES FOLLOWING ROBOT-ASSISTED RADICAL PROSTATECTOMY Wissam Abou Chedid, Sarosh Janardanan, Liam Kavanagh, and Christopher Eden Wissam Abou ChedidWissam Abou Chedid More articles by this author , Sarosh JanardananSarosh Janardanan More articles by this author , Liam KavanaghLiam Kavanagh More articles by this author , and Christopher EdenChristopher Eden More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001996.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Controlling bleeding without disturbing the anatomy and function of the structures in the prostate bed remains a significant challenge during radical prostatectomy (RP). METHODS: The outcomes of 862 patients having robot-assisted RP (RARP) during a 5-year period were analyzed from a prospective database. The last 422 patients in the series had 5 g powdered microporous polysaccharide hemospheres (MPH) (Arista (TM), Becton Dickinson, USA) applied to the prostate bed at the end of surgery and the first 440 patients (control group) did not. Continence was defined as no pads and potency as the ability to have penetrative sex with or without PDE5 inhibitors in previously potent, non-diabetic men aged <70 years following bilateral intra- or inter-fascial neurovascular bundle (NVB) preservation. RESULTS: The control group contained higher-risk patients who had less nerve sparing done with a greater use of the Retzius-sparing approach (p=<0.01) but the two groups otherwise had similar demographic characteristics. Patients who received MPH had a trend towards a lower post-op. transfusion rate (p=0.12) and fewer total complications from post-operative bleeding (p=0.07) but these differences did not reach statistical significance. However, they had a significantly shorter operating time (p=<0.01), lower intra-operative blood loss, (p=<0.01), shorter hospital stay (p=<0.01), better continence and potency (p=<0.01) at 4 weeks, and better potency (p<0.01), trifecta (p=<0.01) and pentafecta (p=<0.01) rates at 1 year. CONCLUSIONS: The mechanism of the superior potency observed in the MPH group is unclear and may be due to less damage to the NVB following its preservation by clips and sutures, less local inflammation due to coating of the NVBs by a gel matrix, greater surgical experience or most likely a combination of these factors. The better early continence observed in the MPH group may be a consequence of better NVB preservation and its recognized beneficial effect on external urinary sphincter function. These results await further investigation within a randomized controlled trial . Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e264-e265 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Wissam Abou Chedid More articles by this author Sarosh Janardanan More articles by this author Liam Kavanagh More articles by this author Christopher Eden More articles by this author Expand All Advertisement Loading ...

New perspectives on the surgical treatment of posterior urethral obstruction.

Posterior urethral obstruction (PUO) from prostate surgery for benign and malignant conditions poses a significant reconstructive challenge. Endoscopic management demonstrates only modest success and often definitive reconstructive solutions are necessary to limit morbidity and firmly establish posterior urethral continuity. This often demands a combined abdominoperineal approach, pubic bone resection, and even sacrifice of the external urinary sphincter and anterior urethral blood supply. Recently, a robotic-assisted approach has been described. Enhanced instrument dexterity, magnified visualization, and adjunctive measures to assess tissue quality may enable the reconstructive surgeon to engage posterior strictures deep within the confines of the narrow male pelvis and optimize functional outcomes. The purpose of this review is to review the literature regarding endoscopic, open, and robotic management outcomes for the treatment of PUO, and provide an updated treatment algorithm based upon location and complexity of the stricture. Contingent upon etiology, small case series suggest that robotic bladder neck reconstruction has durable reconstructive outcomes with acceptable rates of incontinence in carefully selected patients. Initial reports suggest that robotic bladder neck reconstruction for recalcitrant PUO may offer novel reconstructive solutions and durable function outcomes in select patients.

PRSOR03 Presentation Time: 12:10 PM: Interobserver Variability of Target and OAR Delineation in MRI-Based Prostate Brachytherapy across Two Anatomical Pulse Sequences

Purpose: MRI improves the definition of the prostate compared to CT. However, radiotherapy plans based on MRI are still subject to interobserver variability (IoV) from human readers. Human IoV can lead to significant plan variability and inadequacy. The purpose of this study was to quantify the IoV in delineating the prostate, external urinary sphincter (EUS), seminal vesicles (SV), rectum, and bladder in prostate MRIs acquired for treatment planning and postimplant assessment of low-dose-rate prostate brachytherapy (LDRPBT).

Feasibility, technique and accuracy of ultrasound-guided transurethral injections into the urinary sphincter of female cadavers: proof of concept

BackgroundThe injection of muscle precursor cells (MPC) into the external urinary sphincter muscle (EUS) is a promising therapeutic option for regenerative treatment of stress urinary incontinence (SUI). The objective of the present project was to conduct a pre-clinical trial to investigate the feasibility and accuracy of ultrasound (US) guided, transurethral injections into the EUS of female cadavers.MethodsThis is a prospective, anatomical, interventional and radiological cadaveric laboratory investigation. Two urologists performed transurethral US-guided injections to deliver nano-iron particles into the EUS. The intervention was performed in three unfixed, fresh female cadavers. Each cadaver received MRI before and CT as well as MRI of the pelvis after the injections.ResultsThe precision and accumulation of nano-iron particles in the EUS was compared using a rating scale to evaluate left versus right and anterior versus posterior distribution in axial and sagittal orientation with US, MRI and CT. The accuracy of our US-guided injections into the anterior target region yielded 4 points on the rating scale. Adequate precision and accumulation of particles in the left versus right EUS were also demonstrated (3 vs. 3.33 points, respectively). Signal intensity in MRI revealed a mean ratio of 0.33 before and after injection. CT scans showed no relevant artefacts impairing the assessment.ConclusionUS-guided, transurethral injection into the EUS is feasible and imaging reveals a precise accumulation in the target region. Our method provides an appropriate approach to deliver MPC in the EUS muscle for a regenerative treatment of SUI in the near future.

Machine Segmentation of Pelvic Anatomy in MRI-Assisted Radiosurgery (MARS) for Prostate Cancer Brachytherapy

To investigate machine segmentation of pelvic anatomy in magnetic resonance imaging (MRI)-assisted radiosurgery (MARS) for prostate cancer using prostate brachytherapy MRIs acquired with different pulse sequences and image contrasts. Two hundred 3-dimensional (3D) preimplant and postimplant prostate brachytherapy MRI scans were acquired with a T2-weighted sequence, a T2/T1-weighted sequence, or a T1-weighted sequence. One hundred twenty deep machine learning models were trained to segment the prostate, seminal vesicles, external urinary sphincter, rectum, and bladder using the MRI scans acquired with T2-weighted and T2/T1-weighted image contrast. The deep machine learning models consisted of 18 fully convolutional networks (FCNs) with different convolutional encoders. Both 2-dimensional and 3D U-Net FCNs were constructed for comparison. Six objective functions were investigated: cross-entropy, Jaccard distance, focal loss, and 3 variations of Tversky distance. The performance of the models was compared using similarity metrics, including pixel accuracy, Jaccard index, Dice similarity coefficient (DSC), 95% Hausdorff distance, relative volume difference, Matthews correlation coefficient, precision, recall, and average symmetrical surface distance. We selected the highest-performing architecture and investigated how the amount of training data, use of skip connections, and data augmentation affected segmentation performance. In addition, we investigated whether segmentation on T1-weighted MRI was possible with FCNs trained on only T2-weighted and T2/T1-weighted image contrast. Overall, an FCN with a DenseNet201 encoder trained via cross-entropy minimization yielded the highest combined segmentation performance. For the 53 3D test MRI scans acquired with T2-weighted or T2/T1-weighted image contrast, the DSCs of the prostate, external urinary sphincter, seminal vesicles, rectum, and bladder were 0.90 ± 0.04, 0.70 ± 0.15, 0.80 ± 0.12, 0.91 ± 0.06, and 0.96 ± 0.04, respectively, after model fine-tuning. For the 5 T1-weighted images, the DSCs of these organs were 0.82 ± 0.07, 0.17 ± 0.15, 0.46 ± 0.21, 0.87 ± 0.06, and 0.88 ± 0.05, respectively. Machine segmentation of the prostate and surrounding anatomy on 3D MRIs acquired with different pulse sequences for MARS low-dose-rate prostate brachytherapy is possible with a single FCN.

Generation of myogenic progenitor cell-derived smooth muscle cells for sphincter regeneration

BackgroundDegeneration of smooth muscles in sphincters can cause debilitating diseases such as fecal incontinence. Skeletal muscle-derived cells have been effectively used in clinics for the regeneration of the skeletal muscle sphincters, such as the external anal or urinary sphincter. However, little is known about the in vitro smooth muscle differentiation potential and in vivo regenerative potential of skeletal muscle-derived cells.MethodsMyogenic progenitor cells (MPC) were isolated from the skeletal muscle and analyzed by flow cytometry and in vitro differentiation assays. The differentiation of MPC to smooth muscle cells (MPC-SMC) was evaluated by immunofluorescence, flow cytometry, patch-clamp, collagen contraction, and microarray gene expression analysis. In vivo engraftment of MPC-SMC was monitored by transplanting reporter protein-expressing cells into the pyloric sphincter of immunodeficient mice.ResultsMPC derived from human skeletal muscle expressed mesenchymal surface markers and exhibit skeletal myogenic differentiation potential in vitro. In contrast, they lack hematopoietic surface marker, as well as adipogenic, osteogenic, and chondrogenic differentiation potential in vitro. Cultivation of MPC in smooth muscle differentiation medium significantly increases the fraction of alpha smooth muscle actin (aSMA) and smoothelin-positive cells, while leaving the number of desmin-positive cells unchanged. Smooth muscle-differentiated MPC (MPC-SMC) exhibit increased expression of smooth muscle-related genes, significantly enhanced numbers of CD146- and CD49a-positive cells, and in vitro contractility and express functional Cav and Kv channels. MPC to MPC-SMC differentiation was also accompanied by a reduction in their skeletal muscle differentiation potential. Upon removal of the smooth muscle differentiation medium, a major fraction of MPC-SMC remained positive for aSMA, suggesting the definitive acquisition of their phenotype. Transplantation of murine MPC-SMC into the mouse pyloric sphincter revealed engraftment of MPC-SMC based on aSMA protein expression within the host smooth muscle tissue.ConclusionsOur work confirms the ability of MPC to give rise to smooth muscle cells (MPC-SMC) with a well-defined and stable phenotype. Moreover, the engraftment of in vitro-differentiated murine MPC-SMC into the pyloric sphincter in vivo underscores the potential of this cell population as a novel cell therapeutic treatment for smooth muscle regeneration of sphincters.