Mid Urethra Research Articles

Female Urethroplasty with a Buccal Mucosa Graft using a Supraurethral Approach.

In the setting of recurrent female urethral stricture, urethroplasty offer the best chance of cure. However, which approach (dorsal or ventral) and which tissue (buccal mucosa, vaginal graft, vaginal flap) remain areas of controversy. In this article and accompanying video, we describe female urethroplasty with a supraurethral approach using a buccal mucosa graft. A stricture of 3 cm in length was observed in the mid urethra. A supraurethral semi-lunar incision was made and dissection was performed up to the stricture. A dorsal urethrotomy was performed and a 3 × 2 cm oral mucosal graft was harvested from the left cheek. The mucosal graft was anastomosed to both urethral edges with running sutures. The graft was fixed to the supraurethral tissue with quilting sutures. A urethral catheter and a suprapubic catheter were left in place for 3 weeks. Following removal of the catheters, the patient was able to void satisfactorily with no incontinence. No complications were observed in the urethral area or at the graft harvest site. Buccal mucosa graft urethroplasty with a supraurethral approach is a reliable method in the treatment of female urethral stricture.

Trans-Obturator Tension Appliance Tape for failed Mid-Urethral Sling when and how?

Background & Objectives: Female urinary incontinence is a significant health issue affecting adult women, most suffering from stress incontinence. It affects the quality of life. Recurrence after surgery is difficult for the patients and the surgeon. There is no precise data to show how to treat failed Transobturator tape. Transobturator tape with tension may be an alternative method in applying proper tension in the mid urethra to correct the incontinence. We describe our experience to evaluated outcomes of the second mid-urethral sling with tension to treat recurrent incontinence after the failure of the first mid-urethral sling. Methods: A prospective cohort study was conducted between Oct. 2012 to March 2019. A total of 16 patients with failed Transobturator tape surgery underwent second trans-obturator Mid-Urethral Sling surgery. Preoperative data and postoperative complications were recorded. All patients were followed for one year. Results: Sixteen women after failed Mid-Urethral Sling surgery were evaluated. At a mean follow-up of 7.5 months, the cure rate was 62.5% (10 out of 16) patients. Partial cure (improvement) was achieved in 25% ( 4 patients out of 16) and failure in 2 patients, 12.5%. There were statistically significant improvements after surgery in the Q-tip test and the number of the pads. Conclusion: Repeat Transobturator tape with tension treatment tends to result in good outcomes with a reasonable physician-determined success rate.

Differential effects on urethral function, epithelial morphology, and molecular profile in two different rat models of stress urinary incontinence by simulated birth trauma or estrogen deficiency

ABSTRACT Introduction Stress urinary incontinence (SUI) is the common type of urinary incontinence with a significantly negative impact on quality of life, including sexual dysfunction, in women. Although the etiology of SUI in women seems to be multifactorial, multiple vaginal parities and estrogen deficiency (ED) are considered to be major risk factors of SUI in elderly women. Thus, animal models of simulated birth trauma induced by multiple vaginal distention (VD) and ED induced by bilateral ovariectomy (OVX) have been used to study the SUI pathophysiology in rats. In previous studies, bilateral ovariectomy (OVX) reportedly induces the morphological changes in the rat urethral epithelium. It has also been reported that serotonergic (5HT+) paraneurons uniquely located in the urethra modulate urethral sensory function and that their numbers decrease in aged or diabetes rats. However, the difference of changes in the urethra such as those in epithelial morphology and expression of 5HT+ paraneurons in the urethra, in these two models has not been well characterized. Objective We therefore evaluated the histological changes of the urethral epithelium and 5HT+ cell expression, and urethral continence function in rats with OVX-induced ED or VD-induced simulated birth trauma. Methods Nulliparous SD rats were divided into: (1) sham group; (2) OVX 3-weeks group; (3) OVX 6-weeks group; (4) VD-1 group (1 time VD 2 weeks before assays); (5) VD-3 group (3 times VDs every 2 weeks). VD was induced by balloon catheter inflation for 4 hours in the vagina under isoflurane anesthesia. Urethral function was evaluated by the amplitude of urethral pressure responses during sneezing (A-URS) and urethral baseline pressure (UBP), which was measured by a microtransducer-tipped catheter inserted into the mid-urethra (n=6, each group). Following the urethral function analysis, the mid urethra was harvested, and the tissue sections (10 μm) were stained with Hematoxylin-eosin (H&E) and anti-5HT antibodies for immunofluorescent detection of 5HT+ paraneurons. In addition, in separate groups of rats, changes in urethral mRNA levels of tryptophan hydroxylase-1 (TPH1), a key enzyme of 5HT synthesis, were quantified by RT-PCR (n=6, each group). All data are represented as means ± SE. P < 0.05 was considered significant. Results OVX 6-weeks and VD-3 rats exhibited significant decreases in UBP and A-URS vs. sham (Fig. 1A). The mean epithelial thickness was significantly decreased in OVX 3, 6-weeks, VD-1 and 3 rats (Fig 1B,C) vs. sham. The number of urethral 5HT+ paraneurons was significantly decreased in OVX 3, 6 weeks, VD-1 and 3 rats (Fig. 2A,B) vs. sham. TPH-1 mRNA levels were significantly decreased in OVX 3, 6-weeks and VD-3 rats (Fig. 2C) vs. sham. Conclusions These results indicate that urethral epithelial atrophy and loss of 5HT+ paraneurons occur prior to SUI- inducing urethral dysfunction in both models, with the changes being rapid and greater in OVX compared to VD. These histological changes in the urethra may contribute to the establishment of SUI in ED and multiple birth trauma. Disclosure Work supported by industry: no.

Pelvic Fracture Urethral Injury in Females

Background Pelvic fracture urethral injuries (PFUI) in females are very rare. The available literature on the management of this condition is scarce and not clear, mainly because of limited experience among reconstructive surgeons. We present our experience of management of these complex urethral injuries in female patients. Materials and Methods We collected data, retrospectively and prospectively for 22 female patients referred to our center for PFUI repair between 1995 and 2021. During the clinical assessment of these complex injuries, following our internal institutional protocol, all patients underwent pelvic MRI (bladder and urethra are filled with saline solution and jelly to enhance the urethral lumen and the level of the distraction) before anastomotic urethroplasty. Results PFUI compromised the mid urethra in 10 patients (45.5%). A transabdominal approach was used in 8 patients (80%), and urethra-vaginal fistula repair was undertaken in 6 patients (60%). After a median follow-up of 36 months, only 1 patient with proximal PFUI required a surgical revision without compromising urinary continence. Conclusions The most common site of urethral involvement in pelvic fracture is mid urethral, which is owing to avulsion. Urethra-vaginal fistula should be suspected. Treatment consists in anastomotic urethroplasty, mainly through the abdominal approach.

P0100 - Complications, revision and perceived health after surgery for stress urinary incontinence by mid urethra sling inthe VIGI-MESH register: Description and medium-term incidence for 1814 women

P0100 - Complications, revision and perceived health after surgery for stress urinary incontinence by mid urethra sling inthe VIGI-MESH register: Description and medium-term incidence for 1814 women

Is location of urethral kinking a confounder of association between urethral closure pressure and stress urinary incontinence?

Intact urethral support and normal sphincter function are deemed important for urinary continence. We aimed to test whether the location of urethral kinking (as the probable anatomical correlate of maximal pressure transmission) is associated with stress urinary incontinence and/or urodynamic stress incontinence. This was a retrospective study of women seen at a tertiary urogynecological center in 2017. Patients had undergone an interview, multichannel urodynamic testing and four-dimensional translabial ultrasound examination. Those with a history of anti-incontinence surgery, absence of urethral kinking on ultrasound and/or missing or inadequate ultrasound volume data were excluded. Volume data were used to assess urethral mobility using a semi-automated Excel® urethral motion profile program. Mobility vectors were calculated using the formula √((x valsalva - x rest )2 + (y valsalva - y rest )2 ), where x and y are the coordinates of six equidistant points along the length of the urethra from the bladder neck to the external urethral meatus. The location of urethral kinking was identified as a concave contour of the urethra on the vaginal side in the midsagittal plane on maximum Valsalva maneuver. The distance between the center of the kink and the bladder neck was measured and expressed as a centile in relation to the total length of the urethra, using the formula: (distance from bladder neck/total length of urethra) × 100. Univariate and multivariate analyses were performed to test the associations of stress urinary incontinence and urodynamic stress incontinence with age, maximum urethral pressure, urethral mobility vectors and location of urethral kinking. Of 450 women seen during the study period, 61 were excluded owing to previous incontinence surgery and 82 owing to absence of urethral kinking, inadequate volume data or missing data, leaving 307 women included, of whom 227 (74%) complained of stress urinary incontinence and 211 (69%) complained of urgency urinary incontinence. 190 (62%) of the women were diagnosed with urodynamic stress incontinence. On multivariate analysis, maximum urethral pressure (36 vs 50 cmH2 O; P < 0.001), mid-urethral mobility (2.27 vs 2.03 cm; P = 0.003) and location of urethral kinking (63.1st vs 59.7th centile; P = 0.002) were associated significantly with urodynamic stress incontinence. The location of urethral kinking was associated with stress urinary incontinence on univariate analysis (P = 0.026) but not on multivariate analysis (P = 0.21). The location of urethral kinking is associated with urodynamic stress incontinence. The further urethral kinking is from the mid urethra, the more likely is urodynamic stress incontinence. This provides circumstantial evidence for the pressure-transmission theory of stress urinary continence. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Urethral Diameter at the Time of Birth and Its Implication on Urinary Incontinence

Background: Throughout life, many women develop urinary incontinence (UI), and vaginal birth has been implicated as one of the causes of this pathology, once it may cause damages to the pelvic floor and to the continence mechanism. The aim was to compare urethral diameter between primiparous women after vaginal birth and women after elective cesarean section, without previous vaginal birth, correlating these measurements with factors related to pregnancy and childbirth and with presence of UI within 6 months of childbirth. Methods: Urethral diameter was measured in the immediate postpartum period (up to 2 days) by transperineal ultrasound at the level of the bladder neck and mid urethra. The data were collected on pregnancy and birth. Six months after childbirth, the participants were assessed for the presence of UI. Results: Of 151 women, 73 delivered vaginally (group 1) and 78 had a cesarean section (group 2). Urethral diameter at the level of the bladder neck was significantly smaller in group 2 (P ≤ 0.0001). There was no significant difference between the two groups in urethral diameter at the mid urethra (P = 0.505). Only urethral diameter at the mid urethra was inversely correlated with UI at 6 months (P = 0.014). There was a positive correlation between presence of UI during pregnancy and at 6 months after childbirth (r s = 0.214, P = 0.016). Conclusions: A significant difference was observed in the urethral diameter at the bladder neck according to the mode of birth. A positive correlation was also found between presence of UI during pregnancy and at 6 months postpartum. J Clin Gynecol Obstet. 2020;9(4):102-107 doi: https://doi.org/10.14740/jcgo705

The transvaginal tape surgery vs. trans-obturator tape for stress urinary incontinence

: Female urinary incontinence is a highly prevalent condition affecting women’s quality of life and is associated with considerable personal and societal stress. Stress urinary incontinence (SUI) is thought to be due to the loss of urethral support vs. a weakness of the urethra itself. Multiple treatment options exist for the SUI including conservative behavioral modifications, physical therapy, medications, and surgical options. Surgical options can be offered to patients who achieve unsatisfactory results from non-surgical options or who prefer to have surgery by choice. Numerous surgical options for SUI have been described and have evolved over time. This evolution of surgery for SUI has led to more minimally invasive surgical options. The gains in the knowledge of anatomy of the bladder and urethra has also shifted the focus of continence mechanism to be at the mid urethra and not just the bladder neck as previously thought. This has led the mid urethral sling (MUS) to be the surgical options of choice by most surgeons. Patient selection and knowledge of the anatomy associated with midurethral slings are critical as the outcomes and complications associated with surgery are the results of these factors. The retropubic [transvaginal tape (TVT)] and the transobturator [trans-obturator tape (TOT)] MUSs are the main surgical options for SUI. Between the TVT and TOT sling, there is no one sling better or worse than the other.

The learning curve in hypospadias urethroplasty: single-surgeon experience

Introduction: Hypospadias is one of the most frequent urological congenital anomalies. Due to the high difficulty of the procedures, a surgeon must face a steep learning curve at the start of the practice and experiencing the procedure to achieve maximum results. This study would like to evaluate the effect of experiences from a single surgeon doing hypospadias urethroplasty with the clinical outcome in Harapan Kita Mother and Children Hospital.Method: Retrospective cohort study was done from the period of 2016 until 2018 in Harapan Kita Mother and Children Hospital by reviewing the medical records of all patients that underwent hypospadias surgical treatment by a single pediatric urologist. All forms of hypospadias, age, and procedures were included. The operative techniques were done by the operational standard within the literatures. All data were presented as tables and learning curve line graph. Statistical Analysis was done using SPSS v.23(IBM Statistics, New York).Results: Total of 125 patients have undertaken urethroplasty by the surgeon. Most of the cases were new cases (96%) and dominant with 2-6 years group (57.6%). Proximal hypospadias (75%) followed by distal hypospadias (25%). Complications of fistula urethrocutan and stenosis neourethra were found to occur in 23% of the patients. Among the two most frequently done techniques, Onlay preputial island flap showed 10% occurrence of fistula urethrocutan and 1% occurrence of stenosis neourethra, as opposed to TPIF Duckett showing 13% and 20% respectively. There were trends of decrease in occurrences of fistula urethrocutan  and stenosis neourethra following more experience in operating the surgery. All occurrences achieved 0% of occurring complication at the recent experiences of hypospadias urethroplasty.Conclusion: More experience in performing hypospadias urethroplasty seemed to affect clinical outcome, as occurrences of fistula urethrocutan and stenosis mid urethra be decreasing with more experience in a single pediatric urology surgeon.

Study on the Effects of Potential Affecting Factors on the Midurethral Volume by High-Frequency 3-Dimensional Transvaginal Ultrasound.

The anatomic integrity of the female mid urethra is an important factor for urinary continence. However, the associations between the urethral volume and potential affecting factors still remain uncertain. The aim of this study was to investigate the impact of potential factors, including age, height, weight, body mass index (BMI), parity number, delivery mode, and menopause, on the midurethral volume to assist in more-accurate evaluations of urethral anatomy and urinary continence mechanisms in clinical practice. A total of 244 women were included in this study. All patients had no incontinence symptoms and underwent transvaginal ultrasound examinations. Detailed histories and demographic data were collected. Urethral volumes were acquired, and volume parameters were measured offline, including the urethral sphincter volume (USV), midurethral complex volume (CV), and inner core volume (ICV). Correlations were analyzed by the Spearman test. For categorical variables, an analysis of variance, Mann-Whitney tests, or Kruskal-Wallis tests were used to estimate associations of potential affecting factors and volumes. The mean age, height, weight, and BMI ± SD of the patients were 35.42 ± 9.88 years, 161.50 ± 4.96 cm, 60.72 ± 11.42 kg, and 23.29 ± 4.20 kg/m2 , respectively. Among potential affecting factors, age had a weak correlation with the USV, CV, and ICV (P = .031, .003, and .004; r = 0.140, 0.193, and 0.187), whereas parity numbers significantly affected the USV, CV, and ICV (P = .014, .021, and .026). The urethral volume became larger with increasing parity. Height (P = .391, .637, and .647), weight (P = .077, .130, and .245), BMI (P = .583, .592, and .643), delivery mode (P = .483, .171, and .104), and menopausal status (P = .611, .717, and .830) had no significant impact on the midurethral volume data (USV, CV, and ICV). The midurethral volume tended to increase with age and parity in continent women.

Is the anchor matter? A short-term follow-up of the effect of mini-invasive mid urethra sling without anchor for urinary incontinence women

ObjectiveStress urinary incontinence (SUI) is a common disease in aged women, and some of them need surgical correction. Recently, the mid-urethral sling is an accepted surgical approach for SUI. However, complication may occur in this surgery, and some of them are needle-related. Therefore, the needleless system may diminish this-type complication. Materials and methodsWe conducted a retrospective study to evaluate the feasibility of women with SUI undergoing needleless sling surgery in 2017. Assessments were performed by two independent special urogynecologists before, during and post operation periods. We used a category-time-site-pain code following the International Continence Society and International Urogynecological Association (ICS/IUGA) Complication Classification Code (CCC) guidelines. ResultsThirty-eight women were analyzed. The characteristics of the patients were 66.3 ± 12.8 years old (mean ± standard deviation) of age, 2.8 ± 1.2 of parity, and 25.6 ± 4.2 kg/m2 of body mass index. All had history of vaginal delivery for term. The objective cure rate at 2- and 4-week follow-up was 97.4% (n = 37) and 94.7% (n = 36), respectively. The subjective cure rate at 2- and 4-week follow-up was both 89.5% (n = 34). Both objective and subjective cure rates remained constant and similar to the end of 4 weeks. There were 6 patients (15.8%) who had complications according to ICS/IUGA CCC guidelines. ConclusionThis needleless mid-urethral sling procedure seemed to be feasible in the management of women with SUI in this small series and short-term follow-up study, suggesting that a further prospective, randomized, comparative study with other tension-free procedures and mini-sling systems can be conducted.

Initial report on distribution of β3-adrenoceptor in the human female urethra.

Past research has demonstrated that the urethral tonus is mainly under sympathetic control. Since 5 years, a beta 3-adrenoceptor (ADRB3) agonist is available in the treatment of overactive bladder syndrome. The presence of ADRB3 within the human urethra has not been demonstrated to date. Presence of ADRB3 in the urethra could influence urethral tonus. The aim of this study is to investigate the presence of ADRB3 in the human female urethra. We performed anatomical studies in fivefemale specimens. Three specimens were obtained from the body donation program, two from female patients with muscle-invasive bladder cancer, where radical resection of bladder and urethra was performed. The urethra up till the bladder neck was separated from the rest of the bladder and freshly obtained for this study. For demonstrating ADRB3 expression, we used rabbit polyclonal anti-human ADRB3 LS-A4198. Expression of ADBR3 was demonstrated in the epithelial layer of all urethral parts, except at the level of the meatus. The level of ADRB3 expression was highest in the mid urethra. There was no direct contact between ADRB3 and nerve tissue. ADRB3 expression was also demonstrated in the stratified muscle layer at the level of the external urethral sphincter. This is the first study to demonstrate the expression of ADRB3 in the human female urethra. There is an absence of a direct connection between ADRB3 and nerve tissue.

Urethral Diverticulum Excision and Placement of Autologous Fascia Lata Sling

Video Objective To show the repair of an uncommon urogynecological pathology, and to illustrate a case where an autologous fascial graft is placed for management of stress urinary incontinence. Setting The patient is a 59-year-old with abdominal pain, urinary incontinence, incomplete bladder emptying, and hematuria. She has a complex past medical and surgical history. Pre-operative urodynamic testing showed genuine stress urinary incontinence, and office cystoscopy was unremarkable. Imaging demonstrated a urethral diverticulum containing multiple stones. The patient proceeded to the operating room for excision of the diverticulum and placement of an autologous sling. Interventions Fascia lata from patient's right thigh was harvested and prepared with polypropylene sutures at each end. Cystourethroscopy identified the diverticulum opening in the posterior mid urethra. The anterior vaginal mucosa was incised and the pubocervical fascia was dissected. The bulge of the urethral diverticulum was identified. Entry into the diverticulum was encountered during the dissection, and multiple stones were removed. The entire diverticular sac was dissected from the posterior urethra and pubocervical fascia. The urethral wall was reapproximated. The periurethral fibromuscularis was closed in a vest-over-pants fashion in order to avoid overlapping suture line with the urethral closure. An abdominal incision was made above the pubic symphysis. Needle trocars were passed vaginally through retropubic space. The polypropylene stitches on the fascial lata graft were threaded through the needles and pulled onto the abdomen, placing the sling in place. The sutures were then sewn through the rectus fascia and tied in the midline. Final cystourethroscopy confirmed patent ureteral orifices, normal bladder mucosa, and intact urethral repair. A Foley catheter was replaced and maintained for 4 weeks. A voiding cystogram showed intact bladder and urethra. Conclusion This case depicts a scenario where autologous sling is preferable over synthetic mesh due to decreased risk of erosion when a urethral diverticulum is repaired.

Transobturator Tape (TOT) in Management of Female Stress Urinary Incontinence

BACKGROUND Transobtorator tape (TOT) is a minimally invasive procedure that gained increased popularity in the surgical field for management of patients with stress urinary incontinence . The use of TOT had significantly simplified the surgical procedure and made it safer. OBJECTIVES To evaluate the safety and efficacy of the TOT procedure in women with SUI PATIENTS AND METHOD Thirty female patient are complaining of urinary incontinence presented at urology department of Ghazi Al-Hariri surgical specialties hospital from January 2012-Oct. 2013 were enrolled in this study. All of our patients are with pure SUI. The procedure was done under spinal anesthesia. TOT require placement of macroporous polypropylene tape at the mid urethra through the obturator membrane with minimal vaginal incision. The patients were followed up before discharge, 1 month and six month using cough test. RESULTS Mean patients age is 48.2 year (range 30-60 year) with a mean parity of 5(range from 3-7 child). The mean operating time is 26.5 minutes (ranging from 20-30 minutes). Intraoperative complications occur in 6 patients (20%), include hemorrhage in 5 patients, hematoma in one patient. The total incidence of postoperative complication was 36%, transient thigh pain occurred in seven patients, two patients got retention, two patients got de novo urgency. The objective cure rate was 93.3% CONCLUSION The TOT procedure is a safe and effective technique for the management of patient complaining of SUI.

Proximal location of explanted midurethral slings is associated with urinary storage symptoms.

To examine the location of midurethral slings (MUS) at the time of excision to determine associations between presenting symptoms and sling location at explant. We performed an IRB approved, retrospective review of MUS explants between January 2011 and March 2016. Symptoms and physical examination findings were compared between women with slings explanted from the mid-urethra (MU) and women with slings explanted from the proximal urethra/bladder neck (PU/BN). We included 95 consecutive women who underwent MUS explant in the analysis. Presenting symptoms included pain in 69 women (72.6%), urinary urgency in 66 (66.5%), voiding dysfunction in 55 (57.9%), urge urinary incontinence (UUI) in 41 (43.2%), stress urinary incontinence in 34 (35.8%), and recurrent urinary tract infections in 22 (23.2%). At sling explant, 2 (2.1%) slings were found at the distal urethra, 33 (34.7%) at the MU and 60 (63.2%) at the PU/BN. Women with slings explanted from the PU/BN were more likely to present with urgency (78.3% vs54.5%; P = 0.017) and UUI (53.3% vs27.3%; P = 0.015) and less likely to present with pain on examination (48.3% vs75.8%; P = 0.01). The majority of MUS requiring explant in this cohort were found at the PU/BN. The most common presenting symptom before MUS explant was pain, followed by urgency and voiding dysfunction. PU/BN location of MUS is likely a factor in the development of urgency and UUI in women who ultimately undergo explant.

Regional Structural and Functional Specializations in the Urethra of the Female Rat: Evidence for Complex Physiological Control Systems

This study characterizes the complex structural and functional elements of the female rat urethra that may be involved in controlling urethral closure and continence. Urethras were dissected from female Sprague-Dawley rats (N = 12) euthanized by pentobarbital overdose. Tissues were fixed (4% paraformaldehyde), frozen, and sectioned (8 μm) for light microscopy and immunohistochemistry. Antibodies were used to detect immunoreactivity to calcitonin gene related peptide, nitric oxide synthase, vesicular acetylcholine transporter, and tyrosine hydroxylase. Measurements of urethral wall compliance were taken along its length and in different axes using a closed ended catheter with a circular aperture. The bladder neck and proximal urethra are characterized by a highly folded epithelium and lamina propria. A smooth muscle layer is apparent but not pronounced. Distal to this region the smooth muscle layer thickens and forms the body of the internal sphincter, which has a complex innervation. In the mid urethra, the smooth muscle is thickened resulting in a luminal protrusion, producing an occlusion of the lumen. The structure of the distal urethra is different. The epithelium has few folds and, immediately below the lamina propria large thin walled vascular lacunae can be found. Measurements of the urethral wall compliance demonstrate distinct regional differences with proximal and distal specialisations. These variations, which correlate with muscular and vascular elements, suggest the operation of discrete systems, hence effecting urethral closure during filling. An understanding of these systems may yield insights into urethral pathology and direct approaches to develop pharmacological interventions to promote continence. Anat Rec, 301:1276-1289, 2018. © 2018 Wiley Periodicals, Inc.

Novel Bioceramic Urethral Bulking Agents Elicit Improved Host Tissue Responses in a Rat Model.

Objectives. To test the physical properties and host response to the bioceramic particles, silica-calcium phosphate (SCPC10) and Cristobalite, in a rat animal model and compare their biocompatibility to the current clinically utilized urethral bulking materials. Material and Methods. The novel bulking materials, SCPC10 and Cristobalite, were suspended in hyaluronic acid sodium salt and injected into the mid urethra of a rat. Additional animals were injected with bulking materials currently in clinical use. Physiological response was assessed using voiding trials, and host tissue response was evaluated using hard tissue histology and immunohistochemical analysis. Distant organs were evaluated for the presence of particles or their components. Results. Histological analysis of the urethral tissue five months after injection showed that both SCPC10 and Cristobalite induced a more robust fibroblastic and histiocytic reaction, promoting integration and encapsulation of the particle aggregates, leading to a larger bulking effect. Concentrations of Ca, Na, Si, and P ions in the experimental groups were comparable to control animals. Conclusions. This side-by-side examination of urethral bulking agents using a rat animal model and hard tissue histology techniques compared two newly developed bioactive ceramic particles to three of the currently used bulking agents. The local host tissue response and bulking effects of bioceramic particles were superior while also possessing a comparable safety profile.

Genital hiatus size is associated with and predictive of apical vaginal support loss

Recognition and assessment of apical vaginal support defects remains a significant challenge in the evaluation and management of prolapse. There are several reasons that this is likely: (1)Although the Pelvic Organ Prolapse-Quantification examination is the standard prolapse staging system used in the Female Pelvic Medicine and Reconstructive Surgery field for reporting outcomes, this assessment is not used commonly in clinical care outside the subspecialty; (2) no clinically useful and accepted definition of apical support loss exists, and (3) no consensus or guidelines address the degree of apical support loss at which an apical support procedure should be performed routinely. The purpose of this study was to identify a simple screening measure for significant loss of apical vaginal support. This was an analysis of women with Pelvic Organ Prolapse-Quantification stage 0-IV prolapse. Women with total vaginal length of ≥7 cm were included to define a population with "normal" vaginal length. Univariable and linear regression analyses were used to identify Pelvic Organ Prolapse-Quantification points that were associated with 3 definitions of apical support loss: the International Consultation on Incontinence, the Pelvic Floor Disorders Network revised eCARE, and a Pelvic Organ Prolapse-Quantification point C cut-point developed by Dietz etal. Linear and logistic regression models were created to assess predictors of overall apical support loss according to these definitions. Receiver operator characteristic curves were generated to determine test characteristics of the predictor variables and the areas under the curves were calculated. Of 469 women, 453 women met the inclusion criterion. The median Pelvic Organ Prolapse-Quantification stage was III, and the median leading edge of prolapse was+2 cm (range, -3 to 12 cm). By stage of prolapse (0-IV), mean genital hiatus size (genital hiatus; mid urethra to posterior fourchette) increased: 2.0 ± 0.5, 3.0 ± 0.5, 4.0 ± 1.0, 5.0 ± 1.0, and 6.5 ± 1.5 cm, respectively (P < .01). Pelvic Organ Prolapse-Quantification points B anterior, B posterior, and genital hiatus had moderate-to-strong associations with overall apical support loss and all definitions of apical support loss. Linear regression models that predict overall apical support loss and logistic regression models predict apical support loss as defined by International Continence Society, eCARE, and the point C; cut-point definitions were fit with points B anterior, B posterior, and genital hiatus; these 3 points explained more than one-half of the model variance. Receiver operator characteristic analysis for all definitions of apical support loss found that genital hiatus >3.75 cm was highly predictive of apical support loss (area under the curve, >0.8 in all models). Increasing genital hiatus size is associated highly with and predictive of apical vaginal support loss. Specifically, the Pelvic Organ Prolapse-Quantification measurement genital hiatus of ≥3.75 cm is highly predictive of apical support loss by all study definitions. This simple measurement can be used to screen for apical support loss and the need for further evaluation of apical vaginal support before planning a hysterectomy or prolapse surgery.

Cystocele Repair by Autologous Rectus Fascia Graft: the Pubovaginal Cystocele Sling

The autologous rectus fascia pubovaginal sling has been a safe and effective means of correcting stress urinary incontinence. We tested the feasibility of using a larger graft to correct cystocele with or without stress urinary incontinence. Between January 2006 and October 2010, 30 patients with symptomatic cystocele underwent the pubovaginal cystocele sling procedure, including 14 with and 16 without concomitant stress urinary incontinence. The technique is a modification of the standard pubovaginal sling procedure. A large trapezoidal (major base 6 cm, minor base 4 cm and height 5 cm) rectus fascia graft is used with 4 instead of 2 sutures to suspend the graft corners. The 2 sutures at the level of the mid urethra are tied above the rectus muscles in a tension-free manner while the 2 sutures at the level of the cervical fold are tied with tension. Data on anatomical outcomes (Baden-Walker classification), functional outcomes (PFIQ-7), post-void residual urine volume and urinary tract infection were prospectively collected. At a mean followup of 62.6 months (range 46 to 98) there was no recurrence in the anterior compartment. There was 1 recurrence involving the apical and posterior compartments. All patients reported a statistically significant improvement in PFIQ-7 score. When present preoperatively, post-void residual urine volume, urinary tract infection and stress urinary incontinence ceased in all cases. The only complication was donor site wound dehiscence without fascial involvement. The autologous pubovaginal cystocele sling seems to be a safe, effective technique to correct cystocele with or without stress urinary incontinence.

Effects of Duloxetine on Urethral Continence Reflex and Bladder Activity in Rats with Cerebral Infarction

We investigated the effect of duloxetine, a norepinephrine and serotonin reuptake inhibitor, on the sneeze induced continence reflex and on bladder function in rats with cerebral infarction. Using urethane anesthesia the effect of duloxetine (1 mg/kg intravenously) on the amplitude of urethral responses during sneezing as well as urethral baseline pressure at the mid urethra was evaluated in normal female adult rats and cerebral infarction rats. Tilt leak point pressure was also measured. In normal and cerebral infarction rats continuous cystometry was evaluated before and after duloxetine injection. In cerebral infarction rats urethral baseline pressure was 43% lower than in normal rats but the amplitude of urethral responses during sneezing did not differ in the 2 groups. Duloxetine increased the amplitude of urethral responses during sneezing and urethral baseline pressure by 31% and 21%, respectively, in normal rats but did not affect either in cerebral infarction rats. Also, in cerebral infarction rats leak point pressure was 29% lower compared with normal rats. Duloxetine increased leak point pressure in normal rats but not in cerebral infarction rats. Cerebral infarction reduced intercontraction intervals without affecting the amplitude of bladder contractions compared with normal rats. Duloxetine prolonged intercontraction intervals in cerebral infarction rats but not in normal rats. These results suggest that cerebral infarction induces not only bladder overactivity but also stress urinary incontinence, which may account for mixed incontinence in patients with cerebral infarction. After cerebral infarction duloxetine reduced bladder overactivity but failed to enhance active urethral closure mechanisms during sneezing, suggesting that disorganization of the brain network after cerebral infarction might influence the effect of duloxetine on lower urinary tract function.