Pelvic Pressure Research Articles

Epidemiologic, Postmortem Computed Tomography-Morphologic and Biomechanical Analysis of the Effects of Non-Invasive External Pelvic Stabilizers in Genuine Unstable Pelvic Injuries.

Unstable pelvic injuries are rare (3–8% of all fractures) but are associated with a mortality of up to 30%. An effective way to treat venous and cancellous sources of bleeding prehospital is to reduce intrapelvic volume with external noninvasive pelvic stabilizers. Scientifically reliable data regarding pelvic volume reduction and applicable pressure are lacking. Epidemiologic data were collected, and multiple post-mortem CT scans and biomechanical measurements were performed on real, unstable pelvic injuries. Unstable pelvic injury was shown to be the leading source of bleeding in only 19%. All external non-invasive pelvic stabilizers achieved intrapelvic volume reduction; the T-POD® succeeded best on average (333 ± 234 cm3), but with higher average peak traction (110 N). The reduction results of the VBM® pneumatic pelvic sling consistently showed significantly better results at a pressure of 200 mmHg than at 100 mmHg at similar peak traction forces. All pelvic stabilizers exhibited the highest peak tensile force shortly after application. Unstable pelvic injuries must be considered as an indicator of serious concomitant injuries. Stabilization should be performed prehospital with specific pelvic stabilizers, such as the T-POD® or the VBM® pneumatic pelvic sling. We recommend adjusting the pressure recommendation of the VBM® pneumatic pelvic sling to 200 mmHg.

SULFORAPHANE, AN ORGANIC ISOTHIOCYANATE FOUND IN CRUCIFEROUS VEGETABLES, REGULATES EXPRESSION OF GENES INVOLVED IN HIPPO SIGNALING AND FIBROTIC PHENOTYPE IN UTERINE FIBROID CELLS

Uterine fibroids are fibrotic tumors of uterus associated with abnormal menstrual bleeding and pelvic pain or pressure. Our recent data showed that Hippo signaling was dysregulated (OFF) in uterine fibroids and influenced by extracellular matrix (ECM) stiffness. When Hippo signaling is ‘OFF’, the downstream effectors, YAP/TAZ, interact with TEAD to induce transcription of genes involved in cell growth and fibrosis. Sulforaphane (SFN) is an organic isothiocyanate abundantly present in cruciferous vegetables with tumor-preventing properties.

Abstract MP48: Crispr/cas9 Trpv1 Deletion In Rats Does Not Impair Mechano- And Chemo-sensory Renal Afferent Nerve Responses

Elevated renal afferent nerve activity (ARNA) or dysfunctional renal reflexes contributes to hypertension and chronic kidney disease. The transient receptor potential vanilloid type-1 (TRPV1) channel is expressed in renal sensory nerves, and intrarenal administration of the TRPV1 agonist capsaicin increases ARNA. Nonselective denervation of renal sensory nerves using high-concentration capsaicin reduces arterial blood pressure (ABP) in experimental models of hypertension. However, the role of TRPV1 channels in ARNA responses to chemo- and mechano-sensitive stimuli has not been directly tested. To test this hypothesis, we generated a novel TRPV1 rat knockout model (TRPV1 -/- ) using CRISPR/CAS9 to delete exon 3 . ARNA multifiber recordings were performed in male and female TRPV1 -/- and wild-type littermates (250-400g) after decerebration or Inactin anesthesia (data combined). Wild-type and TRPV1 -/- rats had no significant differences in baseline mean ABP (126±4 mmHg vs 138±5 mmHg, respectively; n=8-10) or heart rate (451±25 bpm vs 432±24 bpm, respectively; n=8-10). Baseline ARNA was not different between wild-type and TRPV1 -/- rats (16±3 Hz vs 28±6 Hz, respectively; n=8-10). Intrarenal artery infusion of the TRPV1 agonist capsaicin (0.1-10μM, 50μL per 15s) significantly increased ipsilateral ARNA in wild-type but not TRPV1 -/- rats (Δ discharge with 10μM: 65±3 Hz vs 6±1 Hz, respectively; n=5-7). As a second chemosensitive stimulus, intrarenal artery infusion of bradykinin (0.1-10μM, 50μL per 15s) produced similar increases in ipsilateral ARNA between wild-type and TRPV1 -/- rats (Δ discharge with 10μM: 52±6 Hz vs 73±18 Hz, respectively; n=5-6). Finally, elevated renal pelvic pressures (0-20mmHg; 30s) significantly increased ipsilateral ARNA in both wild-type and TRPV1 -/- rats; however, the ARNA response was significantly greater in TRPV1 -/- versus wild-type rats (Δ discharge with 20mmHg: 47±14 Hz versus 18±6 Hz, respectively; n=5-8). In conclusion, mechanosensitive and chemosensitive ARNA responses remain intact in TRPV1 -/- rats. The mechanisms responsible for renal sensory nerve activation remain unidentified and the impact of TRPV1 deletion in rat models of hypertension and kidney disease remains to be tested.

Changes of Pelvic Organ Prolapse Symptoms and Quality of Life One Year After Pessary Fitting

Pelvic organ prolapse (POP) is the descend of pelvic organs, including the uterus, bladder, and rectum, to the vaginal wall. Patients with POP may present with symptoms such as vaginal bulging with other symptoms like urinary, defecatory, or sexual dysfunction. This study was conducted to evaluate the changes of POP symptoms one year after pessary fitting. Patients with symptomatic pelvic organ prolapse who presented to the pelvic floor clinic of an academic hospital between August 2016 and April 2019 were considered. Pelvic organ prolapse symptoms, including urinary, defecatory, sexual, and bulging symptoms, were recorded before and one year after pessary fitting. Pelvic floor distress inventory (PFDI)-20 and pelvic floor impact questionnaire-7 (PFIQ-7) were evaluated before and after treatment for all subjects. We analyzed the characteristics of 110 patients who used the pessary for 12 months. At the baseline, the most common prolapse symptoms were vaginal bulging and pelvic pressure. All urinary, defecatory, and sexual symptoms significantly improved one year after regular pessary use (P<0.001). Changes in PFDI-20 and PFIQ-7 before and after pessary use showed a significant improvement in both frequency and satisfaction of sexual function (P<0.001). The study showed significant improvement in bulging, urinary, and defecatory symptoms. Although the majority of patients were not sexually active, a significant proportion of sexually active patients reported an increase in sexual satisfaction.

Anti-inflammatory Diet for Interstitial Cystitis (AID-IC): Study Protocol for a Randomized Controlled Cross-Over Trial

ObjectivesIC/BPS is characterized by pelvic pain, pressure, or discomfort in the bladder and pelvic area coupled with urinary frequency and urgency. The cause is unknown. Dietary intake appears to exacerbate IC/BPS symptoms for many patients; however, the association is not well understood. The potential role of saturated fat and other inflammatory dietary components in provoking IC/BPS symptoms will be explored. Animal studies associate high dietary intake of saturated fats with activation of toll-like receptor (TLR4) cell signaling and pro-inflammatory responses. Saturated free fatty acids were linked to changes in the bladder on a cellular level. The goal of the AID-IC study is to investigate the efficacy of an anti-inflammatory diet (limits lipid intake and increases antioxidant intake) on symptom severity. MethodsIn a 22-week, crossover study, women with IC/BPS will be randomized into two groups. Group one will receive 10 weeks of a therapeutic anti-inflammatory diet that eliminates foods commonly bothersome for those with this condition; 5 days/week prepared, home-delivered meals were provided. Group 2 will receive counseling from a dietitian on standard IC/BPS dietary recommendations (control diet). After a two-week washout period, dietary interventions for the two groups will be switched. Primary outcomes include changes in inflammatory biomarkers (TNF-alpha and IL-1) and scores on three validated symptom severity surveys. ResultsWe hypothesize that an anti-inflammatory diet that excludes foods commonly bothersome for individuals with IC/BPS will help manage symptomology for these patients. Furthermore, we hypothesize that the severity of symptoms will be mediated by the reduction of pro-inflammatory responses associated with the influence of a diet low in saturated fats and high in anti-inflammatory dietary components. ConclusionsThe feasibility of managing IC/BPS symptoms by influencing inflammatory activity via restricting lipid intake and increasing antioxidant-rich foods has not previously been investigated. The findings may offer preliminary data on a cost-effective, noninvasive therapy. Funding SourcesMountain West Clinical & Translational Research Infrastructure Network (National Institute of General Medical Sciences, NIH).

Clinical investigation of fertility after uterine artery embolization

Uterine artery embolization is an effective and safe technique for the treatment of uterine fibroids, but its use remains controversial for women who wish to procreate. This study aimed to study the clinical, anatomic, and obstetrical results of uterine artery embolization in patients of childbearing age not eligible for myomectomy. This was a retrospective cohort study of 398 female patients under the age of 43 years who were treated by uterine artery embolization between 2003 and 2017 for symptomatic fibroids and/or adenomyosis. Uterine artery embolization was performed according to a standardized procedure (fertility-sparing uterine artery embolization technique), with ovarian protection in the event of dangerous utero-ovarian anastomosis. Magnetic resonance imaging and pelvic ultrasounds were performed before and after uterine artery embolization. The overall clinical success rate (ie, resolution of preembolization symptoms such as heavy menstrual bleeding, iron-deficiency anemia, pelvic pressure) was 91.2%, and there were no major complications. One year after uterine artery embolization, we observed a mean 73% reduction in myoma volume. A total of 108 patients (49.3%) presented with dangerous utero-ovarian anastomosis and 33 (14.5%) benefited from ovarian protection. In our group, there were 148 pregnancies and 109 live births; 74 children were born at term; 23 were born preterm, on average at 35.12±2.78 weeks. Including preterm births, the mean birthweight and birth length of the children were within normal limits. Restoration of uterine anatomy and ovarian protection were identified as the main predictive factors for obstetrical success. Restoration was also a major predictive factor for clinical success and was associated with a lower rate of miscarriage. This study provided detailed clinical and obstetrical outcomes for 398 female patients who underwent uterine artery embolization for fibroid treatment; it contributes to the identification of anatomic and technical factors that could have an impact on fertility after uterine artery embolization. Further controlled clinical trials are needed to confirm our findings and reevaluate this procedure's indications and limitations for women with a desire to procreate.

The Whitaker Test in the Follow-up of Complex Upper Urinary Tract Reconstruction: Is It Clinical Useful or Not.

To evaluate the feasibility and guiding significance in postoperative management of the Whitaker test after complex reconstruction of the upper urinary tract. Patients who underwent complex ureteral reconstruction and received the Whitaker test after surgery between December 2018 and December 2019 were included. We judged it abnormal that the renal pelvis pressure was higher than 22 cmH2O or the pressure difference was greater than 15 cmH2O. The results were used as a reference for removing the nephrostomy tube. Based on whether the renal pelvic pressure was higher than 22 cmH2O, the patients were divided into the elevated pelvis pressure group and the normal group. Follow ups at 1 month and every 3 months were collected. A total of 19 patients were included. Fifteen patients did not present obvious abnormalities. One patient suffered from contrast infiltrating into the renal parenchyma, and the pressure was higher than 15 cmH2O. Ureteral stent implantation was performed. The other 3 patients had either elevated pelvis pressure or insufficient image, 2 of which prolonged the duration of nephrostomy tubes. The median follow-up time was 12.6 months. CTU/MRU after removing nephrostomy tubes indicated improved/stable hydronephrosis in all patients. The creatinine in the elevated pelvis pressure group was higher than that in the normal group (91.4 ± 27.6 vs 86.7 ± 16.5 μmol/L, P = .782), and the eGFR was lower (76.0 ± 14.0 vs 81.8 ± 24.1 mL/min/1.73m2, P = .695), but without significant difference. The change in creatinine during follow-up in the elevated renal pelvic pressure group was significantly different from that in the normal group (-13.6 ± 1.0 vs -0.2 ± 10.6 umol/L, P = .047). Postoperative Whitaker test can help judge whether nephrostomy could be removed. Elevated pressure in upper urinary tract after reconstruction suggests the need to prolong the time of the nephrostomy tube or even re-intervene. Proper management for patients with elevated renal pelvis pressure can help restore the renal function.

Targeted neuromodulation of pelvic floor nerves in aging and multiparous rabbits improves continence

Pelvic floor muscle stretch injury during pregnancy and birth is associated with the incidence of stress urinary incontinence (SUI), a condition that affects 30–60% of the female population and is characterized by involuntary urine leakage during physical activity, further exacerbated by aging. Aging and multiparous rabbits suffer pelvic nerve and muscle damage, resulting in alterations in pelvic floor muscular contraction and low urethral pressure, resembling SUI. However, the extent of nerve injury is not fully understood. Here, we used electron microscopy analysis of pelvic and perineal nerves in multiparous rabbits to describe the extent of stretch nerve injury based on axon count, axon size, myelin-to-axon ratio, and elliptical ratio. Compared to young nulliparous controls, mid-age multiparous animals showed an increase in the density of unmyelinated axons and in myelin thickness in both nerves, albeit more significant in the bulbospongiosus nerve. This revealed a partial but sustained damage to these nerves, and the presence of some regenerated axons. Additionally, we tested whether electrical stimulation of the bulbospongiosus nerve would induce muscle contraction and urethral closure. Using a miniature wireless stimulator implanted on this perineal nerve in young nulliparous and middle age multiparous female rabbits, we confirmed that these partially damaged nerves can be acutely depolarized, either at low (2–5 Hz) or medium (10–20 Hz) frequencies, to induce a proportional increase in urethral pressure. Evaluation of micturition volume in the mid-age multiparous animals after perineal nerve stimulation, effectively reversed a baseline deficit, increasing it 2-fold (p = 0.02). These results support the notion that selective neuromodulation of pelvic floor muscles might serve as a potential treatment for SUI.

The Value of Adenomyosis Type in Clinical Assessment: A Single-center Experience of 755 Nodular and Diffuse Adenomyosis Cases.

To investigate the incidence of nodular and diffuse adenomyosis, concomitant pathologies and also to compare the demographic and clinic differences among patients with adenomyosis and their surgery indications. This retrospective study was conducted in Tepecik Research Hospital, Izmir, Turkey between 2014 and 2016. Patients were divided into two groups of nodular and diffuse adenomyosis. The following variables were evaluated for both groups: age, gravidity, parity, menopausal status, indication for hysterectomy, ultrasonographic parameters, gynecological symptoms (abnormal uterine bleeding [AUB], pelvic pain and pelvic pressure, postmenopausal vaginal bleeding), preoperative and postoperative histopathological assessment, and coexisting pathologies. Of the total 3457 cases of hysterectomies, 755 (95% CI: 20.4-23.1) were confirmed with adenomyosis. There were 217 (95% CI: 23.9-30.0) postmenopausal women. Adenomyosis was most commonly detected in patients in the age of 40 to 50 (57.6%). The most common symptoms were AUB (n: 336) (95% CI: 40.9-48.0), pelvic pain or pressure (n:139) (18.4%), and postmenopausal vaginal bleeding (n: 119) (95% CI: 13.1-18,4). Seventy-four (95% CI: 7.9-11.9) of the patients had nodular and 681(95% CI: 88.0-92.3) had diffuse adenomyosis. Demographic data, age, parity, gravidity, endometrial thickness, and menopausal status were similar between the groups. AUB was more frequently detected in nodular adenomyosis (56.8%). Myoma uteri was the main hysterectomy indication in both groups. In addition, treatment-resistant AUB for nodular adenomyosis and endometrial pathologies for diffuse adenomyosis were the most frequent indications for hysterectomy after myoma uteri. The most common form of adenomyosis was the diffuse form. Endometrial pathologies were more frequently associated with diffuse adenomyosis. Asymptomatic and incidental adenomyosis were more common with the diffuse form. AUB was more frequently detected with nodular adenomyosis.

Enhanced SMP (eSMP) technique: low renal pelvic pressure and high lithotripsy efficiency

Enhanced SMP (eSMP) technique: low renal pelvic pressure and high lithotripsy efficiency

Does Patient-specific Functional Pelvic Tilt Affect Joint Contact Pressure in Hip Dysplasia? A Finite-element Analysis Study.

Although individual and postural variations in the physiologic pelvic tilt affect the acetabular orientation and coverage in patients with hip dysplasia, their effect on the mechanical environment in the hip has not been fully understood. Individual-specific, finite-element analyses that account for physiologic pelvic tilt may provide valuable insight into the contact mechanics of dysplastic hips, which can lead to further understanding of the pathogenesis and improved treatment of this patient population. We used finite-element analysis to ask whether there are differences between patients with hip dysplasia and patients without dysplasia in terms of (1) physiologic pelvic tilt, (2) the pelvic position and joint contact pressure, and (3) the morphologic factors associated with joint contact pressure. Between 2016 and 2019, 82 patients underwent pelvic osteotomy to treat hip dysplasia. Seventy patients with hip dysplasia (lateral center-edge angle ≥ 0° and < 20° on supine AP pelvic radiographs) were included. Patients with advanced osteoarthritis, femoral head deformity, prior hip or supine surgery, or poor-quality imaging were excluded. Thirty-two patients (32 hips) were eligible to this finite-element analysis study. For control groups, we reviewed 33 female volunteers without a history of hip disease. Individuals with frank or borderline hip dysplasia (lateral center-edge angle < 25°) or poor-quality imaging were excluded. Sixteen individuals (16 hips) were eligible as controls. Two board-certified orthopaedic surgeons measured sagittal pelvic tilt (the angle between the anterior pelvic plane and vertical axis: anterior pelvic plane [APP] angle) and acetabular version and coverage using pelvic radiographs and CT images. Intra- and interobserver reliabilities, evaluated using the kappa value and intraclass correlation coefficient, were good or excellent. We developed individual-specific, finite-element models using pelvic CT images, and performed nonlinear contact analysis to calculate the joint contact pressure on the acetabular cartilage during the single-leg stance with respect to three pelvic positions: standardized (anterior pelvic plane), supine, and standing. We compared physiologic pelvic tilt between patients with and without dysplasia using a t-test or the Wilcoxon rank sum test. A paired t-test or the Wilcoxon signed rank test with a Bonferroni correction was used to compare joint contact pressure between the three pelvic positions. We correlated joint contact pressure with morphologic parameters and pelvic tilt using the Pearson or the Spearman correlation coefficients. The APP angle in the supine and standing positions varied widely among individuals. It was greater in patients with hip dysplasia than in patients in the control group when in the standing position (3° ± 6° versus -2° ± 8°; mean difference 5° [95% CI 1° to 9°]; p = 0.02) but did not differ between the two groups when supine (8° ± 5° versus 5° ± 7°; mean difference 3° [95% CI 0° to 7°]; p = 0.06). The mean pelvic tilt was 6° ± 5° posteriorly when shifting from the supine to the standing position in patients with hip dysplasia. The median (range) maximum contact pressure was higher in dysplastic hips than in control individuals (in standing position; 7.3 megapascals [MPa] [4.1 to 14] versus 3.5 MPa [2.2 to 4.4]; difference of medians 3.8 MPa; p < 0.001). The median maximum contact pressure in the standing pelvic position was greater than that in the supine position in patients with hip dysplasia (7.3 MPa [4.1to 14] versus 5.8 MPa [3.5 to 12]; difference of medians 1.5 MPa; p < 0.001). Although the median maximum joint contact pressure in the standardized pelvic position did not differ from that in the standing position (7.4 MPa [4.3 to 15] versus 7.3 MPa [4.1 to 14]; difference of medians -0.1 MPa; p > 0.99), the difference in the maximum contact pressure varied from -3.3 MPa to 2.9 MPa, reflecting the wide range of APP angles (mean 3° ± 6° [-11° to 14°]) when standing. The maximum joint contact pressure in the standing position was negatively correlated with the standing APP angle (r = -0.46; p = 0.008) in patients with hip dysplasia. Based on our findings that individual and postural variations in the physiologic pelvic tilt affect joint contact pressure in the hip, future studies on the pathogenesis of hip dysplasia and joint preservation surgery should not only include the supine or standard pelvic position, but also they need to incorporate the effect of the patient-specific pelvic tilt in the standing position on the biomechanical environment of the hip. We recommend assessing postural change in sagittal pelvic tilt when diagnosing hip dysplasia and planning preservation hip surgery because assessment in a supine or standard pelvic position may overlook alterations in the hip's contact mechanics in the weightbearing positions. Further studies are needed to elucidate the effect of patient-specific functional pelvic tilt on the degeneration process of dysplastic hips, the acetabular reorientation maneuver, and the clinical result of joint preservation surgery.

The Innovative Use of Ureter Catheter in the Surgery of Obstructive Uropathy.

Purpose Relieving obstruction and protecting renal function are the main therapeutic purposes of obstructive uropathy which often involve surgical treatment, and the ureter catheter is one of the surgical instruments commonly used in surgery. We aimed to explore the innovative use of a ureter catheter in the surgery of obstructive uropathy. Methods We used a ureteral catheter to innovate the surgical procedure of the most common causes of obstructive uropathy: ureteral calculi and stricture, establishing an internal circulation system (ICS), proposing a three-step dilatation method, and reviewing their effects on patients. Furthermore, we introduced a simple real-time intrapelvic pressure measurement device to monitor intrarenal pressure during operation. Results Postoperative laboratory examination showed that blood CRP, leukocyte neutrophil level, changes in the hemoglobin, urine occult blood, and positive rate of urine culture in the ICS group are significantly lower than those in the control group, corresponding to a lower incidence of bleeding and infection-related complications clinically. A three-month follow-up revealed 1/3 rate of ureteral stricture in the ICS group comparing to the control. We applied the three-step dilatation in patients with severe stenosis in which the balloon could not pass; the overall effective rate was 90.9%. The pressure of the renal pelvis was displayed on the monitor in real time. The surgeon could estimate the degree of filling of the renal pelvis and adjust the intake volume through the data. Conclusion The innovative application of ureteral catheters in the operation of obstructive uropathy can realize the real-time monitor of intraoperative renal pelvis pressure, reduce the incidence of lithotripsy postoperative complications, and expand the indications of balloon dilatation in ureteral stricture, which has certain clinical significance.

A Systematic review and meta-analysis of sensate versus non-sensate flaps for the prevention of pressure ulcer recurrence among individuals with spinal cord disease.

Systematic review and meta-analysis. To identify, critically appraise, and synthesize research findings on non-sensate versus sensate flaps among individuals with spinal cord disease and pelvic pressure ulcers, with pressure ulcer recurrence as primary outcome. PubMed, EMBASE, and Cochrane CENTRAL were screened for relevant studies. Data on surgical characteristics, ulcer recurrence, and sensory outcomes were retrieved and tabulated. Risk of bias was assessed with MINORS. The level of evidence was evaluated with GRADE. Meta-analysis was performed when possible. Meta-analysis of 1794 non-sensate locoregional reconstructions indicated a recurrence rate of 34% within several years (95% CI, 27-42). Twenty-one articles provided data on 75 sensate reconstructions, performed in 74 individuals. Meta-analysis of the sensate reconstructions indicated a recurrence rate of 1% (95% CI, 0-8). Sensate reconstructions were not associated with an increase of wound complications (19%; 95% CI, 7-40) compared with non-sensate ones (34%; 95% CI, 27-42). A very low level of evidence was determined with use of GRADE. Although of a very low-level, the present evidence suggests that restoration of sensory innervation may be an effective intervention for the prevention of pressure ulcer recurrence among individuals with spinal cord disease. A prospective RCT is needed to confirm or refute the results of this systematic review.

“Doctor, how long will it take?” Results from an historical cohort on surgical pressure ulcer healing delay and related factors in persons with spinal cord injury

BackgroundFlap surgery for deep pelvic pressure ulcers has already shown its effectiveness. Most studies relating to the postoperative period assessed complications rates and associated risk factors, but none focused on delayed wound healing. The objective of this study was to describe wound healing delay after primary flap surgery in patients with spinal cord injury (SCI) and to assess associated risk factors. MethodsThis observational retrospective study based on medical charts included all persons with SCI operated for primary flap surgery for pelvic PU in the Hérault department of France between 2006 and 2014. Overall, 100 biomedical, psychological, socioeconomics and care management factors were studied. The primary outcome was wound healing delay, defined as time from surgery to complete cutaneous closure. Results85 patients were included. Median healing time was 48 days (R: 20–406). Healing rate was 70% at 3 months and 90% at 4 months. After a multivariate analysis three factors were significantly associated with delayed wound healing: duration of hospitalization in the acute care unit (HR = 2.68; p = 0.004), local post-operative complication (HR = 10.75; p = 0.02), and post-operative sepsis (HR = 2.18; p = 0.02). ConclusionAfter primary skin flap surgery for PU in persons with SCI, delayed wound healing is related to local or general complications as well as care management organization. The risk of delayed wound healing justifies the implementation of a coordinated pre-operative management to prevent complications and a structured care network for an earlier transfer to a SCI rehabilitation center.

Percutaneous nephrolithotomy with suction: is this the future?

The armamentarium of percutaneous nephrolithotomy (PCNL) and the strategy to perform the procedure is constantly evolving. The innovation and development in techniques lead to further miniaturization in PCNL devices and change the lithotripsy and stone removal strategy. Suctioning in PCNL offers urologist a new conception in renal stone management. The present review evaluates the latest results on efficacy, safety and feasibility of suctioning PCNL techniques. Recent literature reported the outcomes of different suctioning PCNL techniques. Most of these studies demonstrated good efficacy when comparing conventional PCNL. Suctioning PCNL improving the lithotripsy efficiency to enhance the stone-free rate (SFR) and reducing renal pelvic pressure to attenuate postoperative infectious complications. The advantage of suction also helps overcome the limitation of potentially higher intrarenal pressure and prolonged operative time in Mini-PCNL. PCNL with suctioning represents a valuable new tool in the armamentarium of modern endourologists. This innovative approach can offer improved safety and efficacy with lower complications rates and higher cost effectiveness than the traditional PCNL technique.

Tandem ureteral stents drainage lowers renal pelvis pressure in malignant ureteral obstruction: Experimental and computational models

Malignant ureteral obstruction may lead to impaired renal function and requires drainage by a percutaneous nephrostomy tube or an internal ureteric stent. Usage of stiff tandem ureteral stents may decrease stent failure rates. In this paper we combined computational and in vitro models to examine the flow in a malignant ureteral obstruction (MUO) managed by 4 methods of drainage: single soft stent, single stiff stent, soft tandem ureteral stents, and stiff tandem ureteral stents. Pressure at the renal pelvis was the primary outcome of the computational and in vitro models. Different drainage modalities were compared using ANCOVA. Results of computational and in vitro models agreed completely. Drainage by stiff tandem ureteral stents provides lower renal pelvis pressure levels compared with single and soft stents (p < 0.001), especially for high levels of external pressure. Usage of stiff tandem ureteral stents may decrease stent-failure rates and postpone the need for percutaneous nephrostomy tube insertion.

Prospective International Multicenter Pelvic Floor Study: Short-Term Follow-Up and Clinical Findings for Combined Pectopexy and Native Tissue Repair.

Efforts to use traditional native tissue strategies and reduce the use of meshes have been made in several countries. Combining native tissue repair with sufficient mesh applied apical repair might provide a means of effective treatment. The study group did perform and publish a randomized trial focusing on the combination of traditional native tissue repair with pectopexy or sacrocolpopexy and observed no severe or hitherto unknown risks for patients (Noé G.K. J Endourol 2015;29(2):210–215). The short-term follow-up of this international multicenter study carried out now is presented in this article. Material and Methods: Eleven clinics and 13 surgeons in four European counties participated in the trial. In order to ensure a standardized approach and obtain comparable data, all surgeons were obliged to follow a standardized approach for pectopexy, focusing on the area of fixation and the use of a prefabricated mesh (PVDF PRP 3 × 15 Dynamesh). The mesh was solely used for apical repair. All other clinically relevant defects were treated with native tissue repair. Colposuspension or TVT were used for the treatment of incontinence. Data were collected independently for 14 months on a secured server; 501 surgeries were registered and evaluated. Two hundred and sixty-four patients out of 479 (55.1%) returned for the physical examination and interview after 12–18 months. Main Outcome and Results: The mean duration of follow-up was 15 months. The overall success of apical repair was rated positively by 96.9%, and the satisfaction score was rated positively by 95.5%. A positive general recommendation was expressed by 95.1% of patients. Pelvic pressure was reduced in 95.2%, pain in 98.0%, and urgency in 86.0% of patients. No major complications, mesh exposure, or mesh complication occurred during the follow-up period. Conclusion: In clinical routine, pectopexy and concomitant surgery, mainly using native tissue approaches, resulted in high satisfaction rates and favorable clinical findings. The procedure may also be recommended for use by general urogynecological practitioners with experience in laparoscopy.

A modified Whitaker test (upper urinary tract videourodynamics) using for evaluating complex upper urinary tract reconstruction surgical effect.

BackgroundTo evaluate the feasibility and effect of upper urinary tract videourodynamics in complex reconstructed upper urinary tract.MethodsFrom January 2016 to December 2018, patients who underwent complex upper urinary tract reconstruction and received upper urinary tract videourodynamics were included in the study. The modified Whitaker test was performed at 3 months after operation. The relative pelvic pressure was defined as the pelvic pressure minus the bladder pressure. Based on the flow rate, the test was divided into physiological phase and high flow phase. The results of pressure and image were classified into 3 types. Successful nephrostomy removal was defined as no symptoms and improved or stable hydronephrosis.ResultsA total of 12 patients who underwent complex upper urinary tract reconstruction received modified Whitaker test. All tests were successfully completed without adverse reactions. The relative pelvic pressure of 3 patients kept steady near the baseline throughout the examination and was classified into type 1. The pelvic pressure of 7 patients increased as the perfusion continued, and the relative pressure dropped to relative low level due to the peristalsis of ureter (type 2). The pressure of 2 patients increased along with increasing perfusion speed, and the relative pelvis pressure could easily reach 15 cmH2O. The peristalsis of ureter disappeared or appeared very weakly on the video record (type 3). Patients in type 1 (3 cases) and type 2 (7 cases) groups were allowed to remove the nephrostomy tube immediately. Patients in type 3 group needed to keep the nephrostomy for close follow up, and the tubes were removed 2 weeks and 4 weeks after the examination, respectively. None of the 12 patients received further treatment for recurrent symptoms and exacerbation of hydronephrosis.ConclusionsThe modified Whitaker test is initially safe and feasible in postoperative evaluation of complex upper urinary tract reconstruction surgery. Detailed results can provide more evidence to judge whether nephrostomy tube could be removed safely.

Impact of fibroids on fertility rate. Surgical management and obstetric outcome

Background. Uterine fibroids are the most common benign tumor in reproductive-age women; when symptomatic, they typically cause pain or pelvic pressure, abnormal uterine bleeding and potential reproductive effects, such as infertility or adverse pregnancy outcome. The intramural and submucosal types produce most prejudice on actual or future pregnancies by distorting the uterine cavity, by affecting the implantation process, as well as by increasing the uterine contractility and producing endometrial inflammation. Myomectomy is cited as the most suitable surgical approach, with benefits and risks. Objectives. To determine the impact of fibroids on fertility rate and the obstetric outcomes of leiomyomas, together with establishing the proper surgical approach for each type, with its benefits. Materials and method. We performed a literature review by searching Cochrane and UpToDate databases, using the keywords: fibroids, fertility, pregnancy, obstetric outcome, myomectomy. Results. Intramural and submucosal fibroids are involved in decreasing implantation and pregnancy rates, with most frequent obstetric outcomes under the form of miscarriage, growth restriction and fetal abnormalities. Myomectomy is suggested to be the best surgical approach for women desiring to preserve fertility, with the possibility to be performed hysteroscopic, laparoscopic or by open surgery, depending on the type, size and clinical picture. Conclusions. Overall, there is an important impact of fibroids on fertility rate and obstetric outcome and hysteroscopic myomectomy performed prior to a pregnancy can improve the fertility rate. The mode of delivery should be individualized in case of myoma and pregnancy.

Massive Leiomyomata and Severe Endometriosis Resulting in a Frozen Pelvis in an Asymptomatic Patient

Leiomyomas, also known as uterine fibroids, are the most common benign uterine tumors in women. The most frequently reported symptoms are uterine bleeding and abdominal and/or pelvic pressure; however, most cases are asymptomatic and may be found incidentally. Endometriosis is a condition where the endometrium proliferates outside of the uterine cavity. Extrauterine endometrial implants are usually found in the ovaries, pelvis, and peritoneum, but can extend anywhere throughout the body. Women with endometriosis may exhibit dysmenorrhea, dyspareunia, dyschezia, and infertility. Inflammation caused by endometriosis may lead to fibrosis, scarring, and adhesions. We report a case of an asymptomatic 36-year-old African-American woman with increasing abdominal girth, consistent with a 28-week gestation, presenting to her obstetrician/gynecologist for her annual exam, who on further investigation is found to have multiple large fibroids, bilateral ovarian cysts, and widespread endometriosis with several adhesions ultimately leading to a frozen pelvis.