Periurethral Tissue Research Articles

Impact of Adding Urethral Sonography with Retrograde Urethrography in Preoperative Assessment of Anterior Urethral Stricture.

Even with underlying risk factors and limitations, retrograde urethrography (RGU) is the most popular imaging modality in the assessment of anterior urethral stricture. Urethral sonography (SUG) is an able imaging modality in use for the last few years which evaluates anterior urethral stricture without these risks, though it is still not much popular due to its complexity. This prospective study was designed to compare the assessment made on SUG with the results of RGU and to analyze its impact on surgical decision-making when the results of SUG were taken into consideration with RGU. Thirty patients with anterior urethral stricture were assessed for stricture location, length, and associated urethral pathologies with RGU and surgery planned accordingly. Later, all were reevaluated with SUG, results compared with that of RGU and surgery replanned, considering both RGU and SUG findings. All results were compared with operative findings. The mean stricture lengths on SUG, RGU, and surgery were 20.45 mm, 17.15 mm, and 20.38 mm, respectively. Overall sensitivity and specificity of SUG in actual stricture length prediction were 92.3% and 96.1%, whereas these were 78.9% and 85.1%, respectively, on RGU. Spongiofibrosis was assessed only with SUG, that too, with 85%-90% accuracy. Surgical plan was changed in 31% of cases when SUG findings were taken into account along with RGU findings. SUG was found more precise modality in the measurement of stricture length and more informative and elaborative in providing added knowledge of degree of spongiofibrosis and associated pathologies of diseased urethra and periurethral tissue. For better preoperative planning of anterior urethral strictures, SUG should be added to work-up along with RGU.

The Therapeutic Effect of Ginsenoside Rb1 against Mechanical Trauma in a Rat Model of Postpartum Stress Urinary Incontinence

Aims. The aim of this study was to confirm the repairing effect of ginsenoside Rb1 (GS-Rb1) on mechanical trauma to periurethral tissues caused by childbirth and to explore its potential preventive mechanisms for mechanical trauma-induced stress urinary incontinence. Methods. 48 healthy adult female Sprague–Dawley (SD) rats were randomly divided into four groups: normal control, SUI groups, L-GS-Rb1 groups, and H-GS-Rb1 groups, with 12 rats in each group. The histopathological examinations of the urethral were performed to detect the morphological changes after repair of periurethral traumatic tissue. The TGF-β1/Smad and NRF2/ARE signaling pathways related to periurethral tissue trauma repair were determined by RT-PCR and western blot. The bladder capacity and LPP were examined in rats. Results. GS-Rb1 significantly decreased the number of fragmented and disorganized elastic and muscle fibers in the urethra and anterior vaginal wall of SUI rats. GS-Rb1 also increased the collagen content and reduced damage to the structural integrity of the periurethral myofibers. Furthermore, GS-Rb1 promoted expressions of TGF-β1, Smad2, Smad3, Smad7, p-Smad3, p-Smad2, and collagens I and III. It also increased the protein levels of Nrf2, GPX1, and MnSOD. The bladder capacity and LPP of rats in the L-GS-Rb1 group were close to those of rats in the normal groups. Conclusions. Ginsenoside Rb1 promotes the repair of periurethral tissue trauma in the postpartum period and has a preventive effect on the occurrence of stress urinary incontinence.

Application of modified urethral separation method in artificial urethral sphincter implantation and its influence on intraoperative urethral pressure profilometry

Objective: To explore the application of modified urethral separation method in artificial urethral sphincter (AUS) implantation in patients with stress urinary incontinence (SUI), and its influence on the results of urethral pressure profilometry. Methods: A prospective collection of clinical data was conducted on 25 patients with stress urinary incontinence who underwent modified urethral separation method in AUS implantation and underwent urethral pressure profilometry in Beijing Hospital, Beijing Jishuitan Hospital Affiliated to Capital Medical University and the Second Hospital Affiliated to Tianjin Medical University from March 2019 to June 2023. The improved urethral separation method was to borrow part of the white membrane tissue of the cavernous body while freeing the dorsal side of the cavernous body of the urethra. The circumference of the urethra, sleeve size, and urethral pressure were recorded, the patient's autonomous urinary control before and after surgery and the changes of the international consultation on incontinence questionnaire-short form (ICI-Q-SF) score, incontinence quality of life questionnaire (I-QoL) score, urinary frequency score, nocturia score were compared. Follow-up was conducted in the clinic or by telephone at 1, 3, 6, and 12 months after activation of the device, and once a year thereafter. Local skin status and urine control were assessed, residual urine volume was measured by ultrasound and subjective score scale was completed. Results: All patients were male, aged 27-85 (65.8±15.7) years old. The circumference of the cuff used in this study was 4.0 cm in 4 patients (16.0%), 4.5 cm in 16 patients (64.0%), 5.0 cm in 4 patients (16.0%), and 5.5 cm in 1 patient (4.0%). Among them, the urethral circumference matched the cuff size in 14 cases (56.0%), the urethral circumference was smaller than the cuff size in 4 cases (16.0%), and the urethral circumference was larger than the cuff size in 7 cases (28.0%). Preoperative urodynamic examination showed that the maximum urethral pressure (MUP) was (78.0±25.9) cmH2O, (1 cmH2O=0.098 kPa) and the maximum urethral closure pressure (MUCP) was (53.4±26.6) cmH2O. The MUP of AUS device in the inactivated state was (88.0±26.5) cmH2O, which was not significantly higher than that before operation (P>0.05). The MUCP was (68.2±24.5) cmH2O, which was significantly higher than that before operation (P<0.05). The MUP and MUCP of the AUS device in the activated state were (146.6±25.2) cmH2O and (123.0±28.3) cmH2O, which were significantly higher than those before surgery and in the inactivated state (both P<0.001). All patients in the group reached the social urinary control standards at the first month of device activation. During a follow-up period of 2-50 months, 22 patients (88.0%) used the initial AUS device and all met social urinary control standards. The AUS device was replaced in 1 case. One patient died of cerebrovascular accident. One patient removed the device due to complications. The number of pads [M (Q1, Q3)] used in 25 patients before and after operation was 4.5 (3.0, 6.5) and 1 (0, 1) respectively, with statistically significant differences (P<0.001). ICI-Q-SF score, I-QoL score, urinary frequency score and nocturia score of 25 patients were significantly improved after surgery (all P<0.05). The incidence of postoperative complications was 20.0% (5/25), including 2 cases of painless hematuria, 1 case of infection, 1 case of urethral erosion, and 1 case of dysuria. Except for one patient who experienced urethral erosion and had his sleeve removed, the remaining four patients regained social urination control with active support treatment, and no symptoms recurred until the last follow-up. Conclusion: The modified urethral separation method has no significant effect on urethral pressure in patients with SUI, and can increase the volume of peri-urethral tissue in the cuff, thereby reducing the risk of intraoperative urethral injury and the incidence of postoperative urethral erosion.

Somatic and autonomic nerve density of the urethra, periurethral tissue, and anterior vaginal wall: an immunohistochemical study in adult female cadavers.

Retropubic procedures may disrupt nerves supplying the pelvic viscera; however, knowledge of pelvic neuroanatomy is limited. We sought to characterize somatic and autonomic nerve density within the urethra, periurethral tissue, and anterior vagina. Axial sections were obtained from pelvic tissue harvested from female cadavers ≤24 h from death at three anatomical levels: the midurethra, proximal urethra, and upper trigone. Periurethral/perivesical tissue was divided into medial and lateral sections, and the anterior vagina into middle, medial, and lateral sections. Double immunofluorescent staining for beta III tubulin (βIIIT), a global axonal marker, and myelin basic protein (MBP), a myelinated nerve marker, was performed. Threshold-based automatic image segmentation distinguished stained areas. Autonomic and somatic density were calculated as percentage of tissue stained with βIIIT alone, and with βIIIT and MBP respectively. Statistical comparisons were made using nonparametric Friedman tests. Six cadavers, aged 22-73, were examined. Overall, autonomic nerve density was highest at the midurethral level in the lateral and middle anterior vagina. Somatic density was highest in the external urethral sphincter (midurethra mean 0.15%, SD ±0.11; proximal urethra 0.19%, SD ±0.19). Comparison of annotated sections revealed significant differences in autonomic density among the lateral, medial, and middle vagina at the midurethra level(0.71%, SD ±0.48 vs 0.60%, SD ±0.48 vs 0.70%, SD ±0.63, p=0.03). Autonomic density was greater than somatic density in all sections. Autonomic and somatic nerves are diffusely distributed throughout the periurethral tissue and anterior vagina, with few significant differences in nerve density among sections analyzed. Minimizing tissue disruption near urethral skeletal muscle critical for urinary continence may prevent adverse postoperative urinary symptoms.

Small Extracellular Vesicles Secreted by Peri-urethral Tissues Regulate Fibroblast Function and Contribute to the Pathogenesis of Female Stress Urinary Incontinence.

This study aimed to explore the existence of small extracellular vesicles (sEVs) in peri-urethral tissues and the role of abnormal expression of sEVs in the pathogenesis of female stress urinary incontinence (SUI). sEVs were extracted from peri-urethral vaginal wall tissues using differential centrifugation and were observed by transmission electron microscopy (TEM). The number of sEVs and their protein contents were compared between SUI and control groups using nanoparticle tracking analysis (NTA) and bicinchoninic acid (BCA) protein assay. Fibroblasts were cultured separately with SUI (SsEVs group) and normal tissue sEVs (NsEVs group). Proliferation and migration of fibroblasts were compared between groups using CCK-8 and wound healing assays, respectively. Expression levels of collagen I and III were compared among blank control (BC), NsEVs, and SsEVs groups using real-time PCR. Protein mass spectrometry was used to test the differentially expressed proteins contained in sEVs between groups. sEVs were extracted and found under the electron microscope. There were significantly more sEVs extracted from the SUI group compared to the normal group. Fibroblasts showed increased proliferative and decreased migratory abilities, and expressed more collagen in the SsEVs group compared to the NsEVs and BC groups. Protein spectrum analysis demonstrated several differentially expressed targets, including components of microfibrils, elastin polymer, and anti-inflammatory factors. sEVs were detected in the peri-urethral tissues. SUI tissues expressed more sEVs than control. The abnormal expression of sEVs and their protein contents may contribute to the pathogenesis and progression of SUI.

(027) Considerations of Mid-Urethral Sling Procedures: Patient and Provider Perspectives on Outcomes and Experiences

Abstract Introduction The mid-urethral sling procedure (MUSP) treats symptoms of stress urinary incontinence. Recent studies have identified the potential for negative outcomes following MUSP; however, there is a limited understanding of the patient and healthcare provider perspectives on procedural experiences and outcomes. Specifically, there is discordance surrounding the role of female periurethral tissue in sexual responses, and limited knowledge of post-MUSP outcomes and symptoms as perceived by patients. Further understanding of current counselling and resource practices is needed, especially regarding informed consent and risk disclosure. Objective To investigate the experiences associated with MUSP from patients who have reported bothersome symptoms following MUSP, and from providers who routinely perform the procedure. Furthermore, to characterize recent patient experiences, explore factors which may influence current provider decision-making, and outline patient-used and provider-recommended counselling and resources. Methods Patients (n=10) who underwent MUSP and reported negative outcomes, and providers (n=22) with experience performing MUSP were recruited. Patients first completed an online survey which captured demographic information, medical history, and sexual function. Both patients and providers completed semi-structured interviews relating to MUSP outcomes and experiences. Interview responses were transcribed using Trint, and qualitative analyses were completed using NVivo 12. Results Perspectives and experiences gathered from patient and provider interviews revealed discordant narrative surrounding MUSP outcomes and treatment. Analysis of patient narratives revealed a unique symptom profile including periurethral pain and numbness, altered lubrication and loss of desire. In addition, patients discussed post-MUSP infections, as well as pain, weakness, and lower limb impairment having impacts on and extending to other aspects of life, including social relationships, work obligations, and day-to-day responsibilities. Patients described a preference for informed pre-procedural care, and supportive and comprehensive post-procedural counselling. Provider narratives revealed aims of fostering open discussions and efforts to offer procedural support. However, providers referenced limitations in time, experience, and understanding of the adverse outcome symptom profile. Further, regarding post-procedural care, both providers and patients discussed limitations in currently available counselling routes and resources. Conclusions The results of this study highlight discordance between the perceptions of patients and providers regarding MUSP outcomes and experiences. There are differences in the understanding of post-MUSP negative outcome experiences as perceived by patients, compared to providers. These findings support the need for improvements in post-MUSP support and targeted counselling, and resources. Differences in the knowledge of symptoms and negative outcome experiences as related to sexual function are emphasized in this context, highlighting, and encouraging the need for improvements in clinical practice which includes sexual health conversations and accessible resources. Disclosure No

(025) Disclosure of Mid-Urethral Sling and Radical Prostatectomy Risks: A Comparative Analysis of Hospital-Affiliated Online Resources

Abstract Introduction Radical prostatectomy (RP) involves the removal of the prostate gland to treat cancer. The mid-urethral sling (MUS) procedure, used to correct symptoms of stress urinary incontinence in women, affects anterior vaginal wall female periurethral tissue (AVW-FPT). Glandular structures in AVW-FPT have similar immunohistochemistry to prostatic tissue. Erectile dysfunction and female orgasmic disorder have been reported following RP and MUS, respectively. The disclosure of these, and other associated risks, in patient education materials has yet to be assessed. Further investigation is required to determine if and how risk information reported in the literature is presented to patients, as it may impact the ability of patients to make informed health-related decisions. Objective To assess the level of knowledge translation to patients of reported risks associated with MUS and RP procedures in hospital affiliated online resources (HAORs) from Canada, Australia, and the United Kingdom, and to evaluate the accessibility of this information using validated measures of health literacy. Methods A list of healthcare institutions in Canada, Australia, and the UK was generated. RP and MUS-specific HAORs were collected from all institutions. Qualitative analysis of 35 HAORs (RP n=20 and MUS n=15) was conducted using NVivo12. The Patient Education Materials Assessment Tool- Print version (PEMAT-P), was used to determine understandability and actionability, and the Flesch-Kincaid Grade Level (FKGL), Gunning Fox Index (GFI), and Simple Measure of Gobbledygook (SMOG) were used to assess the readability. Results Most RP and MUS HAORs were written higher than the recommended grade 5/6 reading level and were below the threshold values for understandability and actionability. The majority of Canadian MUS HAORs met the adequate threshold values for understandability and actionability, unlike the MUS HAORs from Australia and the UK and the RP resources from all three regions. There was inconsistency between the risks reported in the RP and MUS HAORs from Canada and Australia compared to the risks commonly reported in literature. The organization of information including the use of diagrams and medical jargon in the HAORs differed between RP and MUS documents and across the three regions. RP HAORs used diagrams more consistently than MUS HAORs and scored higher on measures of understandability and actionability. The RP and MUS HAORs from the three regions that used medical jargon scored lower on measures of readability. There was inconsistency in the reporting of sexual health risks between the RP and MUS HAORs in all three regions. MUS HAORs less consistently reported sexual health risks following surgery compared to RP HAORs. Conclusions HAORs are important means by which health-related information is translated to patients. There were inconsistencies in the risk information reported for RP versus MUS in Canada, Australia, and the UK. This discordance may impact patient decision-making and health outcomes. The development of guidelines for HAORs curation for healthcare institutions operating under similar healthcare frameworks may be beneficial in ensuring equal access to health information for all patients. Disclosure No

Rectifying disorder of extracellular matrix to suppress urethral stricture by protein nanofilm-controlled drug delivery from urinary catheter

Urethral stricture secondary to urethral injury, afflicting both patients and urologists, is initiated by excessive deposition of extracellular matrix in the submucosal and periurethral tissues. Although various anti-fibrotic drugs have been applied to urethral stricture by irrigation or submucosal injection, their clinical feasibility and effectiveness are limited. Here, to target the pathological state of the extracellular matrix, we design a protein-based nanofilm-controlled drug delivery system and assemble it on the catheter. This approach, which integrates excellent anti-biofilm properties with stable and controlled drug delivery for tens of days in one step, ensures optimal efficacy and negligible side effects while preventing biofilm-related infections. In a rabbit model of urethral injury, the anti-fibrotic catheter maintains extracellular matrix homeostasis by reducing fibroblast-derived collagen production and enhancing metalloproteinase 1-induced collagen degradation, resulting in a greater improvement in lumen stenosis than other topical therapies for urethral stricture prevention. Such facilely fabricated biocompatible coating with antibacterial contamination and sustained-drug-release functionality could not only benefit populations at high risk of urethral stricture but also serve as an advanced paradigm for a range of biomedical applications.

V07-02 URETHRAL BULKING WITH NATIVE TISSUE FOR FRAIL URETHRAS DURING ARTIFICIAL URINARY SPHINCTER SURGERY

You have accessJournal of UrologyCME1 Apr 2023V07-02 URETHRAL BULKING WITH NATIVE TISSUE FOR FRAIL URETHRAS DURING ARTIFICIAL URINARY SPHINCTER SURGERY William Du Comb, Nora Haney, Matthew Rabinowitz, James Liu, and Arthur Burnett William Du CombWilliam Du Comb More articles by this author , Nora HaneyNora Haney More articles by this author , Matthew RabinowitzMatthew Rabinowitz More articles by this author , James LiuJames Liu More articles by this author , and Arthur BurnettArthur Burnett More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003288.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The artificial urinary sphincter (AUS) has long been the ideal surgical treatment option for men with stress urinary incontinence (SUI) and has excellent patient satisfaction rates. However, revision rates remain as high as 50%. We describe our use of native periurethral tissue as a urethral bulking technique in patients with frail urethras during AUS surgery. METHODS: An AUS is inserted or revised in the usual standard fashion. The state of the urethral tissue is inspected, and the circumference is measured. When the urethral circumference is less than 4 cm or the urethral tissue is frail, periurethral tissue bulking is performed. Dissection of the bulbospongiosus muscle is carried out at the level of the bulbar urethra, incorporating it with a circumferential measurement. In the event the bulbospongiosus muscle is inadequate for bulking, the proximal corpus spongiosum is mobilized distally as a ventral flap, beneath the circumferential measurement. The AUS size is then selected. RESULTS: Using native periurethral tissue for urethral bulking can add up to 1 cm in cuff size when placing an AUS in patients with frail urethras. Patient satisfaction rates remain high, and there has been no documented device erosion with our technique. CONCLUSIONS: We have demonstrated an alternative approach to urethral bulking with native periurethral tissue in patients undergoing AUS placement who are found to have frail urethras. Urethral bulking with native tissue provides a durable alternative to transcorporal cuff placement or tandem cuffs to establish proper coaptation. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e596 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information William Du Comb More articles by this author Nora Haney More articles by this author Matthew Rabinowitz More articles by this author James Liu More articles by this author Arthur Burnett More articles by this author Expand All Advertisement PDF downloadLoading ...

V10-10 NOVEL TECHNIQUE: PERIVESICAL FAT ROTATIONAL FLAP FOR RECTAL INTERPOSITION COVERAGE IN SALVAGE ROBOTIC RADICAL PROSTATECTOMY

You have accessJournal of UrologyCME1 Apr 2023V10-10 NOVEL TECHNIQUE: PERIVESICAL FAT ROTATIONAL FLAP FOR RECTAL INTERPOSITION COVERAGE IN SALVAGE ROBOTIC RADICAL PROSTATECTOMY Alexander Hwang, Matthew Watson, Michael Tonzi, and Amar Singh Alexander HwangAlexander Hwang More articles by this author , Matthew WatsonMatthew Watson More articles by this author , Michael TonziMichael Tonzi More articles by this author , and Amar SinghAmar Singh More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003328.10AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The 21st-century urologic oncologist has a spectrum of treatment modalities for localized prostate cancer that can be tailored to patients. For patients with low-risk prostate adenocarcinoma, multiple non-prostatectomy treatment options include whole-gland radiotherapy, brachytherapy, proton therapy, cryotherapy, and high-intensity focused ultrasound (HIFU) therapy. Salvage therapies for recurrent localized prostate cancer include surgical (e.g. radical prostatectomy and cystoprostatectomy) and non-surgical (e.g. whole-gland brachytherapy, whole-gland cryotherapy, and whole-gland HIFU). Surgical salvage therapies are plagued with significant morbidity carrying the increased risk for urinary incontinence (>50% requiring use of pads) rectal injuries (3.3-50% requiring diversion in setting of radiation), and anastomotic stricture (17-32%) (1). METHODS: We describe a 67-year-old male who initially presented to our practice after undergoing whole-gland HIFU due to biopsy proven grade group 1 prostate cancer. Unfortunately, he developed biochemical recurrence with a PSA of 2.0 and biopsy discovered grade group 3 localized prostate cancer. After discussing the associated risks, the patient elected to undergo a salvage robotic radical prostatectomy (sRRP). We modified our sPPP approach by performing a posterior dissection to free the seminal vesicles prior to dropping the bladder which allowed us to mobilize our flap through the posterior defect and interpose the flap over the anterior rectal wall and tether it to periurethral tissue with absorbable suture. Please see accompanying video for procedural details. RESULTS: The patient had a negative cystogram and denied bowel or urinary symptoms. He presented to the emergency department 3 months post-operatively complaining of nonspecific abdominal pain and computed tomography demonstrated the perivesical flap appropriately interposed in its new heterotopic location. CONCLUSIONS: The perivesical tissue flap is an anatomically accessible and vascularized tissue that can be mobilized to interpose between a radiated, tenuous anterior rectal wall and vesicourethral anastomosis to reinforce perfusion and prevent fistulas. This technique allows expansion to the armamentarium of reconstructive urology. Source of Funding: No sources of funding to disclose. © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e929 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Alexander Hwang More articles by this author Matthew Watson More articles by this author Michael Tonzi More articles by this author Amar Singh More articles by this author Expand All Advertisement PDF downloadLoading ...

V09-07 HOW TO USE A MESH SLING SAFELY AFTER THE POST-VESICOVAGINAL FISTULA REPAIR REPAIR PATIENT WITH STRESS URINARY INCONTINENCE

You have accessJournal of UrologyCME1 Apr 2023V09-07 HOW TO USE A MESH SLING SAFELY AFTER THE POST-VESICOVAGINAL FISTULA REPAIR REPAIR PATIENT WITH STRESS URINARY INCONTINENCE Micheal Breen Tamatave, Madagascar, Ly Hoang Roberts, and Larry Sirls Micheal Breen Tamatave, MadagascarMicheal Breen Tamatave, Madagascar More articles by this author , Ly Hoang RobertsLy Hoang Roberts More articles by this author , and Larry SirlsLarry Sirls More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003317.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Patients with complicated obstetric fistulas may have stress urinary incontinence (SUI) after vesicovaginal fistula repair (VVF), especially if the urethra in involved. Various techniques to treat post-VVF SUI have low success rates or is technically challenging due to thin and scarred peri-urethral tissue. We describe a technique to place a midurethral mesh sling outside of the pre-existing vaginal mucosa. METHODS: With the patient in dorsal lithotomy under spinal anesthesia, a foley catheter is placed into the bladder and the labial majora is retracted for adequate exposure. A rectangular area of the same size as the mesh sling (3x1cm) at the midurethra is marked. A number 15 scalpel is used to incise the vaginal mucosa at the marked lines, and Metzenbaum scissors are used to dissect and mobilize the edges. The dissection is then carried out laterally to be behind the inferior pubic bone. This is done on both sides. The island of vaginal mucosa is then superficially scored using low power bovie cauterization to allow for mesh adhesion and tissue ingrowth. The mesh is sutured to the island of skin using a 3-0 Chromic or vicryl suture at the mesh edges in 4 areas. 0- prolen sutures are then placed on each lateral edge of the mesh in a running stitch. The Metzenbaum scissors are then used to enter into the endopelvic fascia behind the pubic bone to develop the retropubic space. Next, a suprapubic incision is made 1cm cranial to the pubic bone down to the rectus fascia. The Stamey needle is passed in a top-down approach approximately 2cm from midline and end delivered into the vaginal incision. To check for bladder perforation, a metal catheter is placed into the bladder and swept laterally to evaluate for any metallic noise indicative of contact. The prolene suture is passed up to the suprapubic incision and the same is done contralaterally. Bladder is backfilled with sterile saline with methylene blue by gravity and foley removed. Sutures are tied together midline with the sling tension adjusted while patient performs a Valsalva. Suprapubic incision is then closed in multiple layers. The vaginal incision is closed with mobilization of the proximal vaginal mucosa and reapproximation to the distal edge. For larger incisions, a Singapore flap can be done for adequate coverage. RESULTS: Successful managment of SUI. CONCLUSIONS: For challenging cases of SUI after a post-VVF repair, this technique can be an option. Further investigation is needed for clinical outcomes. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e839 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Micheal Breen Tamatave, Madagascar More articles by this author Ly Hoang Roberts More articles by this author Larry Sirls More articles by this author Expand All Advertisement PDF downloadLoading ...

Somatic and autonomic nerve distribution of the urethra, periurethral tissue, and anterior vaginal wall: an immunohistochemical study in adult female cadavers

Somatic and autonomic nerve distribution of the urethra, periurethral tissue, and anterior vaginal wall: an immunohistochemical study in adult female cadavers

The prostate in women: an updated histological and immunohistochemical profile of the female periurethral glands and their relationship to an implanted midurethral sling.

There is evidence of glandular tissue in the region of the anterior vaginal wall-female periurethral tissue (AVW-FPT) that has similar morphology and immunohistochemistry to the prostate in men. Surgical injury to this tissue has been suggested as a potential cause of sexual dysfunction following midurethral sling (MUS) procedures. However, the anatomy and embryology of these glands have not been fully resolved. This has led to difficulties in classifying this tissue as a prostate and defining its clinical significance related to MUS procedures. To describe the histological and immunohistochemical characteristics of the female periurethral glands using markers of prostate tissue and innervation and to examine their anatomical relationships to an implanted MUS. Using gross and fine dissection, the AVW-FPT was dissected from 9 cadavers. Prior to dissection, 2 cadavers underwent simulation of the MUS procedure by a urogynecologist. Samples were paraffin embedded and serially sectioned. Immunohistochemistry was performed using markers of prostate tissue and innervation. Immunohistochemical localization of markers for prostatic tissue and innervation of the glandular tissue of the AVW-FPT, including the region of MUS implantation. Female periurethral glands were immunoreactive for markers of male prostatic tissue, including prostate-specific antigen, androgen receptor, HOXB13, and NKX3.1. Markers of innervation (protein gene product 9.5, choline acetyl transferase, and vasoactive intestinal polypeptide) also localized to certain regions of the glandular tissue and associated blood supply. Surgical simulation of the MUS procedure demonstrated that some periurethral glands are located in close proximity to an implanted sling. The AVW-FPT contains glandular tissue in the surgical field of MUS implantation. Iatrogenic damage to the female periurethral glands and the associated innervation during surgery could explain the negative impacts on sexual dysfunction reported following MUS procedures. This is the first study to characterize the female periurethral glands using markers of prostatic tissue in concert with markers of general and autonomic innervation and characterize their anatomical relationships within the surgical field of MUS implantation. The small sample size is a limitation of this study. We provide further evidence that the AVW-FPT contains innervated glands that are phenotypically similar to the male prostate and may share a common embryonic origin. The microscopic and immunohistochemical features of the periurethral glands may be indicative of their functional capacity in sexual responses. The location of these glands in the surgical field of MUS procedures underscores the clinical significance of this tissue.

The Use of Preputial Dartos Flap in the Primary Repair of Distal Hypospadias: A Single-centre Experience.

An additional flap during the tubularization of incised urethral plate urethroplasty (TIPU) is believed to minimize the postoperative complications. It is still debatable whether using an additional flap is worth the risk given the hazards associated with doing so. This study aims to re-evaluate the benefits and drawbacks of TIPU with or without a preputial dartos (PD) flap. We assessed the results of patients with distal hypospadias who underwent surgery in our institute over the past 2 years. The urethral plate's width, thickness, and depth, the periurethral tissue's quality, and the width of the glans at the mid-glans level determined whether the neourethra was covered with a PD flap or left uncovered. Data on intra-operative blood loss, operating time, length of hospital stay, postoperative complications, and outcome were analysed. There were 96 patients: 58 received an extra PD flap, whereas the other 38 did not. In the flap group, ventral skin necrosis was a prevalent problem, whereas meatal stenosis predominated in the no-flap group. Both the flap group (25.66%) and the no-flap group (23.86%) experienced comparable postoperative complications (P = 0.503). In comparison to the no-flap group, the flap group showed statistically significant differences (P<0.001) in intra-operative blood loss (22.10 ± 6.96 vs. 10.34 ± 3.02 mL), operating time (96.34 ± 6.661 vs. 71.39 ± 9.76 min), and hospital stay (10.04 ± 0.87 vs. 8.47 ± 1.64 days). The additional PD flap does not always affect the result of TIPU in terms of complications.

The IL-4/IL-13 signaling axis promotes prostatic fibrosis.

BackgroundLower urinary tract symptoms (LUTS) are a costly and pervasive medical problem for millions of aging men. Recent studies have showed that peri-urethral tissue fibrosis is an untreated pathobiology contributing to LUTS. Fibrosis results from excessive extracellular matrix deposition which increases transition zone and peri-urethral tissue stiffness and compromises prostatic urethral flexibility and compliance, producing urinary obstructive symptoms. Inflammatory cells, including neutrophils, macrophages, and T-lymphocytes, secrete a medley of pro-fibrotic proteins into the prostatic microenvironment, including IFNγ, TNFα, CXC-type chemokines, and interleukins, all of which have been implicated in inflammation-mediated fibrosis. Among these, IL-4 and IL-13 are of particular interest because they share a common signaling axis that, as shown here for the first time, promotes the expression and maintenance of IL-4, IL-13, their cognate receptors, and ECM components by prostate fibroblasts, even in the absence of immune cells. Based on studies presented here, we hypothesize that the IL-4/IL-13 axis promotes prostate fibroblast activation to ECM-secreting cells.MethodsN1 or SFT1 immortalized prostate stromal fibroblasts were cultured and treated, short- or long-term, with pro-fibrotic proteins including IL-4, IL-13, TGF-β, TNF-α, IFNγ, with or without prior pre-treatment with antagonists or inhibitors. Protein expression was assessed by immunohistochemistry, immunofluorescence, ELISA, immunoblot, or Sircoll assays. Transcript expression levels were determined by qRT-PCR. Intact cells were counted using WST assays.ResultsIL-4Rα, IL-13Rα1, and collagen are concurrently up-regulated in human peri-urethral prostate tissues from men with LUTS. IL-4 and IL-13 induce their own expression as well as that of their cognate receptors, IL-4Rα and IL-13Rα1. Low concentrations of IL-4 or IL-13 act as cytokines to promote prostate fibroblast proliferation, but higher (>40ng/ml) concentrations repress cellular proliferation. Both IL-4 and IL-13 robustly and specifically promote collagen transcript and protein expression by prostate stromal fibroblasts in a JAK/STAT-dependent manner. Moreover, IL-4 and IL-13-mediated JAK/STAT signaling is coupled to activation of the IL-4Rα receptor.ConclusionsTaken together, these studies show that IL-4 and IL-13 signal through the IL-4Rα receptor to activate JAK/STAT signaling, thereby promoting their own expression, that of their cognate receptors, and collagens. These finding suggest that the IL-4/IL-13 signaling axis is a powerful, but therapeutically targetable, pro-fibrotic mechanism in the lower urinary tract.

V07-07 ANATOMICAL ROBOTIC-ASSISTED RADICAL PROSTATECTOMY: STEP-BY-STEP NERVE-SPARING TECHNIQUE FOR DIFFERENT GRADES OF PRESERVATION

You have accessJournal of UrologyCME1 May 2022V07-07 ANATOMICAL ROBOTIC-ASSISTED RADICAL PROSTATECTOMY: STEP-BY-STEP NERVE-SPARING TECHNIQUE FOR DIFFERENT GRADES OF PRESERVATION Marcio Covas Moschovas, Travis Rogers, Jonathan Noel, Jaber Abdel, Seetharam Bhat, and Vipul Patel Marcio Covas MoschovasMarcio Covas Moschovas More articles by this author , Travis RogersTravis Rogers More articles by this author , Jonathan NoelJonathan Noel More articles by this author , Jaber AbdelJaber Abdel More articles by this author , Seetharam BhatSeetharam Bhat More articles by this author , and Vipul PatelVipul Patel More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002598.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Over the years, since Binder and Kramer described the first Robotic-assisted Radical Prostatectomy (RARP) in 2000, different Nerve-sparing (NS) techniques have been proposed by several authors. However, even with the robotic surgery advantages, functional outcomes following RARP, especially erection recovery, still challenge surgeons and patients. In this scenario, we have described different ways and grades of neurovascular bundle preservation (NVB) using the prostatic artery as a landmark until our most recent technique with lateral prostatic fascia preservation and modified apical dissection. In this video compilation, we have illustrated the details of different grades of NVB preservation. METHODS: Our video describes the details of different degrees of nerve-sparing using anatomical landmarks. We have illustrated the key aspects of a full nerve sparing, partial nerve sparing and intrafascial dissection preserving the lateral prostatic fascia. RESULTS: After the anterior and posterior bladder neck dissection, we lift the prostate by the seminal vesicles to access the posterior aspect of the prostate. Then, we incise the Denonvilliers layers and work between an avascular plane to release the posterior NVB from 5 to 1 and 7 to 11 o’clock positions on the right and left sides, respectively. In sequence, we access the prostate anteriorly by incising the endopelvic fascia bilaterally (close to the prostate) until communicating the anterior and posterior planes. Finally, we control the prostatic pedicles with Hem-o-lok clips and then proceed for the apical dissection preserving the maximum amount of urethra length and periurethral tissues. CONCLUSIONS: Potency recovery following radical prostatectomy remains a challenge due to its multifactorial etiology. However, basic concepts for nerve-sparing are crucial to achieving optimal outcomes, such as minimizing the amount of traction used on dissection, avoiding excessive cautery, and neural preservation based on anatomical landmarks (arteries and planes of dissection). Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e661 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Marcio Covas Moschovas More articles by this author Travis Rogers More articles by this author Jonathan Noel More articles by this author Jaber Abdel More articles by this author Seetharam Bhat More articles by this author Vipul Patel More articles by this author Expand All Advertisement PDF downloadLoading ...

Should We Call It a Prostate? A Review of the Female Periurethral Glandular Tissue Morphology, Histochemistry, Nomenclature, and Role in Iatrogenic Sexual Dysfunction

There is evidence of glandular tissue within the region of the anterior vaginal wall-female periurethral tissue (AVW-FPT) having similar morphology and immunohistochemistry to the prostate in men and having physiological roles in the female sexual response (FSR). Whether this tissue should be called a prostate in women has been debated. Iatrogenic injury to structures of the AVW-FPT, including these glands and the associated neurovasculature, could be a cause of female sexual dysfunction (FSD). To consolidate the current knowledge concerning the glandular tissue surrounding the urethra in women, evidence was reviewed to address whether: (i) these glands comprise the prostate in women, (ii) they have specific functions in the FSR, and (iii) injury to the AVW-FPT and prostate has sexual dysfunction as a likely outcome. A literature review was conducted using keywords including female prostate, Skene's/paraurethral glands, periurethral tissue, Gräfenberg (G)-spot, female ejaculation, mid-urethral sling (MUS), and sexual dysfunction. Histological and immunohistochemical studies of the glandular tissue surrounding the urethra support the existence of prostate in women. Evidence suggests this tissue may have physiologically and clinically relevant autonomic and sensory innervation, and during sexual arousal may contribute to secretions involved in ejaculation and orgasm. Gaps in knowledge relating to the functional anatomy, physiological roles, and embryological origins of this tissue have impeded the acceptance of a prostate in women. Injury to the innervation, vasculature, and/or glandular tissue within the surgical field of MUS implantation suggests iatrogenic sexual dysfunction is plausible. Continuing to advance our understanding of the morphology, histochemistry, and physiologic capacity of this glandular tissue will clarify the characterization of this tissue as the "prostate" involved in the FSR, and its role in FSD following surgical injury. Tomalty D, Giovannetti O, Hannan J, etal. Should We Call It a Prostate? A Review of the Female Periurethral Glandular Tissue Morphology, Histochemistry, Nomenclature, and Role in Iatrogenic Sexual Dysfunction. Sex Med Rev 2022;10:183-194.

Role of magnetic resonance imaging in the management of male pelvic fracture urethral injury.

The management of male pelvic fracture urethral injury remains a urological challenge. Pelvic fracture urethral injury can be associated with sequelae, such as urethral gap, erectile dysfunction and urinary incontinence. Delayed anastomotic urethroplasty, the gold standard treatment for urethral gaps caused by pelvic fracture urethral injuries, is technically demanding, and reconstructive urologists should preoperatively obtain as much detailed anatomical information as possible. A combination of antegrade and retrograde urethrography is the fundamental preoperative evaluation, but it cannot accurately assess the urethral gap length, the degree of lateral prostatic displacement, the anatomical relationship of the urethra with its surrounding structures (such as the rectum and dorsal venous complex) or periurethral problems (such as minor fistulae or cavitation). To make up for these limitations of urethrography, magnetic resonance imaging has emerged as a non-invasive, multiplanar and high-resolution modality for the evaluation of pelvic fracture urethral injury. Magnetic resonance imaging has excellent soft-tissue contrast, and can clearly show the urethra and periurethral tissues without the effects of radiation, thus enabling clinicians to anticipate the required ancillary techniques for delayed anastomotic urethroplasty and to predict functional outcomes, such as erectile function and urinary continence, after delayed anastomotic urethroplasty. This review discusses the role of magnetic resonance imaging in the evaluation of pelvic fracture urethral injury and its impact on patient management.

Urethroplasty in a post irradiation urethral stricture - a review

Radiotherapy-induced urethral strictures (RIUS) decrease quality of life and present a great challenge for surgical reconstruction, especially due to proximal location, compromised vascular supply, and poor wound healing. It is unclear whether urethroplasty is an option in cases with stricture resulting from exposure to pelvic radiation. We review the pathophysiology, diagnostic workup, and disease-specific aspects of RIUS. Furthermore, we discuss several management alternatives such as excision and primary anastomosis, as well as techniques for open reconstruction with flaps. The most extensive techniques in the treatment of strictures include, for example, those using gracilis muscle flaps, as they can involve periurethral tissue to provide sufficient vascularity for excellent post-surgery urethral healing. In brief, RIUS represent a significant challenge. In carefully chosen patients, urethroplasty should be considered as a feasible and durable treatment. However, medical practitioners should always take into consideration that the results of urethroplasty in RIUS are not comparable to urethroplasties without a radiation background.

Immunohistochemical Investigation of Autonomic and Sensory Innervation of Anterior Vaginal Wall Female Periurethral Tissue: A Study of the Surgical Field of Mid-Urethral Sling Surgery Using Cadaveric Simulation

Female sexual dysfunction, including female orgasm disorder, has been reported following mid-urethral sling (MUS) surgery to treat bothersome stress urinary incontinence. Anterior vaginal wall-female periurethral tissue (AVW-FPT) likely contains autonomic and sensory innervation involved in the female sexual response, and injury to these nerves may result from MUS implantation. To characterize, using fresh cadaveric tissue, autonomic and sensory nerves in AVW- FPT using immunohistochemistry (IHC), and to assess their proximity to an implanted MUS. AVW-FPT was excised following careful dissection from four fresh cadavers. Prior to dissection, one cadaver underwent simulation of the MUS procedure by a urogynegologist, using a fascial sling. All samples were paraffin embedded, sectioned, and stained with hematoxylin. Serial sectioning and IHC were performed to identify nerves. IHC markers were used to characterize the sensory and autonomic innervation. IHC localization of autonomic and sensory nerve markers consistent with neural tissue within the region of MUS implantation. IHC of AVW-FPT using protein gene product 9.5 (PGP9.5), a general nerve stain, revealed innervation throughout the region targeted by the MUS implantation. More specifically, immunoreactivity for both autonomic (tyrosine hydroxylase, TH) and sensory (Nav1.8 and S100ß) nerves were found in close proximity (<1 mm) to the implanted MUS. In addition, a subset of S100ß positive nerves also showed immunoreactivity for calcitonin gene-related peptide (CGRP). Combining the IHC findings with the surgical simulation of the MUS implantation revealed the potential for damage to both autonomic and sensory nerves as a direct result of the MUS procedure. The identified autonomic and sensory nerves of the AVW-FPT may contribute to the female sexual response, and yet are potentially negatively impacted by MUS procedures. Given that surgeries performed on male genital tissue, including the prostate, may cause sexual dysfunction secondary to nerve damage, and that urologists routinely provide informed consent regarding this possibility, urogynaecologists are encouraged to obtain appropriate informed consent from prospective patients undergoing the MUS procedure. This is the first study to characterize the sensory and autonomic innervation within the surgical field of MUS implantation and demonstrate its relationship to an implanted MUS. The small sample size is a limitation of this study. The present study provides evidence of potential injury to autonomic and sensory innervation of AVW-FPT as a consequence of MUS implantation, which may help explain the underlying mechanisms involved in the reported post-operative female sexual dysfunction in some women.