Sphincter Zone Research Articles

FR02-05 THE EVOLUTION OF MANAGEMENT OF MALE URINARY INCONTINENCE

INTRODUCTION AND OBJECTIVE: The struggle to treat male urinary incontinence (UI) dates back centuries, with descriptions of UI in Egyptian manuscripts as early as 1500 BCE. In this review, we chronicle the history of UI interventions that have educated the modern options available to us today. METHODS: A comprehensive literature review was performed to elucidate relevant historical and clinical information. RESULTS: Various strategies have been employed for managing UI, including storage and barrier devices, urethral bulking agents, and surgical implants. While storage devices in some form have been used for centuries, French surgeon Ambrose Pare is credited with developing the first portable urinals in 1564. In the 1600s, Wilhelm Hildanus, ‘father of German surgery’, created the first documented condom catheter and the first penile clamp. A modern version of his invention, the Cunningham Clamp, was popularized in the 1980s. Urethral bulking agents for treating UI have been used since the late 19th century. Dr. Robert Gersuny, a surgeon famous for his discovery of paraffin and Vaseline as media for injection, attempted to cure UI by injecting paraffin into periurethral tissue with mixed outcomes. Since then, various bulking agents have been shown to improve coaptation of the sphincteric zone. Lorenz Heister invented the first recorded surgical device for compressing the bulbar urethra to treat UI in 1747. Two hundred years later, Frederic Foley created a urinary sphincter, which was worn around a surgically isolated segment of corpus spongiosum. In the 1960s, surgeons attempted to reduce UI by attaching the 7th rib to the pubic bone to reduce undesired voiding. In 1973, F. Brantley Scott created the first multi-component artificial urinary sphincter (AUS), which remains the benchmark therapy for UI today. In the 1960s, John Berry described an acrylic mesh urethral sling, which was implanted ventrally into the bulbar urethra and attached to the pubic ramus. Joseph Kaufman invented a similar silicone sling in the 1970s. Early on, these devices were fraught with complications, including urethral erosion, fistulas, and pain. More recently, the transobturator male sling, which came to market during the 2000s, has become an option for select men. CONCLUSIONS: The modern devices we use for the treatment of IU are evolutionary byproducts of centuries of experimental designs by pioneering surgeons from around the world. While the materials have improved, barriers, storage devices and bulking agents almost identical to the versions first invented remain in use today. The electronic AUS will usher in the next phase of advancement in this field. Source of Funding: None.

Vaginal Anatomy on MRI: New Information Obtained Using Distention.

To demonstrate and confirm the presence of three anatomic zones of the vagina (a superficial sphincteric zone; a central wedge shaped transition zone; and a deep, expanded forniceal zone) using pelvic magnetic resonance imaging with contrast distention of the vagina. A total of 107 consecutive female pelvic magnetic resonance imaging scans using vaginal contrast distention were retrospectively reviewed. The images were observed for the three-zone configuration. Anteroposterior and transverse diameter measurements were taken in the proximal, mid, and distal sphincteric, transition, and forniceal zones. Means and standard deviations were calculated at each site. Adjacent sites were compared using paired t tests. The three-zone configuration was observed in all of the cases but one. Statistically significant increases and decreases of mean anteroposterior diameters occurred at all levels expected by visual observation. The three-zone configuration of the distended vagina was confirmed by this study. The configuration of the vagina is more complex than has been reported previously. This configuration may facilitate parturition and may be useful in the design of intravaginal devices.

Biomechanical properties of an implanted engineered tubular gut-sphincter complex.

Neuromuscular diseases of the gut alter the normal motility patterns. Although surgical intervention remains the standard treatment, preservation of the sphincter attached to the rest of the gut is challenging. The present study aimed to evaluate a bioengineered gut-sphincter complex following its subcutaneous implantation for 4weeks in rats. Engineered innervated human smooth muscle sheets and innervated human sphincters with a predefined alignment were placed around tubular scaffolds to create a gut-sphincter complex. The engineered complex was subcutaneously implanted in the abdomen of the rats for 4weeks. The implanted tissues were vascularized. In vivo manometry revealed luminal pressure at the gut and the sphincter zone. Tensile strength, elongation at break and Young's modulus of the engineered complexes were similar to those of native rat intestine. Histological and immunofluorescence assays showed maintenance of smooth muscle circular alignment in the engineered tissue, maintenance of smooth muscle contractile phenotype and innervation of the smooth muscle. Electrical field stimulation induced relaxation of the smooth muscle of both the sphincter and the gut parts. Relaxation was partly inhibited by nitric oxide inhibitor indicating nitrergic contribution to relaxation. The present study has demonstrated for the first time a successfully developed and subcutaneously implanted a tubular human-derived gut-sphincter complex. The sphincteric part of Tubular Gut-Sphincter Complex (TGSC) maintained the basal tone characteristic of a native sphincter. The gut part also maintained its specific neuromuscular characteristics. The results of this study provide a promising therapeutic approach to restore gut continuity and motility. Copyright © 2016 John Wiley & Sons, Ltd.

Jackhammer esophagus: Observations on a European cohort.

With the advent of high-resolution manometry (HRM), a new diagnosis, jackhammer esophagus, was introduced. Little is known about this rare condition, and the relationship between symptoms and hypercontractility is not always straightforward. The aim of our study was to describe a large cohort of patients with jackhammer esophagus and to investigate whether manometric findings are associated with the presence of symptoms. All patients from 06, 2014 until 12, 2015 seen at two tertiary centers with at least one hypercontractile swallow (distal contractile integral [DCI] >8000mm Hg/s/cm) on HRM were analyzed. Patients with ≥20% premature swallows, or patients with another diagnosis explaining their symptoms were excluded. Of the 34 patients identified with jackhammer esophagus, most suffered from dysphagia (67.6%) and/or chest pain (47.1%). The symptom chest pain was not associated with any of the manometric findings, whereas dysphagia was associated with the DCI of the hypercontractile swallows and with intrabolus pressure. In addition, all patients who had an isolated DCI of the lower esophageal sphincter (LES) zone >2000mm Hg/s/cm had dysphagia. The differences in HRM and clinical characteristics between subgroups based on the contraction type (single- or multi-peaked) or based on meeting criteria of the Chicago Classification v3.0 and v2.0 were limited. The symptom dysphagia is accompanied with strong contractions of the LES, signs of a possible outflow obstruction, and a very high DCI. The presence of a multipeaked contraction seems to be of limited relevance, and caution is warranted in labeling patients with one hypercontractile swallow as normal.

Levator–sphincter reinforcement after ultralow anterior resection in patients with low rectal cancer: the surgical method and evaluation of anorectal physiology

To determine whether ultralow anterior resection with levator-sphincter reinforcement (uLAR-LSR), which is first introduced in the current study, offers functional preservation in patients with low rectal cancer. We assessed the functional outcomes in 56 of 61 consecutively enrolled patients who underwent uLAR-LSR. After rectal resection, levator-sphincter reinforcement (LSR) was performed by approximation of the dissected muscles. The functional outcomes were assessed preoperatively, and then 3, 12, and 24months postoperatively. There were no significant differences in the sphincter or high-pressure zone length between the preoperative and postoperative periods in the uLAR-LSR group (P=0.298-0.981), which indicated functional preservation by the LSR. The percentage of patients with moderate to severe incontinence (>10 using the Wexner score) was significantly decreased at 24months as compared to 3months postoperatively (15.7 vs, 39.6%, P<0.001). At the limited mean follow-up of 41months, local recurrence had been detected in one patient (1.8%). The uLAR-LSR method is a novel technical option, which maintains the anorectal function as well as accomplishing oncological safety during a short-term evaluation.

3D-high resolution manometry of the esophagogastric junction

The esophagogastric junction (EGJ) is a complex structure that challenges accurate manometric recording. This study aimed to define EGJ pressure morphology relative to the squamocolumnar junction (SCJ) during respiration with 3D-high resolution manometry (3D-HRM). A 7.5-cm long 3D-HRM array with 96 independent solid-state pressure sensors (axial spacing 0.75 cm, radial spacing 45°) was used to record EGJ pressure in 15 normal subjects. Concurrent videofluoroscopy was used to localize the SCJ marked with an endoclip. Ex vivo experiments were done on the effect of bending the probe to match that seen fluoroscopically. 3D-high resolution manometry EGJ pressure recordings were dominated by an asymmetric pressure peak superimposed on the lower esophageal sphincter (LES) attributable to the crural diaphragm (CD). Median peak CD pressure at expiration and inspiration (51 and 119 mmHg, respectively) was much greater in 3D-HRM than evident in HRM with circumferential pressure averaging. Esophagogastric junction length, defined as the zone of circumferential pressure exceeding that of adjacent esophagus or stomach was also substantially shorter (2.4 cm) than evident in conventional HRM. No consistent circumferential EGJ pressure was evident distal to the SCJ in 3D-HRM recordings and ex vivo experiments suggested that the intra-gastric pressure peak seen contralateral to the CD related to bending the assembly rather than the sphincter per se. 3D-high resolution manometry demonstrated a profoundly asymmetric and vigorous CD component to EGJ pressure superimposed on the LES. Esophagogastric junction length was shorter than evident with conventional HRM and the distal margin of the EGJ sphincteric zone closely correlated with the SCJ.

Risk factors of treatment failure after retrourethral transobturator male sling

Prospective evaluation of independent risk factors for failure of the retrourethral transobturator sling suspension (RTS) with special attention on sphincter function and surgical technique. A total of 189 patients with postprostatectomy stress urinary incontinence (SUI) were treated with RTS (AdVance(®) sling) in a prospective clinical study with a mean follow-up of 20.8 months. Eleven patients were lost to follow-up. Uni- and multivariate analyses were performed to identify independent risk factors for RTS failure. The success rate was defined as cured (no pad use or one dry 'security' pad) or improved (one to two pads and pad reduction ≥ 50%). At a mean follow-up of 20.8 months, the overall success rate was 73.1%. Multivariate analysis revealed that weak residual function and incomplete closure of the sphincter (OR, 29.0), no elongation of the coaptive sphincter zone (OR, 26.9), no sling tunnelling (OR, 22.6) and use of resorbable sutures with a small number (≤ 4) of stitches (OR, 8.4) are significant predictors for RTS failure. Preoperative selection of the patients with regard to residual sphincter function and a special attention on better sling fixation may increase RTS efficacy.

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Octreotide

Management of Gastroesophageal Reflux Disease: Medications, Surgery, or Endoscopic Therapy? (Current Status and Trends)

Gastroesophageal reflux disease (GERD) is a common chronic disorder in the Western world. The basic cause of GERD has been well characterized--the fundamental defect is a loss of integrity of the gastroesophageal barrier. What is less clear is the most appropriate means of addressing this reflux. GERD has a variety of symptoms, ranging from typical presentations of heartburn and regurgitation (without esophagitis) to atypical presentations, such as severe erosive esophagitis and its associated complications. Because of its symptomatic diversity, physicians may select from a variety of therapeutic approaches. Medical therapy aims at decreasing acidity by suppressing proton secretion and has been well established. Available medications include antacids and alginates, H2-receptor antagonists, motility agents, and proton pump inhibitors (PPIs). Antireflux surgery, commonly performed laparoscopically, aims at reinforcing and repairing the defective barrier through plication of the gastric fundus. The earliest performed successful procedures were the Nissen and Toupet fundoplications, to which several modifications have since been made. It has been demonstrated in preliminary studies and long-term outcomes of such open surgery and preliminary studies of such laparoscopic surgery that antireflux surgery is an effective approach, with overall outcomes superior to those achieved with medications. The precise indications for the surgical treatment of patients with GERD, however, remain controversial. In recent years, endoscopic intraluminal antireflux approaches have attracted the attention of physicians, surgeons, and commercial companies, especially after the approval of two endoscopic intraluminal methods by the United States FDA in 2000. The common element is prevention of acid reflux by construction of a functional or controlled barrier in the lower esophageal sphincter zone. Three main methods are currently employed: endoscopic intraluminal valvuloplasty, endoscopic radiofrequency therapy, and endoscopic injection or implantation of foreign material. The endoluminal suturing method is highly demanding technically, and its short-term results are encouraging, although largely dependent on the experience of the endoscopist. Several prospective cohort studies have shown that the radiofrequency procedure (Stretta) significantly improves GERD symptoms and quality of life while reducing esophageal acid exposure and eliminating the need for antisecretory medications in the majority of patients within 6-12 months. Most recently, some researchers have studied the endoluminal implantation of polymers, such as Plexiglas (polymethyl-methylacrylate), Gatekeeper hydrogel, and Enteryx (ethylene vinyl alcohol copolymer). The preliminary results of these studies showed that the implantation method was feasible and safe; however, the only multicenter trial related to outcome that has been published has included just 1 year of follow-up. Here, we review the treatment of GERD: medical, surgical, and endoscopic. In addition, we provide an algorithm based on symptoms and response to treatment for management of these patients.

Endoscopic therapy for gastroesophageal reflux disease.

Many new and developing endoscopic techniques for treatment of gastroesophageal reflux disease (GERD) are now or will soon be available for clinical use. These new therapies are directed to the gastroesophageal junction and include three basic techniques, which are outlined in this review: thermal remodeling and neurolysis of the lower esophageal sphincter (LES) zone; bulking or reinforcing of the LES; and plicating gastric folds at the gastric cardia. Only two of these treatments, radiofrequency ablation and fundic fold plication, have been approved by the US Food and Drug Administration (FDA). Published clinical research on endoscopic treatment is reviewed, although it is mostly comprised of open-label trials and anecdotal clinical reports. Complications of endoscopic GERD treatments are described as well as real and potential pitfalls of these techniques. Problems caused by premature introduction of endoscopic GERD treatments into the marketplace are also discussed, along with the rationale for FDA approval of similar devices.

FUNCTIONAL ANATOMY OF THE GASTROESOPHAGEAL JUNCTION

The study of the functional anatomy of the gastroesophageal junction allows for the demonstration of a double mechanism that combats the conflict of pressures that tends to lead to gastroesophageal reflux. On one hand, the LES, an intrinsic structure, is directly related to the muscle fibers of the organ and responds to a neurohormonal physiologic command. On the other hand is an anatomic entity, centered by the crura of the diaphragm, closely related to the movements of respiration. These structures constitute a second, extrinsic sphincter that gives rise to the zone of high pressure in the terminal esophagus. This role is difficult to assess, and its importance is underestimated. The proper functioning of these two mechanisms implies that the gastroesophageal junction remains in place within the diaphragmatic channel of the esophagus. Also important are the postural phenomena associated with the sloping position of the fundus. In patients with gastroesophageal reflux, the decrease of the pressure measured in the terminal esophagus accounts for the occurrence of reflux. Investigators concede that, under the influence of abdominal straining, the gastroesophageal junction tends to ascend into the diaphragmatic channel. The results are twofold: (1) the muscle fibers of the lower esophagus relax, explaining the incompetence of the intrinsic sphincter, and (2) the sphincteric zone is withdrawn from its muscular diaphragmatic environment. Physicians should consider these structures as a whole in approaching the surgical treatment of reflux. The construction of a periesophageal valve has no anatomophysiologic basis. A gastropexy procedure must be added to replace the gastroesophageal junction in its anatomic setting and keep it there. This procedure also allows retightening of the muscle fibers of the esophageal wall, which is essential in long-term surgical correction.

Intestinal metaplasia and the squamocolumnar junction: what does it all mean?

See article on page 659 In theory, the diagnosis of Barrett’s oesophagus should be fairly simple, namely the presence of intestinal metaplasia anywhere in the tubular oesophagus. However, recognising where...

Use of memokath, a second generation urethral stent for relief of urinary retention in male spinal cord injured patients

Memokath (Engineers & Doctors A/S, Hornbaek, Denmark) a second generation urethral stent composed of titanium nickel alloy with shape memory effect was deployed in 10 male spinal cord injured patients with urinary retention. The stent was inserted under sterile conditions via a delivery catheter under fluoroscopic control in seven and with the aid of a flexible cytoscope in three. The proximal end of the stent was positioned at the bladder neck and 50 ml of normal saline at 45 degrees C was flushed through the stent which resulted in expansion of the distal most four coils of the stent in the proximal bulbar urethra; thus the internal sphincter (bladder neck) and external sphincter zone were kept open by the stent. Urethral stenting helped to achieve complete vesical emptying in all 10 patients. The complications included transient autonomic dysreflexia in two, transient urinary retention due to blood clot in one, and acute urinary tract infection in one patient. With a follow up of 3-7 months, all 10 patients have been asymptomatic, with residual urine of less than 50 ml. There has been no migration or blocking of the stent. However, these stents require replacement at 12-18 months, but it is a short procedure as the Memokath, when cooled with saline at 4 degrees C, becomes supersoft, enabling its easy and nontraumatic removal.(ABSTRACT TRUNCATED AT 250 WORDS)

Pathophysiologic basis for operation on Zenker's diverticulum

An increased resistance to bolus flow through the upper esophageal sphincter has in the past been considered the main cause of increased pharyngeal contraction and the subsequent development of Zenker's diverticulum (ZD). Our study was designed to elucidate the pathophysiologic characteristics of the swallowing mechanism and its possible role in the development of ZD. Fourteen patients with radiologically proved ZD and a matched control group of healthy volunteers with no gastrointestinal symptoms were investigated with esophageal manometry using the station pull-through technique. Although the mean amplitude of pharyngcai coniraction was higher in the ZD group, there was no difference in the duration of contraction. The testing tone of the upper esophageal sphincter zone in patients with ZD was found to be lower than normal, but the dosing pressure was higher and its duration longer. Though present in 2 patients, pharyngosphlncteric incoordination was not the main feature in the ZD group. Sphincteroesaphageal incoordination was noted in 9 patients, however. The mean amplitude of the upper esophageal contraction was higher and the duration longer in the ZD group. There was no upper esophageal peristalsis in 3 patients. An operation for the repair of ZD should therefore be undertaken only after careful interpretation of the manomeiric features of each patient.

Gastric muscularis as a urinary sphincter

Objejective To test the ability of gastric muscularis to act as a urinary sphincter in a rat model system. Methods. Fourteen Long-Evans rats had an ileal conduit constructed joining the bladder to the ventral skin, creating urinary incontinence. A segment of gastric muscle maintained on its vascular pedicle was encircled around the conduit. The first 7 animals (group A) had both conduit and sphincter constructed simultaneously, whereas the remaining 7 animals had the conduit constructed first, followed by a two-week period of observation, after which gastric sphincters were added (group B). All animals were observed for urine leakage via the cutaneous stoma. At two weeks after sphincter placement, all animals underwent surgical exploration, pressure profilometry of the conduit, and histologic examination of the sphincter zone. Results. Pressure profilometry demonstrated elevated pressures in the sphincter zone relative to baseline pressures in the conduit of all animals (group A: mean baseline, 4.8 cm water, mean maximum, 20.6 cm water; group B: rnean baseline, 5.2 cm water, mean maximum, 18.1 cm water). At exploration, no intra-abdominal complications were noted in 13 of 14 animals. All conduits were easily catheterizable and were found to be continent after they had been filled to capacity. The ileum and gastric segments were histologically found to be viable with no evidence of necrosis or ischemia. Conclusions. These preliminary results suggest that gastric muscularis may be a potential substitute urinary sphincter in the management of sphincteric urinary incontinence.

Manometric study of the biliary sphincter zone: A comparison between the length of phasic activity and the narrow distal segment

Manometric study of the biliary sphincter zone: A comparison between the length of phasic activity and the narrow distal segment

Characterization of pressure changes in the lower urinary tract during coughing with special reference to the demands on the pressure recording equipment

The exact demands on urodynamic equipment for measurement of coughs and cough associated pressure changes in the lower urinary tract have been analyzed from high-speed pressure recordings using a double microtip transducer and a storage oscilloscope. The equipment was tested in vitro by the step-test method. The natural frequency response was 175.6 Hz and the rise-time 2.5 ms, resulting in accurate measurements of frequencies up to about 60 Hz, which is way above the clinically measured frequencies. Four men and 2 women, all of whom were healthy volunteers, were examined in the supine position with an empty bladder. Pressures were measured in the bladder and in the external sphincter zone of the urethra. The spectral power density of the bladder and urethral pressures were calculated by Fourier analysis. The pressure changes in the urethra were in all volunteers equal to or slower than in the bladder. The analysis of the spectral power density showed that 99% of the pressure changes could be recorded with an instrument capable of recording 9 Hz frequencies, i.e., with a sampling rate of 18 Hz or more.

Endoscopic Manometry of the Sphincter of Oddi and Pancreatic Duct in Patients with Papillary Stenosis

The function of the sphincter of Oddi (SO) in patients with papillary stenosis was evaluated using endoscopic manometry to determine its possible contribution to pancreatic dysfunction. A total of 30 patients with papillary stenosis were divided into two groups according to the pattern of narrowing of the sphincter zone observed in ERCP studies: group A, a mild form, and group B, a severe form. Group C (control) comprised 12 subjects with no abnormality of the pancreas or biliary system. The SO contraction pressure was significantly higher in group A (115.1 mmHg) than in groups B (79.2) and C (91.1). The SO basal pressure in groups A (11.5 mmHg) and B (10.3) was significantly higher than in group C (5.8). The pancreatic duct pressure in group A (15.5 mmHg) was significantly higher than in group C (9.7), while group B (11.1) showed an intermediate value. The increase in pancreatic duct pressure following intravenous secretin was significantly greater in groups A and C than in B. The BT-PABA test in groups A and C revealed a normal value in contrast to group B. A significant correlation was observed between these two factors. The function of both the SO and the pancreas thus appears to be abnormal in patients with severe narrowing of the SO and papillary stenosis.

Manometry and Electromyography of the Pharyngeal Muscles in Patients With Dysphagia

Simultaneous recording of the electromyographic activity of the pharyngeal muscles and the intraluminal pressure in the upper sphincter zone was performed routinely in patients with swallowing problems for the first time, to our knowledge. This technique was found to be very useful for the localization of the "site of lesion." The procedure is safe, easy to master, and causes minimal inconvenience. It can reveal, in the most direct way, whether the disturbance is in the hypopharyngeal musculature (represented by the inferior constrictor muscle), in the cricopharyngeal muscle (spasm or lack of relaxation), or in the synchronization between them. Simultaneous recording of intraluminal pressure adds valuable information about the mechanical events associated with electromyographic activity. It was found that in pathologic cases there is quite often no correlation between the electrical and mechanical events. Thus, simultaneous recording of both electrical and mechanical events is essential for the understanding of the pathophysiology of disturbances of deglutition.

Response of lower esophageal sphincter to alterations of intraabdominal pressure.

It is well documented that lower esophageal sphincter pressure increases significantly in response to increases in intraabdominal pressure in order to maintain the gastroesophageal barrier. The mechanism by which this response is elicited is controversial. It has been suggested that the response of the sphincter persists after the intraabdominal pressure stimulus is removed. The present study sought to define the response of the sphincter to increased intraabdominal pressure (achieved by straight leg raising) by continuously monitoring it with the Dent sleeve in a group of 10 normal volunteers. A reproducible pressure profile was observed in both the sphincter and the stomach, characterized by an initial peak, a sustained plateau, and a second peak. The pressure profiles of the stomach and the sphincter were closely approximated and peak and plateau pressures for both did not differ significantly. The onset and offset of the pressure increase were simultaneous in the stomach and the sphincter. No significant changes in sphincter pressure were noted when the rapid pull-through technique was used. This study defines the pressure profiles of the stomach and the lower esophageal sphincter zone during increased intraabdominal pressure in man. Our data suggest that the response of the sphincter is passively mediated.