Bulking for stress urinary incontinence in men: A systematic review.

AIMS: An updated literature review on outcomes in men treated with currently commercially available bulking agents was performed to determine whether this is a reasonable option in selected patients. METHODS: The review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses framework of systematic reviews. A comprehensive search of PubMed, Medline, and Embase was undertaken. Abstracts were independently screened by two investigators to include men with stress urinary incontinence treated with a peri-urethral injection of bulking agents currently available in the market. RESULTS: Only eight original articles met the inclusion criteria. The bulking agents used were Macroplastique in five studies (total 123 patients), Opsys, Durasphere, and Urolastic in one study each (10, 7, and 2 patients, respectively). Only one study was randomized; Macroplastique vs AUS in men with mild or total incontinence. The included populations were heterogeneous and encompassed endoscopic, perineal, abdominal and laparoscopic prostate surgery as well as spinal cord injuries and urethral sphincter insufficiency. Significant dissimilarity was evident for the duration of incontinence (9-108 months), mean volume of bulking agent used (2.3-13.5 mL), number of cushions (1-5), depth and position of the cushions. The outcomes varied significantly, with reported dry rates between 0% and 83%. Outcomes were limited by relatively short follow-up in most studies. CONCLUSION: Following initial enthusiasm and then dismay with collagen-based compounds, sparse and heterogeneous literature data were produced on newer non-migrating and nonabsorbable bulking agents. Some studies have suggested encouraging, if short term outcomes, however, future studies are needed in this field to support recommendations for widespread use.

Female urethral stricture: a contemporary series.

PURPOSE: To report the etiology, presenting symptoms and outcomes of the different treatments performed in female patients with recurrent urethral stricture. MATERIALS AND METHODS: Twenty-six patients with refractory LUTS were diagnosed with a urethral stricture. The symptoms, the treatment performed and the outcomes were prospectively recorded. Sixteen patients were treated with a urethroplasty using a buccal mucosal graft (BMG) in 14 cases (54 %) and a vaginal flap in 2 (8 %). Urethral dilatation, optical urethrotomy and meatoplasty were performed in 8 (31 %), 1 (3.8 %) and 1 (3.8 %) patients, respectively. RESULTS: Strictures were idiopathic in 11 patients (42 %). Previous urethral instrumentation and traumatic vaginal delivery were the commonest causes of urethral stricture (42 and 15 %, respectively). The most frequent symptoms were reduced flow (93 %), detrusor overactivity (50 %) and UTIs (42 %). The stricture was cured in 93 % of patients treated with a BMG urethroplasty and in all the patients in which a vaginal flap urethroplasty was performed. In the same group, the improvement in urethral pain was observed in the 67 and the 88 % of patients were cured from recurrent UTIs. All the patients treated with urethral dilatation needed further dilatations; hence, the cure of the stricture was achieved in none of them. Improvement in urethral pain, UTIs and detrusor activity was not recorded in the latter group. CONCLUSION: Urethroplasty in its various forms has demonstrated in the present series the highest cure rate for the treatment of recurrent urethral stricture.

Complications of Synthetic Midurethral Slings: Is There a Relevant Discrepancy Between Observational Data and Clinical Trials?

CONTEXT: The complications of synthetic midurethral slings (MUSs) in women with stress urinary incontinence (SUI) have become a globally debated issue. OBJECTIVE: To systematically review the short- and long-term complications of mesh slings reported in observational data compared with clinical trial data, to determine whether the complication rates from clinical trials reflects "real-world" observational data. EVIDENCE ACQUISITION: PubMed and Cochrane Library were searched. Methods as detailed in Preferred Reporting Items for Systematic Reviews and Meta-analyses and Cochrane Handbook for Systematic Reviews of Interventions were followed. EVIDENCE SYNTHESIS: Thirty registries/databases including 709 335 MUS procedures (1-22 yr of follow-up) were identified. MUS procedures were associated with intraoperative bladder perforation in 0.86-3.6%, urethral perforation in 0-0.1%, vascular injury in 0.04-0.1%, voiding lower urinary tract symptoms (LUTS) in 1.47-3.5%, vaginal exposure in 0.2-1.9%, and reoperation in up to 9% of cases. Forty-three randomised clinical trials were identified, including 6284 women who underwent MUS procedures and 2177 women who underwent other interventions (1-10 yr of follow-up). MUS procedures were associated with urinary tract perforation in 2.58%, vaginal injury in 1.43%, de novo voiding LUTS in 4.37%, de novo storage LUTS in 5.41%, mesh extrusion/exposure (vaginal/urinary tract) in 2.54%, dyspareunia in 2.26%, pain (pelvic/suprapubic/perineal) in 2.83%, and reoperation for complications required in 1.82% of cases. Meta-analyses of the randomised controlled trials revealed that retropubic MUSs were associated with more events of urinary tract perforation (risk ratio [RR] 9.81, 95% confidence interval [CI] 5.05-19.04, high certainty of evidence [COE]) and voiding LUTS (RR 1.57, 95% CI 1.19-2.07, high COE) than transobturator MUSs. MUSs were associated with more events of pain than mini-slings (RR 1.72, 95% CI 1.04-2.87, moderate COE). CONCLUSIONS: Short- and long-term data on complications of polypropylene mesh used for female SUI are fairly comparable when using outcome data from well-designed clinical trials or from less structured prospective or retrospective registries. Comparisons have to be made with caution since the two systems of data collection are inherently incomparable. This knowledge should be incorporated in the discussion on how to implement polypropylene mesh for female stress incontinence. PATIENT SUMMARY: In order to know whether mesh tapes used for treating stress incontinence work well and are safe, high-quality information is important. It appears that well-designed clinical studies give similar results to large registration databases. These data should be interpreted with caution in view of the different ways the information was collected. These results will help physicians and patients understand the risks of mesh tapes.

Proper understanding of recurrent stress urinary incontinence treatment in women (PURSUIT): a randomised controlled trial of endoscopic and surgical treatment.

BACKGROUND: Women with stress urinary incontinence (SUI) experience urine leakage with physical activity. Currently, the interventional treatments for SUI are surgical, or endoscopic bulking injection(s). However, these procedures are not always successful, and symptoms can persist or come back after treatment, categorised as recurrent SUI. There are longstanding symptoms and distress associated with a failed primary treatment, and currently, there is no consensus on how best to treat women with recurrent, or persistent, SUI. METHODS: A two-arm trial, set in at least 20 National Health Service (NHS) urology and urogynaecology referral units in the UK, randomising 250 adult women with recurrent or persistent SUI 1:1 to receive either an endoscopic intervention (endoscopic bulking injections) or a standard NHS surgical intervention, currently colposuspension, autologous fascial sling or artificial urinary sphincter. The aim of the trial is to determine whether surgical treatment is superior to endoscopic bulking injections in terms of symptom severity at 1 year after randomisation. This primary outcome will be measured using the patient-reported International Consultation on Incontinence Questionnaire - Urinary Incontinence - Short Form (ICIQ-UI-SF). Secondary outcomes include assessment of longer-term clinical impact, improvement of symptoms, safety, operative assessments, sexual function, cost-effectiveness and an evaluation of patients' and clinicians' views and experiences of the interventions. DISCUSSION: There is a lack of high-quality, randomised, scientific evidence for which treatment is best for women presenting with recurrent SUI. The PURSUIT study will benefit healthcare professionals and patients and provide robust evidence to guide further treatment and improve symptoms and quality of life for women with this condition. TRIAL REGISTRATION: International Standard Randomised Controlled Trials Number (ISRCTN) registry ISRCTN12201059. Registered on 09 January 2020.

["Flowsecure" artificial urinary sphincter: a new adjustable artificial urinary sphincter concept with conditional occlusion for stress urinary incontinence]. / Esfínter Urinario Artificial "FlowSecure": un nuevo concepto de esfínter artificial regulable y con oclusión condicional para la incontinencia urinaria de esfuerzo.

INTRODUCTION: To spread de concept of a new artificial urinary sphincter with conditional occlusion for stress incontinence. The new prototype was conceived and designed in The Institute of Urology and Nephrology of London by Professor Craggs M. and Professor Mundy A.R. METHODS: The FlowSecure sphincter consists of an adjustable pressure-regulating balloon, a stress relief reservoir, a control pump and valve assembly unit with self-sealing port and a urethral cuff. The pressure regulating balloon determinates de operating pressure of the device; the pressure is adjustable in the range 0-80 cm H2O and can be altered by injection or removal of normal saline through the self sealing port. The stress relief balloon transmits transient intrabdominal pressure to the cuff during periods of stress. An adjustable circular urethral cuff minimises creasing and possible stress fractures. RESULTS: The device is implanted as a one-piece assembly which is pre-filled with sterile saline. The surgical technique is simple and associated with little handling, reducing risk of infection and potential assembly errors. The adjustable pressure regulating balloon in association with the stress relief reservoir enables the cuff occluding pressure to be set at a low range, therefore reducing the risk for atrophy and erosion. DISCUSSION: The new FlowSecure urinary artificial sphincter with conditional occlusion is designed to provide good continence rates adjusting regulating pressures when needed and conceived to reduce the risk of potential complications associated with excessive occluding pressures and mechanical failures.

Aggressive Angiomyxoma of the Bladder Neck Requiring Local Excision and Mitrofanoff Formation.

Aggressive angiomyxoma is a rare mesenchymal tumour predominantly affecting the female pelvis and perineum but has also been described in males. This tumour can often present a diagnostic challenge and has a propensity for local recurrence after surgical excision. We present an unusual case of aggressive angiomyxoma arising from the bladder of a female patient which required local excision and Mitrofanoff formation.

Chromophore-enhanced 805 nm laser therapy for gastrointestinal neoplasia.

BACKGROUND: A new technique of 805 nm semiconductor diode laser-tissue interaction potentiation using indocyanine green (ICG) as an exogenous chromophore has been assessed for use in the palliation of advanced gastrointestinal malignancy. MATERIALS AND METHODS: The tissue effects of ICG potentiated 805 nm laser were assessed both in-vivo using rat stomach and colon, and in vitro using normal and neoplastic human gastric and colonic mucosa. RESULTS: Intravenous ICG did not potentiate the laser-tissue effects of the 805 nm laser in in-vivo studies. Local techniques of ICG application (submucosal injection +/- surface painting of 0.1% ICG solution) enhanced the total depth and diameter of laser induced thermal injury in all in-vitro tissues. Without ICG enhancement thermal tissue injury was minimal in normal gastric and colonic mucosa. CONCLUSION: Local techniques of ICG application enhance laser induced thermal injury in normal and neoplastic gastric and colonic mucosa. This may permit targeting of 805 nm laser-tissue effects with minimal collateral damage during endoscopic laser palliation of advanced gastrointestinal malignancy.

Standing the test of time: the long-term results of urethroplasty.

The principle indication for urethral surgery is stricture disease. There are a number of factors that influence the outcome of surgery including location of the stricture, stricture length, aetiology, previous surgery and selection of procedure. Outcomes for different techniques are summarised. The gold standard remains anastomotic urethroplasty, where appropriate, with patch urethroplasty or two-stage stage procedures for more complicated strictures especially the penile urethra.

The long-term outcome of artificial urinary sphincters.

PURPOSE: We reviewed the outcome of artificial urinary sphincters inserted more than 10 years ago. MATERIALS AND METHODS: We analyzed the records of 100 patients and mailed a questionnaire to those without recent followup. RESULTS: Overall 84 patients were continent, including 36 with the original artificial urinary sphincter in place who were dry at a median followup of 11 years and 27 in whom the device was successfully replaced due to mechanical failure who were previously continent for a median of 7 years. In 21 patients it was removed due to infection or erosion and reimplantation was successful 3 to 6 months later or they remained dry without another artificial urinary sphincter. Of the male patients with a bulbar and bladder neck sphincter 92% and 84%, respectively, were continent at 10 years as well as 73% of the females. Device survival was 66% at 10 years. Overall 37% of the prostheses were removed due to infection or erosion in the 10-year period with the highest risk in females (56%) and lowest in males with a bulbar sphincter (23%). CONCLUSIONS: The artificial urinary sphincter is effective long-term treatment for incontinence in male patients. In female patients the risk of erosion is high, although overall long-term continence is satisfactory.

Pelvic fracture injuries of the female urethra.

OBJECTIVE: To review pelvic fracture urethral injuries in women, generally regarded as rare and thus discussed infrequently. PATIENTS AND METHODS: Twelve patients (age range 7-51 years) with such injuries were reviewed; most had associated injuries, generally more severe than seen in males with urethral injuries. RESULTS: Patients with milder injuries, perhaps damaging just the innervation of the urethra, presented with incontinence; more severe injuries seemed to cause a longitudinal tear in the urethra but again patients presented mainly with incontinence problems. The most severe injuries were associated with complete rupture of the urethra and a distraction defect suggesting an avulsion injury. These problems were difficult to treat both reconstructively and in providing continence. CONCLUSIONS: Pelvic fracture urethral injuries occur in females, but less often than in males. The female urethra seems relatively resistant to injury; differing degrees of severity of pelvic trauma cause different types of urethral injury but in general, a more severe injury is needed to damage it than is necessary in males.

Changing practice in anterior urethroplasty.

OBJECTIVE: To describe our experience of penile urethral repair and reconstruction, cataloguing the change in practice from one-stage flap to two-stage free graft procedures for anterior urethroplasty. PATIENTS AND METHODS: Between January 1992 and December 1996, 79 patients underwent anterior urethroplasty. Of the 45 one-stage bulbar patch urethroplasties, 37 (76%) used buccal mucosal free grafts rather than flaps. Of the 34 penile urethroplasties, 26 (82%) (including all of the circumferential reconstructions) were two-stage procedures. RESULTS: Buccal mucosal free grafts were at least as good as local skin flaps for patch urethroplasty and two-stage repairs gave much better results than one-stage repairs for total circumferential reconstruction of the penile urethra. CONCLUSIONS: For a patch urethroplasty of an uncomplicated stricture in the bulbar urethra, buccal mucosal free grafts are now the material of choice. For a patch urethroplasty of an uncomplicated stricture in the penile urethra the Orandi procedure remains the 'gold standard'. For a circumferential repair of the urethra, particularly the penile urethra, a two-stage repair using a free graft gives better results than a one-stage repair using a flap.

The problems of penile urethroplasty with particular reference to 2-stage reconstructions.

PURPOSE: We evaluate the anecdotal high revision rate of 2-stage urethroplasty. MATERIALS AND METHODS: The short-term revision rates after 1-stage (139 cases) and 2-stage (103) urethroplasties were compared. RESULTS: There were 4 revisions after 1-stage urethroplasty (4 of 139, 3%) and all involved the penile urethra (20%). The revision rate was 37.8% after stage 1 and 25.3% after stage 2 and of 2-stage urethroplasty 85%, involved the penile urethra. CONCLUSIONS: Although 2-stage has a significantly lower re-stricture rate than 1-stage urethroplasty for complex strictures in the penile urethra, it does so at the expense of a significantly higher revision rate particularly of the penile urethra.

Biophysical characterization of recombinant proteins expressing the leucine zipper-like domain of the human immunodeficiency virus type 1 transmembrane protein gp41.

Envelope oligomerization is thought to serve several crucial functions during the life cycle of human immunodeficiency virus type 1 (HIV-1). We recently reported that virus entry requires coiled-coil formation of the leucine zipper-like domain of the HIV-1 transmembrane envelope glycoprotein gp41 (C. Wild, T. Oas, C. McDanal, D. Bolognesi, and T. Matthews, Proc. Natl. Acad. Sci. USA 89:10537-10541, 1992; C. Wild, J. W. Dubay, T. Greenwell, T. Baird, Jr., T. G. Oas, C. McDanal, E. Hunter, and T. Matthews, Proc. Natl. Acad. Sci. USA 91:12676-12680, 1994). To determine the oligomeric state mediated by this region of the envelope, we have expressed the zipper motif as a fusion partner with the monomeric maltose-binding protein of Escherichia coli. The biophysical properties of this protein were characterized by velocity and equilibrium sedimentation, size exclusion chromatography, light scattering, and chemical cross-linking analyses. Results indicate that the leucine zipper sequence from HIV-1 is capable of multimerizing much larger and otherwise monomeric proteins into extremely stable tetramers. Recombinant proteins containing an alanine or a serine substitution at a critical isoleucine residue within the zipper region were also generated and similarly analyzed. The alanine- and serine-substituted proteins behaved as tetrameric and monomeric species, respectively, consistent with the influence of these same substitutions on the helical coiled-coil structure of synthetic peptide models. On the basis of these findings, we propose that the fusogenic gp4l structure involves tetramerization of the leucine zipper domain which is situated approximately 30 residues from the N-terminal fusion peptide sequence.

The outcome of renal denervation for managing loin pain haematuria syndrome.

OBJECTIVE: To evaluate the outcome of renal denervation for the treatment of loin pain-haematuria syndrome (LPHS), a rare syndrome of unknown cause associated with debilitating and intractable loin pain. PATIENTS AND METHODS: The case notes of 32 patients having 41 renal denervations were reviewed. Data collected included patient demographics, possible causes, cure or not after renal denervation, time to recurrence of pain after denervation and further operative intervention for managing LPHS. RESULTS: Full data were available for 24 patients (13 women; median age 43 years, range 28-74) having 33 denervations (eight bilateral and one repeat) with a median follow-up of 39.5 months. Most patients had no identifiable underlying cause although many had initially been diagnosed as having stone disease (42%) or pyelonephritis (25%), but with no corroborative evidence. All patients had been extensively investigated and had normal urine samples and cytology, and no abnormality on intravenous urography, renal tract ultrasonography and isotopic renography. Twenty-four renal denervations (73%) were followed by recurrent ipsilateral pain at a median (range) of 11 (0-120) months after surgery. Nine denervations (25%) in six men and two women were curative (median follow-up 16.5 months). Of those with recurrent pain, nine (38%) proceeded to nephrectomy, of whom three then developed loin pain on the contralateral side and two developed disabling wound pain. The analgesic requirement was less after eight non-curative denervations. There were no significant postoperative complications. CONCLUSIONS: Renal denervation has only a 25% success rate for managing pain associated with LPHS and should be used cautiously for this indication. Men had more benefit from the treatment; a third of patients had less requirement for analgesic after non-curative denervation.

Unenhanced helical CT for renal colic--is the radiation dose justifiable?

AIM: The purpose of this study was to define and compare the radiation doses to patients undergoing computed tomography (CT) or intravenous urography (IVU) for the investigation of renal colic. METHODS: The IVU dose was calculated from dose area product measurements for 27 abdominal films (AXR) and a review of 30 IVUs performed to investigate renal colic. The effective dose to a patient undergoing CT was calculated using anthropomorphic model data. Fifty patients underwent CT for the investigation of renal colic over a 6-week period. RESULTS: CT following our protocol confers an average effective dose of 4.7 mSv. An IVU to investigate renal colic used 2.5 AXRs. A 3 film IVU gives an average dose of 1.5 mSv. Forty-two CT examinations were abnormal and the findings are described in the text. CONCLUSION: Although unenhanced CT confers diagnostic advantages and avoids the risks of intravenous contrast medium, this should be considered against the increased radiation dose to the patient which in our institution is over three times that of an IVU.