Application of small intestinal submucosa graft for repair of complicated vesicovaginal fistula: a pilot study.

PURPOSE: Vesicovaginal fistula is a socially debilitating problem with important psychological and medicolegal implications. Complicated fistulas include large fistulas or those with failed prior repair attempts. The key to successful closure of such fistulas is the use of adjuncts such as a Martius, peritoneal or omental flap. Small intestinal submucosa is an acellular collagen matrix graft that is nonimmunogenic, biodegradable and ready to use off the shelf. We evaluated small intestinal submucosa as an interposition patch during complicated vesicovaginal fistula repair. MATERIALS AND METHODS: A total of 23 women with a mean age of 33.5 years who had a complicated vesicovaginal fistula were enrolled in this clinical trial. Complicating factors were failed primary repair in 9 cases, excessive perifistulous scarring in 4 patients and a fistula 1.5 cm or greater in the remainder. Transvaginal repair was done in 7 low fistula cases and transabdominal repair was done in the remainder with a high fistula. A small intestinal submucosa patch was interposed in all cases at classic abdominal or vaginal repair. All patients were evaluated 1, 3 and 6 months postoperatively. RESULTS: All patients who underwent vaginal repair were dry during followup. Of the 16 women who underwent transabdominal repair 14 were dry. The overall success rate was 91.3%. No reported allergic or inflammatory reactions were documented. CONCLUSIONS: Using small intestinal submucosa as an interposition layer at anatomical vaginal and/or transabdominal repair of complicated vesicovaginal fistulas seems to be a simple, feasible solution.

Validity of a sponge trainer as a simple training model for percutaneous renal access.

OBJECTIVE: To evaluate the efficacy of our simply designed trainer for junior urologists to acquire the initial skills for percutaneous renal access (PRA). SUBJECTS AND METHODS: Three sponge sheets (60 × 50 × 10 cm) were arranged horizontally over each other. A rectangular groove was made in the middle sheet to accommodate an inflated balloon of a Foley catheter, radio-opaque metal balls, metal rings, or a plastic tube that were sequentially placed for the four training tasks. In each session, 18 trainees were asked to pass a fluoroscopically guided puncture needle from a surface point to the placed object in middle sheet. Clinical impact of training was evaluated by an experience survey on a 5-piont Likert scale (for model usefulness, tactile and fluoroscopic-guidance feedback) and success rate in further mentored practice. RESULTS: There was a gradual increase in tasks' and sessions' scores over the training sessions. According to the experience survey after first clinical practice, the mean (SD) score for overall model usefulness by trainees was 3.8 (0.9) with high fluoroscopic guidance reality [3.6 (1.1)] but poor tactile realism [2.3 (0.9)]. On mentored PRA, the success rate for trainees was 78.3%. CONCLUSION: Our early evaluation showed our novel, cost-effective and reproducible sponge trainer could be an effective training model for PRA with a beneficial impact on subsequent clinical practice.

A randomized prospective controlled study for assessment of different ureteral occlusion devices in prevention of stone migration during pneumatic lithotripsy.

OBJECTIVE: To compare the safety and efficacy of two different ureteral occlusion devices (stone cone and entrapment net) in preventing retrograde stone migration during ureteroscopic pneumatic lithotripsy. Proximal migration of stone fragments during ureteroscopic lithotripsy is a common problem, especially when the pneumatic lithotripter is used for stone fragmentation. PATIENTS AND METHODS: A total of 195 patients with proximal ureteric stones were prospectively randomized into one of three groups in this study, with 65 patients in each group. In group I, the Stone Cone was used as a ureteral occlusive device; in group II, the N-Trap was used; and in group III (control group), the patients underwent pneumatic lithotripsy without any ureteral occlusive device. RESULTS: The ureteroscopic procedure was completed successfully in 180 patients; 63 patients in group I, 59 patients in group II, and 58 patients in group III. Patients in group I showed significantly lower incidence of stone migration compared with the other 2 groups (P <.05). Both ureteral occlusive devices significantly lowered the incidence of residual fragments (>3 mm), ureteral trauma, operative time, and the need for ureteral stenting compared with control group. The stone-free rate at 3 weeks was 95.24%, 83.05%, and 72.41% in groups I, II, and III, respectively. The patients in group I had a statistically significant stone-free rate compared with the other two groups (P <.05). Auxiliary procedures were required in 3 (4.76%), 10 (16.94%), and 16 cases (27.58%) in groups I, II, and III, respectively. CONCLUSION: The use of Stone Cone or N-Trap is valuable during ureteroscopic pneumatic lithotripsy for treatment of proximal ureteral stones. Both devices significantly diminish residual fragments, the incidence of ureteral wall trauma, and the need for the auxiliary procedure. However, the stone cone was more effective in preventing proximal stone migration and the subsequent stone-free rate.

Endoscopic urethroplasty using small intestinal submucosal patch in cases of recurrent urethral stricture: a preliminary study.

OBJECTIVES: The objective of this study was to evaluate the results of internal urethrotomy with endoscopically placed small intestinal submucosa (SIS) graft for treatment of selected cases of recurrent urethral stricture. PATIENTS AND METHODS: This prospective study included 10 patients with recurrent inflammatory bulbar urethral stricture of 0.5-2 cm in length with no dense spongiofibrosis. Following the 12 o'clock visual internal urethrotomy, a prepared 12F Foley's silicon catheter with the SIS patch was introduced into the urethra over a preplaced super-stiff guidewire. The advancement of this catheter was monitored via a 15F urethroscope to enable us to put its balloon with the overlying SIS patch at the site of the urethral incision. Thereafter, the balloon was inflated with saline and the catheter was secured with a silk suture to the glans. In addition, a suprapubic cystostomy was fixed for bladder drainage. These catheters were kept in place for 2 weeks. The patients were followed up at regular intervals using uroflowmetry and ascending urethrography. RESULTS: At 3-month follow-up, only two cases showed mild recurrent stricture and the rest of cases had a normally patent functional urethra. The subsequent follow-up studies of all the eight successful cases for 12-18 months revealed no evidence of recurrent stricture in all of them and no more interventions were required for any of them. On the other hand, the two cases with recurrent stricture showed a satisfactory response to regular monthly urethral dilatation. CONCLUSION: Endoscopic urethroplasty using SIS patch can be considered as a minimally invasive solution for cases with recurrent, short urethral stricture that are associated with mild spongiofibrosis.