A pilot study of cardiac electrophysiology catheters to map and pace bladder electrical activity.

AIMS: This is a pilot study to evaluate the feasibility of using diagnostic cardiac electrophysiology catheters for recording intrinsic urinary bladder electrical activity and for electrical pacing capture of bladder tissue. METHODS: During cystoscopy, a curved quadripolar catheter was introduced and contact was made with the right and left halves of the dome and trigone in adult female patients undergoing cystoscopy. Electrical activity was recorded, using a commercially available cardiac electrophysiologic recording system, before and during pacing at 0.5-3.0 Hz. RESULTS: Apparent spontaneous electrical depolarizations were detected in both the trigone and the dome. The amplitude of these depolarizations was in the microVolt range. During pacing, local electrical capture was noted in the trigone, but not in the dome. CONCLUSIONS: Spontaneous low-amplitude electrical activity was detected in the bladder through the use of commercially available cardiac electrophysiology equipment. While these low-level signals could represent noise, the voltage, and morphology resemble detrusor muscle action potentials previously seen in animal studies. Pacing induced local electrical capture in the trigone but not the dome.

Mesh erosion following abdominal sacral colpopexy in the absence and presence of the cervical stump.

INTRODUCTION AND HYPOTHESIS: We compared the role of abdominal sacral colpopexy (ASCP) with concomitant supracervical hysterectomy to ASCP alone in patients with prior hysterectomy in the prevention of mesh erosion. MATERIALS AND METHODS: We performed a retrospective chart review of 277 consecutive patients who underwent ASCP with one surgeon. Patients were separated into two groups based on the presence of a uterus at the time of surgery. Group A comprised195 patients with a uterus who underwent ASCP and concomitant supracervical hysterectomy; group B comprised 82 patients with prior total hysterectomy who underwent ASCP. The outcome measures included peri- and postoperative findings, complications, and surgical success. Data were analyzed by t test and chi-square test using SPSS software. RESULTS: No significant difference was found between groups during surgery in terms of anesthesia type, total operative time, and estimated intraoperative blood loss. At mean postoperative follow-up of 7-8 months, there was no difference between groups in terms of de novo urinary symptoms, recurrent vaginal-wall prolapse, or dyspareunia and Pelvic Organ Prolapse Quantification (POP-Q) point C examination. Sling erosion was observed in four (4.2 %) patients in group A versus none in group B. Apical mesh erosion was diagnosed in one patient in group A (0.5 %) and two (2.4 %) patients in group B. These differences were not statistically significant. CONCLUSION: Concomitant supracervical hysterectomy with ASCP was associated with a low incidence of mesh erosion and had the same intraoperative course and postoperative outcome as ASCP with previous hysterectomy.

Long-term quality of life and pelvic floor dysfunction after bariatric surgery.

OBJECTIVE: To evaluate effects of bariatric surgery on pelvic floor mediated quality of life in morbidly obese women. STUDY DESIGN: Prospective cohort study of 44 women undergoing bariatric surgery. RESULTS: Thirty-six women gave data at baseline and at mean follow-up of 3.15 years following bariatric surgery. Although urinary impact questionnaire scores improved (-34.92, P = .0020), colorectal-anal impact questionnaire and pelvic organ prolapse impact questionnaire scores did not improve despite significant weight loss. Baseline female sexual function index scores were low (17.70 ± 8.38) and did not improve with weight loss (16.91 ± 9.75, P = .5832). Pelvic organ prolapse/urinary incontinence sexual questionnaire scores did improve (35.78 ± 6.06 preoperatively vs 38.22 ± 6.03 postoperatively, P = .0193). CONCLUSION: Bariatric surgery is associated with significant improvement in the impact of urinary incontinence on quality of life. Sexual function was poor, and improved only on the pelvic organ prolapse/urinary incontinence sexual questionnaire that evaluated urinary incontinence.

Magnetic resonance imaging of abdominal versus vaginal prolapse surgery with mesh.

INTRODUCTION AND HYPOTHESIS: We compared two surgical approaches in patients with symptomatic prolapse of the vaginal apex with normal controls by analyzing pelvic landmark relationships measured using magnetic resonance imaging (MRI) before and after surgery. METHODS: In this prospective multicenter pilot study involving 16 participants, nulliparous controls (n = 6) were compared with ten parous (3.0 ± 1.0) women with uterine apical prolapse equal to or greater than stage 2. Group A (n = 5) underwent abdominal sacral colpopexy with monofilament polypropylene mesh and group B (n = 5) with vaginal mesh kit repair (Total ProLift). Subtotal hysterectomy was performed in all group A and no group B women. All patients underwent preoperative and 3-month postoperative Pelvic Organ Prolapse Quantification (POP-Q) and dynamic MRI. Comparison of MRI pelvic angles and distances was performed and analyzed by Mann-Whitney rank sum test and chi-square test. RESULTS: Vaginal apical support is similar at 3 months for abdominal sacral colpopexy (ASCP) and ProLift by POP-Q examination and MRI analysis. In both treatment groups, the postoperative POP-Q point C and MRI parameters were similar to nulliparous controls at 3 months. CONCLUSIONS: Anatomic outcomes for ASCP compared with ProLift were similar at 3 months in terms of vaginal apical support by POP-Q and MRI analysis. Continued comparative analysis of postoperative support with objective imaging seems warranted.

Effect of hormone replacement and selective estrogen receptor modulators (SERMs) on the biomechanics and biochemistry of pelvic support ligaments in the cynomolgus monkey (Macaca fascicularis).

OBJECTIVE: To evaluate the effect of selective estrogen receptor modulators and ethinyl estradiol on the biomechanical and biochemical properties of the uterosacral and round ligaments in the monkey model of menopause. STUDY DESIGN: A randomized, double-blind, placebo-controlled study on 11 female macaque monkeys. Ovariectomized monkeys received 12 weeks of placebo, raloxifene, tamoxifen, or ethinyl estradiol. Biomechanical step-strain testing and real-time polymerase chain reaction was performed on the uterosacral and round ligaments. RESULTS: Tamoxifen and raloxifene uterosacrals expressed differing collagen I/III receptor density ratios, but both selective estrogen receptor modulators showed decreased tensile stiffness compared to ethinyl estradiol and controls. CONCLUSION: These findings support a possible effect of selective estrogen receptor modulators on biomechanical and biochemical properties of uterosacrals. This may play a role in pelvic organ prolapse.

Use of pelvic organ prolapse staging systems in published articles of selected specialized journals.

INTRODUCTION AND HYPOTHESIS: A standardized system for reporting pelvic organ prolapse is important for clinical communication, patient follow-up, and meaningful comparisons between studies. In 1996, the description of the Pelvic Organ Prolapse Quantification system (POPQ) was published. We hypothesized that its use in published articles of specialized journals would increase over time. METHODS: Articles from eight journals in 2004 and 2007 were included if any attempt to grade prolapse was mentioned. Reviews, editorials, and abstracts were excluded. RESULTS: Use of POPQ increased from 64.9% to 82.1% (p = 0.01) while other systems decreased. POPQ was used more frequently in the US than other countries. Urologists used POPQ less and Baden-Walker more frequently than other specialists. CONCLUSIONS: Use of POPQ has increased in the period studied. This trend was observed in all the subgroups analyzed, showing that POPQ is being adopted as the universal language of prolapse in the published literature.

Anterior intravaginal slingplasty tunneller device for stress incontinence and posterior intravaginal slingplasty for apical vault prolapse: a 2-year prospective multicenter study.

OBJECTIVE: The purpose of this study was to report the outcome for (1) anterior intravaginal slingplasty in the treatment of urodynamic stress incontinence and (2) posterior intravaginal slingplasty for apical prolapse (> or = stage II). STUDY DESIGN: This was a 2-year prospective multicenter study: patients, 430; anterior intravaginal slingplasty, 144; posterior intravaginal slingplasty, 164; both procedures, 122 (552 tapes total). At 6 and 12 months, the results of the Pelvic Floor Impact Questionnaire, cough stress test, and Pelvic Organ Prolapse Quantitation were assessed. Statistical analyses used paired t-tests. RESULTS: Of the women in the study, 95% (42 women) had a negative cough stress test result through 12 months (n = 44 women), and 96% (127 women) had a negative cough stress test result at 6 months (n = 132). At 6 months, apical support was optimal in 95.3% (143/150 women) and was satisfactory in 2.7% (4/150 women) and at 12 months, 98.1% (52/53 women), 1.9% (1/53 women). Seventeen of 430 patients (4.0%) had vaginal mesh extrusion. Pelvic Floor Impact Questionnaire scores significantly improved (P < .0001). CONCLUSION: Anterior intravaginal slingplasty and posterior intravaginal slingplasty are safe and effective when performed with other procedures. For anterior intravaginal slingplasty, the rates of perforation and retention are low, but early extrusions are seen. Patients showed improvements in the Pelvic Floor Impact Questionnaire, regardless of extrusion.

Teaching of pelvic organ prolapse quantification system among obstetrics/gynecology and urology residents in the United States.

OBJECTIVES: The objective of this study was to compare the Pelvic Organ Prolapse Quantification (POPQ) system teaching practices among obstetrics/gynecology (ob/gyn) and urology residents in the United States. METHODS: Anonymous Web-based survey was e-mailed to the residency program directors/coordinators of all urology and ob/gyn programs in the United States with a request to forward it to all their residents. Fisher exact and z tests for proportions and multivariate regression analysis examining factors associated with POPQ system use were used in the statistical analysis. RESULTS: Sixty percent (45/75) of urology and 78.9% (105/133) of responding ob/gyn residents (P = 0.006) reported having used the POPQ system, whereas 42.7% and 59.4% of them, respectively, reported current use (P = 0.03). The latter also reported more protected educational time (P < 0.001), more urogynecologists in their programs (P = 0.032), and learning more frequently from drawings (P = 0.025). Opinions about the routine clinical and scientific usefulness of POPQ system and the perceived difficulty in learning it did not vary between groups. After performing multivariate logistic regression analysis, the presence of a fellowship, the number of subspecialists in the program, and the number of POPQ system teaching sessions were the studied variables found to contribute independently to the residents' use of that system. CONCLUSIONS: Obstetrics/gynecology residents use POPQ system more frequently than do urology residents. This could be related to differences in teaching practices between urology and ob/gyn programs.

Efficacy of Solifenacin on Overactive Bladder Symptoms, Symptom Bother, and Other Patient-Reported Outcomes in Subjects With or Without Incontinence: A Post Hoc Analysis of Data From VIBRANT.

OBJECTIVE: : To evaluate the efficacy of solifenacin versus placebo by baseline continence status using post hoc analysis. METHODS: : Patients with overactive bladder (OAB) were randomized to solifenacin or placebo for 12 weeks; patient-reported outcome (PRO) measures and bladder diaries were completed at prespecified time points. VESIcare Investigation of Bother and Quality of Life in Subjects with OAB (VIBRANT) was not designed to show treatment differences within continence status subgroups. RESULTS: : In the full analysis set (n = 750), 73% of patients were incontinent (n = 545) at baseline. After 12 weeks, incontinent patients receiving solifenacin showed significant improvements versus placebo on PRO measures and most diary-based end points; continent patients (n = 205) showed smaller but similar treatment-related changes. Tolerability was similar in both subgroups and by treatment; most frequent adverse events were dry mouth and constipation. CONCLUSIONS: : In the VIBRANT study, solifenacin significantly improved OAB symptom bother, health-related quality of life, and most symptoms versus placebo in incontinent patients. Continent patients showed smaller but similar trends. Solifenacin was well tolerated in both subgroups.

Sacral Neuromodulator InterStim Surgical Site Infection: Two Case Reports.

OBJECTIVE: : The surgical site infection rate of sacral neuromodulator placement for the treatment of refractory urge urinary incontinence is reported to be between 5% and 7.9%. Our objective was to report the investigation process of these infections and a possible source for their occurrence. METHODS: : We performed infection control surveillance of two patients that underwent sacral neuromodulator placement on the same date, in the same operating room, and by the same staff who developed similar sacral cellulitis postoperatively. RESULTS: : The investigation revealed Staphylococcus aureus infections with a common antibiogram in both patients. Nasal cultures of all personnel involved in their care, showed Staphylococcus aureus with the same antibiogram only in a Medtronic representative who had manipulated the InterStim settings. Genetic analysis showed this to be an identical strain in one patient infection. CONCLUSIONS: : The postoperative manipulation of device settings may be a source of surgical site infection, and infection control practices including strict hand washing, gloves, gown and mask may be warranted.

The effects of hormone replacement on the biomechanical properties of the uterosacral and round ligaments in the monkey model.

OBJECTIVE: The purpose of this study was to determine effects of ovariectomy (OVX) and conjugated equine estrogens plus medroxyprogesterone acetate (CEE/MPA), or ethinyl estradiol plus norethindrone acetate (EE/NA) on biomechanics of uterosacral (USL) and round (RL) ligaments in postmenopausal (PMP) monkeys. STUDY DESIGN: This was a randomized, triple blind, placebo-controlled study. OVX monkeys received 12 months no treatment (Pbo) (n = 19), CEE/MPA (n = 19), or EE/NA (n = 21). USL and RL step strains and stress-relaxation data were curve-fitted, giving strain-dependent tensile modulus (TM) from 0% to 30%. RESULTS: (1) USL: TM for both treatment groups was greater than Pbo for strains from 0% to 12% (P < .04). (2) RL: TM for both treatment groups was smaller than Pbo for strains from 12% to 30% (P < .05). No differences were found between treatment regimens. CONCLUSION: CEE/MPA and EE/NA both affect functional biomechanical properties by increasing tensile stiffness in the USL and decreasing it in the RL.

Short-term urogenital effects of raloxifene, tamoxifen, and estrogen.

OBJECTIVE: The purpose of this study was to assess the urogenital effects of raloxifene, tamoxifen, conjugated equine estrogen, and placebo in healthy postmenopausal women. STUDY DESIGN: This randomized, double-blind, placebo-controlled study compared the urogenital effects of 0.625 mg of conjugated equine estrogen (n = 15 women), 20 mg of tamoxifen (n = 14 women), 60 mg of raloxifene, (n = 15 women), and placebo (n = 13 women). Evaluations at baseline and evaluations after 20 weeks receiving the drug included a pelvic examination with cytologic evaluation of vagina and urethra, pelvic organ prolapse quantitation, and urethral axis deflection by cotton swab test (only in patients with incontinence [33%]). RESULTS: Conjugated equine estrogen increased the maturation value of both urethral and vaginal cytologic condition (P =.002, P =.032, respectively). There was a decrease in vaginal maturation value in the raloxifene group (not significant). Two of 8 women in the conjugated equine estrogen group showed evidence of worsening prolapse by pelvic organ prolapse quantitation; the condition of 2 of 8 women improved. In the raloxifene, tamoxifen, and placebo groups 8 of 12 women, 4 of 13 women, and 2 of 11 women had worsening in prolapse scores, respectively, whereas none of the women had improvement. Increased cotton swab deflection was found in 3 of 5 women in the raloxifene group, in 5 of 8 women in the tamoxifen group, in 0 of 4 women in the placebo group, and in 0 of 2 women in the conjugated equine estrogen group. Seventy-five percent of the patients who received raloxifene and 60% of the patients who received tamoxifen had increases in prolapse by any measure (ie, pelvic organ prolapse quantitation or cotton swab or clinical assessment) compared with 18% of the patients in the placebo group and 22% of the patients in the conjugated equine estrogen group (P =.015), although symptoms did not differ among groups. CONCLUSION: Neither raloxifene nor tamoxifen improve cytohormonal effects in the vagina or urethra, whereas conjugated equine estrogen does. Raloxifene and tamoxifen appear to show worsening prolapse compared with conjugated equine estrogen and placebo. The clinical relevance of these effects is unknown and requires investigation.