Extracorporeal shockwave therapy in treatment of chronic prostatitis/chronic pelvic pain syndrome: Systematic review and meta-analyses.

AIMS: Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) prevalence varies from 8.4% to 25% of the male population and is associated with diminished health-related quality of life. Managing CP/CPPS remains challenging and there is not any common option to treat all patients effectively because of the complex disease nature. The currently available data for the extracorporeal shockwave therapy (eSWT) effect on pain relief and well-being were analyzed in the present study. METHODS: We adhered to PRISMA 2022 guidelines for reporting the quantitative and qualitative data synthesis. A literature search was conducted in March 2023 using PubMed/Medline, Scopus, and Google Scholar. Randomized prospective studies of eSWT alone or eSWT plus conventional medicinal treatment were included. The risk of bias was estimated using the RoB 2.0. Primary outcomes were self-reported scores, including the NIH-CPSI questionnaire and VAS, at 1 month or 2, 3, and 6, months follow-up. RESULTS: The CP/CPPS patients who receive eSWT have more pronounced pain relief and improvement of other subjective NIH-CPSI scores compared with control groups that received placebo or medication therapy. The effect of eSWT seems to be long-lasting and was confirmed in the 6-month follow-up (p < 0.01). CONCLUSIONS: Based on the meta-analysis of accessible studies, we receive the equivalence eSWT applicability for the CP/CPPS treatment and can be offered to patients because of its noninvasiveness, high level of safety, and successful clinical results demonstrated in this analysis.

A comparison of native vaginal and ligament surgery for cure of pelvic organ prolapse and overactive bladder.

The key messages from the Shkarupa et al. native cardinal/uterosacral ligament (CL/USL) study, was that, in premenopausal women, ligament repair alone is sufficient for cure of pelvic organ prolapse (POP) and urgency, achieving cure rates of 85.7% for POP and 81.6% for urgency at 12 months. However, in postmenopausal women, the cure rates were 20.5% for POP and 33.3% for urge at 12 months. The Lancet Prospect Trial recorded 21% for native vaginal repair at 12 months. The poor POP cure rate in the Prospect Trial, and the rapid deterioration in the post-menopausal CL/USL repair group, can be explained by known biomechanics. The vagina has little structural strength. Ligaments, with a much higher breaking strain, are the main structural support of pelvic organs. Yet, even native ligament repair reported very low cure rates at 12 months. The poor results in postmenopausal women with native ligament repair can be explained by collagen breakdown after the menopause, as collagen is the key structural component of ligaments. An important question posed in the ligament repair study was, "What happens to women cured by ligament repair after the menopause when the collagen leaches out of the ligaments?". One recommendation was that collagen creating tapes be routinely applied in prolapse surgery and OAB, at least in postmenopausal women. The recommendation for routine collagen-creating ligament repair methods, especially in older women, are supported by high 5-year surgical cure rates in 70-year-old Japanese women, 91.2% for POP, at 12 months, falling to 79.0 at 60 months, using collagen creating Tissue Fixation System (TFS) minislings.

A brief physiology and pathophysiology of the bladder.

The remit of this review is confined to experimental works and publications relevant to the integral theory of female urinary incontinence (IT). Since its first publication in 1990, the IT has challenged the general view that the pathogenesis of overactive bladder (OAB) (urge, frequency, nocturia) is unknown and there is no cure. According to the IT, normal function bladder control is binary, either closed or open. Control is cortical via a peripheral feedback component: oppositely acting reflex striated pelvic muscles contract against suspensory ligaments to close the urethra for continence, open it prior to evacuation, and stretch the vagina like a trampoline to prevent excess impulses from the urothelial stretch receptors which may cause unwanted urgency at low bladder volumes (OAB). The pathogenesis of female urinary incontinence is from outside the bladder, mainly weak ligaments or vagina, due to collagen deficiency. Damage in childbirth (collagen depolymerization) and age (collagen loss) make ligaments vulnerable to damage. With weak ligaments, muscles contracting against them weaken: the muscles cannot close the urethra (manifested as stress incontinence), open it (manifested as emptying problems or retention) or stretch the vagina to prevent the urothelial stretch receptors firing off prematurely (manifested as urge incontinence). Weak pubourethral ligaments can cause stress urinary incontinence (SUI), or SUI plus urge (mixed incontinence). Weak uterosacral ligaments (USLs) can cause urge, frequency, nocturia and emptying difficulties. Treatment consisting of surgical/non-surgical strengthening of ligaments can cure or improve SUI, OAB, and emptying dysfunctions. In summary, bladder control is from outside the bladder, binary, with cortical and peripheral components. A small change in definition, from "overactive" to "overactivated" is consistent with this concept, retains the acronym "OAB", and opens the door to probability of cure and a massive increase in research endeavours.

Functional mapping of the lower urinary tract by epidural electrical stimulation of the spinal cord in decerebrated cat model.

Several neurologic diseases including spinal cord injury, Parkinson's disease or multiple sclerosis are accompanied by disturbances of the lower urinary tract functions. Clinical data indicates that chronic spinal cord stimulation can improve not only motor function but also ability to store urine and control micturition. Decoding the spinal mechanisms that regulate the functioning of detrusor (Detr) and external urethral sphincter (EUS) muscles is essential for effective neuromodulation therapy in patients with disturbances of micturition. In the present work we performed a mapping of Detr and EUS activity by applying epidural electrical stimulation (EES) at different levels of the spinal cord in decerebrated cat model. The study was performed in 5 adult male cats, evoked potentials were generated by EES aiming to recruit various spinal pathways responsible for LUT and hindlimbs control. Recruitment of Detr occurred mainly with stimulation of the lower thoracic and upper lumbar spinal cord (T13-L1 spinal segments). Responses in the EUS, in general, occurred with stimulation of all the studied sites of the spinal cord, however, a pronounced specificity was noted for the lower lumbar/upper sacral sections (L7-S1 spinal segments). These features were confirmed by comparing the normalized values of the slope angles used to approximate the recruitment curve data by the linear regression method. Thus, these findings are in accordance with our previous data obtained in rats and could be used for development of novel site-specific neuromodulation therapeutic approaches.

Validation of the Russian Version of the Prolapse Quality-of-life Questionnaire and its Application to Assess the Impact of Pelvic Organ Prolapse on Quality of Life and the Effect of Treatment in Women Undergoing Reconstructive Surgery.

INTRODUCTION AND HYPOTHESIS: The objective was to validate the translated Russian version of the prolapse quality-of-life (P-QoL) questionnaire and test its applicability to assess the impact of pelvic organ prolapse (POP) on QoL and the effect of treatment in women undergoing reconstructive surgery. METHODS: Following a forward- and back-translation of the original English P-QOL questionnaire into Russian, the translated questionnaire was reviewed by a group of patients as well as an expert panel. Women with POP who were admitted to a university hospital for reconstructive surgery were recruited. All the women completed the P-QoL questionnaire, Pelvic Floor Distress Inventory (PFDI-20) and 36-Item Short Form Survey (SF-36) questionnaires before surgery. Clinical data and POP Quantification (POP-Q) Index according to the International Continence Society were obtained. Psychometric properties of the questionnaire were assessed. RESULTS: A total of 303 women with POP were included in the study. Most patients presented with POP-Q >2. The P-QoL questionnaire demonstrated good psychometric properties. High internal consistency was shown in all domains (Cronbach's alpha coefficient from 0.65 to 0.92). The test-retest reliability confirmed a highly significant stability between the total scores for each domain. Significant correlations of the P-QoL domains with the PFDI-20 and SF-36 scales (p < 0.05) were obtained, demonstrating satisfactory convergent validity. Discriminative construct validity was proved by the differences in the mean scores for P-QoL domains across POP-Q stages (p < 0.05): general health perceptions, role limitations, physical limitations, social limitations and severity measures were significantly higher for POP-Q stages 3 and 4 than for POP-Q stage 2 (p < 0.01); general health perceptions and severity measures were higher for POP-Q stage 4 than for POP-Q stage 3 (p < 0.05); sleep/energy was higher for POP-Q stage 3 than for POP-Q stage 2 (p < 0.05). Significant improvement of QoL in the 2 months after surgery (p < 0.05) indicated that the P-QoL questionnaire is sensitive to change. CONCLUSIONS: The Russian version of the P-QoL questionnaire is characterized by appropriate psychometric properties. The P-QoL questionnaire is a useful tool for describing the QoL profile in women with POP before reconstructive surgery and evaluating treatment outcomes after the procedure.

Tunable tension tape versus transobturator tape in treatment of stress urinary incontinence in women: Randomized controlled trial.

INTRODUCTION: The synthetic mid-urethral slings are currently considered to be the most widely used technique for the surgical treatment of stress urinary incontinence (SUI). The most challenging aspect of the existing approaches is to achieve the optimal tension of the sling which treatment results are directly dependent on. To solve this problem, sling systems enabling an adjustment of the tension in the early postoperative period were created. A comparative study of the effectiveness and safety of such a system and a nonadjustable sling seems to be a relevant task. MATERIALS AND METHODS: A double-blind, randomized, multicenter trial enrolled 320 patients with a mean age of 55.2 ± 11.2 years and confirmed SUI. Patients were randomized into two groups: the first group underwent a standard synthetic suburethral sling (transobturator tape [TOT]) procedure and the second group underwent a tunable tension tape sling (TTT) procedure. All patients underwent stress test, uroflowmetry and ultrasound scan to determine the postvoid residual volume. Urinary Distress Inventory Short Form 6, International Consultation on Incontinence Questionnaire-Short Form, Pelvic Organ Prolapse Incontinence Sexual Questionnaire 12 questionnaires were used to assess subjective efficacy. RESULTS: Enhancement of prosthesis tension in the second group was required in 44 (28%) patients. Due to the possibility of tightening of the sling in the early postoperative period, the operation was effective in 143 (89%) patients in the adjustable sling group and in 109 (68%) patients in Group 1, p < 0.001. Loosening of the sling tension was performed in 25 (16%) patients in Group 2. The signs of obstructive voiding symptoms at the follow-up time of 36 months remained in Group 1 in 13 (8%) patients. Subjective satisfaction with treatment on the PGI-I scale was higher in Group 2: 100 (62%) versus 132 (82%), p < 0.001. CONCLUSION: A synthetic mid-urethral TTT is superior to a standard nonadjustable sling in long-term effectiveness and safety.

Native tissue repair of cardinal/uterosacral ligaments cures overactive bladder and prolapse, but only in pre-menopausal women.

INTRODUCTION: The aim of this article was to study the effect of native tissue cardinal/uterosacral ligament repair on overactive bladder (OAB) and pelvic organ prolapse (POP). MATERIAL AND METHODS: Inclusion criteria included decrease of urge symptoms following insertion of a gauze tampon in the posterior fornix of vagina ('simulated operation'). Exclusion criteria included SUI, POP grades 3-4. The surgery consisted of plication of cardinal/uterosacral ligaments. Post-operative assessment was performed at3, 6, 12 and 18 months after surgery and included evaluation by stage of prolapse, Urinary Distress Inventory Short Form 6 (UDI-6), Overactive Bladder Questionnaire (OAB-q), Pelvic Floor Impact Questionnaire- Short Form 7 (PFIQ-7), and International Consultation on Incontinence Questionnaire - Urinary Incontinence Short Form (ICIQ-SF) questionnaires and voiding diary. RESULTS: At 3 months, cure rates for frequency, urgency, nocturia and prolapse were comparable. By the 6-month review, catastrophic failure commenced in the postmenopausal group, parallel for all pa-rameters, starkly contrasting with premenopausal group. At 18 months, % cure rates for pre-menopausal (post-menopausal in brackets) were 79.6 (15.4) for POP, 67.3 (20.5) for urgency, 87.7 (20.5) for nocturia and 59.2 (15.4) for frequency. CONCLUSIONS: We hypothesize the stepwise parallel recurrence of POP and symptoms in the menopausal group was a consequence of collagen deficiency in the plicated ligaments. Nevertheless, plication of uterosacral-cardinal ligament complex is simple, inexpensive, effective, especially applicable pre-menopausally for POP and as an alternative treatment option in that difficult group of pre-menopausal women who have major OAB/nocturia symptoms but only minimal prolapse.

Full-thickness vascularized vaginal flap as the fixation point in the surgical treatment of vaginal vault prolapse.

INTRODUCTION AND HYPOTHESIS: Post-hysterectomy vaginal vault prolapse is quite frequent and at the same time a challenging surgery for pelvic organ prolapse. METHODS: One of the most popular methods of treatment is sacrospinous fixation, including its mesh modification. RESULTS: Despite the high efficiency in the apical compartment, the incidence of the anterior compartment prolapse is quite high. Erosion remains an unsolved problem. A 44-year-old patient with grade IV post-hysterectomy prolapse underwent a sacrospinous fixation procedure with mesh according to the described technique. Surgery was performed successfully without complications. The duration of the operation was 40 min. A year after the operation, the recurrence of POP was not recorded in any compartments of the pelvic floor. It was possible to maintain the length of the vagina. Dyspareunia and vaginal erosion were not detected. The patient also noted a significant improvement in her quality of life. CONCLUSION: The demonstrated approach allows performing minimally invasive reconstruction of all three compartments of the pelvic floor. Moreover, the use of a full-thickness vascularized vaginal flap allows safely fixing the mesh to the vaginal vault, minimizing the risk of erosion and pain syndrome due to excessive tension.

Site-Specific Neuromodulation of Detrusor and External Urethral Sphincter by Epidural Spinal Cord Stimulation.

Impairments of the lower urinary tract function including urine storage and voiding are widely spread among patients with spinal cord injuries. The management of such patients includes bladder catheterization, surgical and pharmacological approaches, which reduce the morbidity from urinary tract-related complications. However, to date, there is no effective treatment of neurogenic bladder and restoration of urinary function. In the present study, we examined neuromodulation of detrusor (Detr) and external urethral sphincter by epidural electrical stimulation (EES) of lumbar and sacral regions of the spinal cord in chronic rats. To our knowledge, it is the first chronic study where detrusor and external urethral sphincter signals were recorded simultaneously to monitor their neuromodulation by site-specific spinal cord stimulation (SCS). The data obtained demonstrate that activation of detrusor muscle mainly occurs during the stimulation of the upper lumbar (L1) and lower lumbar (L5-L6) spinal segments whereas external urethral sphincter was activated predominantly by sacral stimulation. These findings can be used for the development of neurorehabilitation strategies based on spinal cord epidural stimulation for autonomic function recovery after severe spinal cord injury (SCI).

Feasibility of Percutaneous Nephrolithotomy in Positive Urine Culture: A Single Center Retrospective Study.

PURPOSE: To determine the efficacy and safety of PCNL in patients with positive urine culture without an any other risk factors prior to surgery, and to define an optimal pre-operative antibiotic regimen for these patients. MATERIALS AND METHODS: The study included 269 consecutive PCNL cases. These cases were divided into 2 groups according pre-operative urine culture results: sterile (group 1, n=166) and positive (group 2, n=103). Patients with risk factors linked to infection complications were excluded from study. All patients underwent PCNL in the prone position. In group 1, the antibiotic regimen included parenteral injection 30 minutes prior to operation and for 3 days after surgery. Group 2 was given antibiotics 24 hours before PCNL as well as 30 minutes before PCNL and then for 3 days following surgery. On the first day after the operation low dose CT and common blood count were performed on all patients to determine residuals, hematomas, blood loss, and inflammatory markers.  Results:  Mean age, stone size, failed ESWL, and prior nephrostomy tube insertion were higher in group 2. Although rate of pre-stented patients was equal in groups. No significant differences were observed between group 1 and 2 in regard to operative time (74,3±26,9 vs 70,2±26,5  min, P=.52), length of stay (3,9±1,2 vs 3,8±1,6 days, P=.24), SIRS (6,0% vs 7,8% patients, P=.07), and leukocyte levels exceeding  10*10*9 (77 (46,4%) vs 49 (47,6%) P=.11). Moreover, there was no sepsis or hemotransfusion in either group. Stone-free rates were also similar (78,9% vs 77,7%, P=.35). CONCLUSION: 24-hours continuous antibiotic administration before the operation (paying respect to specific resistance bacterial features) can be considered as alternative to 1-week treatment and allow to perform PCNL with sufficient safety in selected patients. Infected urine is not an independent risk factor of post-operative infections complications after PCNL in low risk patients with kidney stones.

The resurrection of sacrospinous fixation: unilateral apical sling hysteropexy.

INTRODUCTION AND HYPOTHESIS: The apical compartment is a keystone in POP treatment. Sacrospinous fixation, suggested half a century ago, today is still one of the most popular and efficient methods of colpo-hysteropexy. However, it has specific side effects: chronic pain syndrome, dyspareunia and а high rate of cystocele de novo. We aimed to evaluate the efficacy and safety of unilateral sacrospinous hysteropexy with a synthetic apical sling combined with anterior subfascial colporrhaphy. METHODS: Following the suggested technique, 174 women with anterior-apical prolapse underwent surgery. The follow-up period took 12 months. Pre- and postoperative examination included: urogynecological examination (POP-Q), uroflowmetry, ultrasound of the bladder and filling in of validated questionnaires (PFDI-20, PISQ-12). RESULTS: The mean surgery time was 26 ± 7.84 min. No cases of damage of the bladder or rectum or of intraoperative clinically significant bleeding were noted. At the 12-month follow-up, the recurrence rate in the apical compartment was 0.7% (1/147) and in the anterior compartment 7.4% (11/147). The efficacy of the surgery reached 96.5%. During 12 months of follow-up, no cases of mesh exposure or chronic pelvic pain syndrome were detected. The incidence of dyspareunia de novo was observed in just one patient. CONCLUSIONS: A unilateral sacrospinous fixation with a synthetic mesh (apical sling) combined with anterior subfascial colporrhaphy enhances the anatomical efficacy of surgery. It also helps to avoid specific side effects of traditional sacrospinous fixation.

Adjustable transobturator sling for the treatment of primary stress urinary incontinence.

INTRODUCTION AND HYPOTHESIS: The purpose of the study was to evaluate the rate of postoperative voiding dysfunction after the insertion of an adjustable transobturator sling for the treatment of primary stress urinary incontinence (SUI). The secondary aim was to assess the objective and subjective cure rates and the impact of the surgery on quality of life. METHODS: This prospective study included 171 patients with primary SUI who underwent insertion of an adjustable transobturator tape. A postoperative tension adjustment algorithm that included a cough stress test (CST), uroflowmetry and postvoid residual volume (PVR) measurement was applied in all patients the day after surgery. The baseline and control postoperative evaluations included vaginal examination, CST, Q-tip test, uroflowmetry and PVR measurement, 1-h pad test and administration questionnaires (UDI-6, IIQ-7, PISQ-12, ICIQ-SF). RESULTS: The day after surgery 65 patients (38.0%) required tape tension adjustment: an increase in tension in 53 patients (31.0%) and a decrease in 12 (7.0%). Continence was achieved in all patients. No patients showed voiding dysfunction after adjustment. Follow-up data for 12 months were available in 157 patients (91.8%). The objective and subjective cure rates were 96.2% and 97.5%, respectively. There was no statistically significant decrease in Qmax (p = 0.899) or increase in PVR (p = 0.187). According to the questionnaires scores, quality of life was improved in all patients. CONCLUSION: The adjustable transobturator sling minimizes the risk of postoperative voiding dysfunction and allows high objective and subjective cure rates to be achieved in patients with primary SUI. The technique also improves the patient's quality of life.

The novel technique of post-hysterectomy vaginal vault prolapse repair: Apical sling and "neocervix" formation.

OBJECTIVE: We primarily aimed to evaluate the effectiveness of the novel technique: bilateral sacrospinous fixation by monofilament polypropylene apical sling combined with "neocervix" formation in surgical treatment of post - hysterectomy vaginal vault prolapse. The secondary objective was to estimate the impact of the surgery on voiding function and quality of life. STUDY DESIGN: This prospective study involved 61 women suffering from post-hysterectomy prolapse. We used the following criteria to evaluate the results of surgical treatment: results of vaginal examination (POP-Q system), uroflowmetry, bladder ultrasound, validated questionnaires were used. All listed parameters were determined before the surgery and at control examinations in 1, 6, 12 months after the treatment. RESULTS: Mean operation time was 35min. No cases of intraoperative damage to the bladder/rectum, as well as clinically significant bleeding were noted.At 12-month follow-up anatomical cure rate (≤stage I, POP-Q) was 100%, 94,4% and 100% for vaginal apex, anterior and posterior vaginal walls, respectively. The following long-term complications were noted stress urinary incontinence de novo and urgency de novo were noted in 6.5% and 4,9%, respectively. Statistically significant (P<0.05) improvement in peak flow rate was observed according to uroflowmetry. Comparison of the scores by the questionnaires revealed a significant improvement in the quality of life in the postoperative period. CONCLUSION: The novel technique: combination of the apical sling and purse-string "neocervix" formation appears to be effective and safe method for treatment patients with vaginal vault prolapse. The technique improves voiding function and quality of life.

The hybrid technique of pelvic organ prolapse treatment: apical sling and subfascial colporrhaphy.

INTRODUCTION AND HYPOTHESIS: The majority of patients with cystocele undergoing reconstructive surgery have combined defects of pubocervical fascia and uterosacral/cardinal ligament complex. In this regard, the simultaneous correction of both defects is rational. Furthermore, decreasing the use of synthetic materials in pelvic floor surgery is an important goal. The aim was to evaluate the objective and subjective cure rate of a hybrid technique: bilateral sacrospinous fixation using modern monofilament synthetic tape (apical sling) combined with the original technique of subfascial colporrhaphy. MATERIALS AND METHODS: This prospective study involved 148 women suffering from cystocele combined with apical prolapse. We used the following criteria to evaluate the results of surgical treatment: results of the vaginal examination (POP-Q system), urodynamic tests, bladder ultrasound, special questionnaires (Pelvic Floor Distress Inventory [PFDI-20], Pelvic Floor Impact Questionnaire [PFIQ-7], Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire [PISQ-12], International Consultation on Incontinence Modular Questionnaire Short Form [ICIQ-SF]). All listed parameters were determined before the surgery and at control examinations at 1, 6, and 12 months after the treatment. RESULTS: At the 1-year follow-up, the objective cure rate for prolapse was 97.8%. The rate of anatomical recurrence was 2.2% (3 out of 138). The following long-term complications were noted: de novo urgency and stress urinary incontinence de novo in 2 (1.4%) and 4 (2.9%) patients, respectively. Comparison of the scores by the questionnaires also revealed a significant improvement in the quality of life in the postoperative period. Patient satisfaction rate was 97.1%. CONCLUSION: The hybrid technique is an effective and safe uterus-sparing method for patients with advanced forms of cystocele combined with apical prolapse. This technique improves voiding function, quality of life, and provides a high satisfaction rate.

Ultrasound-Guided Ureteral Stent Removal in Women.

OBJECTIVES: The purpose of this study was to develop a fast, comfortable, and safe method of ureteral stent removal in women. METHODS: From February 2014 to July 2015, a retrospective multicenter controlled study including 82 female outpatients was conducted. The control group was composed of 46 patients who underwent stent removal using a 22F cystoscope. The experimental group was composed of 36 patients who underwent stent removal under ultrasound guidance with a 15F spiral-ending device. Exclusion criteria were pelvic organ prolapse quantification stage II or higher and complicated stents (with migration or encrustation). RESULTS: All studied patients had successful ureteral stent removal. No complications were seen in both groups. Differences between mean visual analog pain scale scores and stent removal durations were statistically significant in favor of the experimental group (P = .0077 and .0075, respectively). CONCLUSIONS: The proposed method for ureteral stent removal in women under ultrasound guidance was shown to be faster and to have lower visual analog pain scale scores, in comparison with removal by a cystoscope, which makes it an attractive option for outpatient urologic praxis in uncomplicated cases, and because it is free of the risk of ionizing radiation and more comfortable, it can be used in pregnant patients.