Limited Functional Effects of Subacute Syngeneic Bone Marrow Stromal Cell Transplantation After Rat Spinal Cord Contusion Injury.

Cell transplantation might be one means to improve motor, sensory, or autonomic recovery after traumatic spinal cord injury (SCI). Among the different cell types evaluated to date, bone marrow stromal cells (BMSCs) have received considerable interest due to their potential neuroprotective properties. However, uncertainty exists whether the efficacy of BMSCs after intraspinal transplantation justifies an invasive procedure. In the present study, we analyzed the effect of syngeneic BMSC transplantation following a moderate to severe rat spinal cord injury. Adult Fischer 344 rats underwent a T9 contusion injury (200 kDy) followed by grafting of GFP-expressing BMSCs 3 days postinjury. Animals receiving a contusion injury without cellular grafts or an injury followed by grafts of syngeneic GFP-expressing fibroblasts served as control. Eight weeks posttransplantation, BMSC-grafted animals showed only a minor effect in one measure of sensorimotor recovery, no significant differences in tissue sparing, and no changes in the recovery of bladder function compared to both control groups in urodynamic measurements. Both cell types survived in the lesion site with fibroblasts displaying a larger graft volume. Thus, contrary to some reports using allogeneic or xenogeneic transplants, subacute intraparenchymal grafting of syngeneic BMSCs has only a minor effect on functional recovery.

Magnetic resonance-visible polypropylene mesh for pelvic organ prolapse repair.

AIM: To develop a magnetic resonance (MR)-visible mesh using iron oxides and prove visibility. METHODS: In a phantom study, a suitable iron oxide, Fe3O4 [iron(II,III) oxide] and FeOOH [iron(III) oxide-hydroxide], concentration was determined using relaxometric MR measurements of the transverse relaxation rates R2 and R2*. Next, a nonabsorbable mesh was designed from the MR-visible threads woven into a polypropylene mesh. The mesh was implanted into a fresh female cadaver via the transobturator route, and MR visibility was assessed with various MR pulse sequences in a clinical 3-tesla system. RESULTS: Optimal contrast was achieved with Fe3O4 at 0.2 weight-% in all imaging sequences, and the optimal contrast was achieved in a 3D spoiled gradient-echo (fast low-angle shot) acquisition. In this concentration range the apparent transverse relaxation rate R2* is below 10 ms. The mesh was visible in the cadaver on T1-weighted 3D spoiled gradient-echo images and T1-weighted fast spin-echo images. CONCLUSION: Mesh materials can be manufactured to be visible on MR with a negative contrast. Fe3O4 meshes could simplify follow-up examinations and help diagnose origins of postsurgical lesions after urogynecological procedures with mesh material.

Is a wider angle of the membranous urethra associated with incontinence after radical prostatectomy?

PURPOSE: To investigate whether differences in the anatomy and dynamics of the pelvic floor (PF) in patients after radical prostatectomy (RP) depicted on magnetic resonance imaging (MRI) are associated with continence status. METHODS: In the prospective designed study, 24 patients with post-prostatectomy stress urinary incontinence were enrolled. Additionally, 10 continent patients after RP were matched for age, body mass index and perioperative parameters. All patients underwent continence assessment and MRI (TrueFISP sequence; TR 4.57 ms; TE 2.29 ms; slice thickness 7 mm; FOV 270 mm) 12 months after RP. Images were analyzed for membranous urethra length (MUL), angle of the membranous urethra (AMU), severity of periurethral/urethral fibrosis, lifting of the levator ani muscle, lowering of the posterior bladder wall (BPW), bladder neck (BN) and external urinary sphincter (EUS), and symphyseal rotation of these structures during the Valsalva maneuver and voiding. RESULTS: Compared to continent controls, incontinent patients showed a significant wider AMU during voiding (p = 0.002) and more pronounced lowering of the BN and EUS (p < 0.001). No differences between the groups were found in symphyseal rotation of the analyzed structures, MUL and severity of periurethral/urethral fibrosis. CONCLUSIONS: The angle of the membranous urethra as a result of anchoring of the BN and EUS in the PF appears to be an important functional factor with an essential impact on continence after RP. Functional MRI seems to be a helpful imaging tool for morphologic and dynamic evaluation of the PF.

Impact of the 'repositioning test' on postoperative outcome of retroluminar transobturator male sling implantation.

OBJECTIVE: To evaluate prospectively the value of the 'repositioning test' (RT) in preoperative patient selection for the efficacy of male stress urinary incontinence (SUI) treatment using a retroluminar transobturator male sling (AdVance sling). PATIENTS AND METHODS: 65 consecutive patients with SUI after radical prostatectomy were included in this single-center prospective study. Preoperatively, patients were classified into those with 'positive' and 'negative' RT. Postoperative results were analyzed and the association between the result of the RT and postoperative outcome was evaluated. RESULTS: 53 patients (81.5%) showed preoperatively a positive RT and 12 patients (18.5%) a negative RT. After a follow-up of 12 months, patients with positive RT showed a cure rate (0 pads/day) of 83% and patients with a negative RT showed only a cure rate of 25%. A positive RT significantly correlated with cure in outcome (p < 0.001). CONCLUSIONS: Patients with positive RT have a significantly better chance for successful AdVance sling implantation. The RT is minimally invasive, easy to learn and easy to perform. Therefore, the RT is a very useful tool for preoperative patient selection.

Morphology and dynamics of the male pelvic floor before and after retrourethral transobturator sling placement: first insight using MRI.

PURPOSE: We prospectively evaluated changes in morphology and dynamics of the male pelvic floor on magnetic resonance imaging (MRI) associated with retrourethral transobturator sling (RTS) placement. PATIENTS AND METHODS: Twenty-six men with post-prostatectomy incontinence consecutively underwent functional cine-MRI before and 12 months after RTS. The membranous urethra length (MUL) and severity of periurethral/urethral fibrosis were assessed on static MRI. A lowering of the posterior bladder wall (BPW), the bladder neck (BN), the external urinary sphincter (EUS) and symphysial rotation of these structures were analysed on dynamic MR images. The success rate was defined as cure (0-1 dry 'security' pad) or improvement (pad reduction ≥ 50 %). RESULTS: The success rate was 77 % (20/26 patients). The mean follow-up was 20.4 months. The MUL significantly increased post-operatively (p < 0.001). There were no significant pre- and post-operative differences in severity of periurethral/urethral fibrosis. Significant elevation of the BPW (p < 0.021), BN and EUS (p < 0.002) was observed post-operatively. The RTS failure was significantly associated with the severity of periurethral fibrosis pre- (p < 0.032) and post-operatively (p < 0.003). CONCLUSIONS: RTS placement is associated with MUL increase, elevation of the BN, BPW and EUS. De novo development of periurethral or urethral fibrosis seems not to be confirmed. The RTS failure was related to the severity of pre- and post-operative periurethral fibrosis. The impact of MRI on pre-operative diagnostics of RTS failure needs further evaluation.

Functional interactions between the fossa ischioanalis, levator ani and gluteus maximus muscles of the female pelvic floor: a prospective study in nulliparous women.

PURPOSE: We evaluated the role of the fossa ischioanalis (FI) in functional relations between the levator ani (LA) and gluteus maximus muscles (GM) in healthy female volunteers. METHODS: Twenty-three nulliparae were examined. Electromyogramms of LA and GM were simultaneously recorded during voluntary contraction of the pelvic floor muscles (PFM) and at rest in six body positions. The surface areas of LA (LAA), FI (FIA) and GM (GMA) were evaluated using MRI. RESULTS: Simultaneous LA and GM contractions were electromyographically observed irrespectively of body position in 97.2 %. MRI revealed synchronous movement of all structures: while LAA (-7.4 %) reduced, GMA increased (+6.8 %), FIA changed significantly (+3.4 %). CONCLUSIONS: The LA, FI and GM are morphologically and functionally connected. We recommend considering these structures as the 'LFG-Complex', emphasising the importance of this unit for functional integration of the pelvic floor. The findings of this study may contribute to understanding of urinary continence mechanism and disorders after pelvic floor surgery and obstetrical trauma.

Risk factors of treatment failure after retrourethral transobturator male sling.

PURPOSE: Prospective evaluation of independent risk factors for failure of the retrourethral transobturator sling suspension (RTS) with special attention on sphincter function and surgical technique. METHODS: 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%). RESULTS: 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. CONCLUSIONS: Preoperative selection of the patients with regard to residual sphincter function and a special attention on better sling fixation may increase RTS efficacy.

Urodynamic parameters after retrourethral transobturator male sling and their influence on outcome.

OBJECTIVE: To evaluate prospectively detailed urodynamic parameters before and after retrourethral transobturator sling (RTS) placement and the impact of adverse preoperative urodynamic parameters on postoperative outcome. METHODS: Fifty-five consecutive patients with postprostatectomy stress urinary incontinence (SUI) underwent urodynamics with pressure flow and abdominal leak point pressure (ALPP) measurements, quality of life, 1-hour pad test, and daily pad use assessment before RTS (AdVance) and 12 months postoperatively. Volume of first sensation and first desire to void, maximum cystometric capacity (MCC), ALPP, maximum flow rate (Qmax.), average flow rate, time to Qmax., detrusor voiding pressure at Qmax., voiding time, and postvoid residual urine volume (PVR) were assessed. The success rate was defined as cure (no or one dry "security" pad) or improvement (1-2 pads or pad reduction≥50%). Adverse parameters included ALPP≤30 cm H2O, Qmax.≤10 mdL/s, and MCC≤200 mL. RESULTS: Success rate after RTS was 73% (40/55 patients). Mean follow-up was 21±11.7 (range, 12-41) months. Only ALPP changed significantly (61±14.2 vs 79±20.4 cm H2O). No PVR>30 mL, de novo reduced bladder compliance and hypo- or overactivity were observed. Urine loss by 1-hour pad test (136.1±119.4 vs 39.4±77.0) and daily pad use (4.6±2.0 vs 1.9±2.1) decreased significantly. Adverse preoperative urodynamic parameters were not associated with postoperative outcome. CONCLUSION: The RTS is an effective and safe device for SUI treatment without signs of compression or obstruction of the urethra or any influence on voiding parameters. Adverse preoperative urodynamic parameters have no influence on postoperative outcome.

Results of the AdVance transobturator male sling after radical prostatectomy and adjuvant radiotherapy.

OBJECTIVES: To prospectively evaluate the efficacy of the functional AdVance transobturator sling for the treatment of male stress urinary incontinence (SUI) in patients after radical prostatectomy and additional adjuvant radiotherapy. METHODS: Between February 2007 and November 2008, 24 patients with postprostatectomy SUI (ICS grade 2-4) and additional adjuvant radiotherapy were treated consecutively with the AdVance sling. Preoperatively, intensive workup, including urodynamic assessment and flexible urethroscopy, was performed. Physical examinations (pad test, uroflowmetry, ultrasound) and questionnaires (I-QOL score, ICIQ-UI-SF score) were performed during baseline and during follow-up. Cure rate was defined as no pad use or one dry pad, and improved rate as 1-2 pads or reduction of pads by ≥50%. RESULTS: After a median follow-up of 18.0 months (range 12-33 months, mean 18.8 months), the success rate was 50%. Daily pad use and pad weight in the 1-hour pad test decreased significantly. Patients with ICS grade 2 SUI exhibited a trend for a better success rate in comparison with patients with grade 3 and 4 SUI. Results were durable over time. Postoperatively, 16.7% of the patients exhibited transient acute urinary retention which resolved without further treatment after a maximum of 6 weeks. 1 sling had to be removed because of initial misplacement. CONCLUSIONS: In selected patients after adjuvant radiotherapy, the AdVance sling achieved a success rate of 50% and results were stable in a median follow-up of 18 months. Complication rates were low and comparable to complication rates for patients without additional radiotherapy.

Mid-term results for the retroluminar transobturator sling suspension for stress urinary incontinence after prostatectomy.

OBJECTIVE: • To evaluate prospectively the efficacy of the retroluminar transobturator male sling (AdVance® sling) for the functional treatment of stress urinary incontinence (SUI) after prostatectomy. PATIENTS AND METHODS: • A total of 137 patients with grade II-IV SUI, resulting from radical prostatectomy, were treated with the AdVance® sling in a prospective clinical study. In all, 11 patients were lost to follow-up. A total of 17 patients (13.5%) had additional adjuvant radiotherapy before sling implantation. • Before and after sling implantation, a standardized 1-h pad test was performed and post-void residual urine, uroflowmetry, quality-of-life scores and the International Index of Erectile Function (IIEF-5) were assessed. • When calculating the cure and improvement rates, 'cure' was defined as no pad use or one dry prophylactic pad; and 'improved' was defined as 1-2 pads or reduction of pads ≥ 50%. RESULTS: • After a median (range) follow-up of 27 (20-37) months, and a mean follow-up of 27.2 months, the success rate was 75.4% with 51.6%'cured' and 23.8%'improved'. • Overall daily pad use, urine loss in the 1-h pad test and quality-of-life scores improved significantly after sling implantation. • Compared with 1-year follow-up data, no worsening over time was noticed and no additional complications were seen. CONCLUSION: • With a mid-term follow-up, the retroluminar transobturator male sling is an effective, safe and attractive treatment option for SUI after radical prostatectomy. Results are stable over time.

Repeat retrourethral transobturator sling in the management of recurrent postprostatectomy stress urinary incontinence after failed first male sling.

BACKGROUND: A failure rate between 20% and 45.5% after retrourethral transobturator sling (RTS) is reported. Recommendations for the management of persistent or recurrent postprostatectomy stress urinary incontinence (SUI) after failed male sling do not exist. OBJECTIVE: The aim of this study was the prospective evaluation of the efficacy of repeat RTS (RRTS) in patients after failed first RTS. DESIGN, SETTING, AND PARTICIPANTS: Between March 2007 and August 2009, 35 patients with mild to severe SUI after failed first RTS were treated with a second AdVance sling (American Medical Systems, Minnetonka, MN, USA). MEASUREMENTS: Preoperative and postoperative evaluation included daily pad use, 1-hr pad test, postvoiding residual (PVR) urine, uroflowmetry, and quality-of-life (QoL) scores. RESULTS AND LIMITATIONS: After 6 mo, 45.5% (15 of 33 patients) showed no pad use; 30.3% (10 of 33 patients), one dry "security" pad; 3% (1 of 33 patients), one wet pad; 6.1% (2 of 33 patients), two pads; 3% (1 of 33 patients), pad reduction ≥50%; and 12.1% (4 of 33 patients), treatment failure. After 16.6 mo, 34.5% (10 of 29 patients) showed no pad use; 37.9% (11 of 29 patients), one dry "security" pad; 3.4% (1 of 29 patients), one wet pad; 3.4% (1 of 29 patients), two pads; 10.3% (3 of 29 patients), pad reduction ≥50%; and 10.4% (3 of 29 patients), treatment failure. Daily pad use and pad weight decreased significantly. PVR and uroflowmetry results showed no significant change. QoL improved significantly. Postoperative acute urinary retention was observed in 23.6% of patients. CONCLUSIONS: RRTS is an effective and safe treatment option for the management of SUI after failed first RTS.

Complications of the AdVance transobturator male sling in the treatment of male stress urinary incontinence.

OBJECTIVE: To evaluate prospectively the complication rate of the retrourethral transobturator sling (AdVance sling) for the functional treatment of male stress urinary incontinence (SUI). METHODS: In 230 patients with SUI due to nonintrinsic sphincter deficiency (without direct sphincter lesion) after radical prostatectomy (n=213), radical cystoprostatectomy with ileal neobladder (n=2) and transurethral resection of the prostate (n=15) a retrourethral transobturator sling was implanted. Patients were followed up for a median of 17 months (range, 4-42 months) with regard to intraoperative, early postoperative, and midterm postoperative complications. RESULTS: Overall complication rate of the AdVance sling was 23.9%. Despite one accidental sling misplacement, no intraoperative complication occurred. Forty-nine patients (21.3%) experienced urinary retention postsurgery. Two slings were explanted (0.9%), 1 due to initial wrong placement and the other due to a symphysitis, attributed to a Guillain-Barré syndrome and not to a sling infection. One sling was transected (0.4%) due to slippage of the sling with obstruction of the urethra. Further complications were local wound infection (0.4%), urinary infection with fever (0.4%), and persistent moderate perineal pain (0.4%). There was no correlation between postoperative acute urinary retention and age at sling implantation, time of incontinence before sling implantation, preoperative daily pad use, or prior invasive incontinence treatment, respectively. CONCLUSIONS: The retrourethral transobturator AdVance sling is a safe treatment option for male nonintrinsic sphincter deficiency SUI, with the main postoperative complication being transient acute urinary retention. Severe intra- and postoperative complications are rare and sling explantation rate is very low.

Semen quality in men with malignant diseases before and after therapy and the role of cryopreservation.

OBJECTIVE: To review the literature and answer questions about semen quality in young cancer patients before and after therapy and the importance of sperm cryopreservation. METHODS: All aspects of sperm cryopreservation and effects of therapies on semen quality were examined on the basis of MedLine database searches. RESULTS: Chemotherapy, radiation, or their combination results in a significant reduction of sperm quality and as a consequence an indefinite time of infertility follows. The type of cancer and the pretreatment sperm concentrations were the most significant factors governing posttreatment semen quality and recovery of spermatogenesis. Due to their age, fertility and sexual functioning are key issues for these patients. Yet there is no medical protection of the germinal epithelium available. Male germ cell transplantation is in its infancy and still there are no therapeutical options to improve spermatogenesis after damage has occurred. Consequently, cryopreservation represents the only preemptive measure for conserving fertility. CONCLUSION: This manuscript updates the current knowledge of diverse chemotherapeutic treatment regimens and their gonadotoxic effects as well as the development of posttreatment fertility in cancer patients. The importance and rationale of sperm cryopreservation are discussed and possible future options are highlighted.