An Experimental Protocol for the Boyden Chamber Invasion Assay With Absorbance Readout.

The phenomenon of cell invasion is an essential step in angiogenesis, embryonic development, immune responses, and cancer metastasis. In the course of cancer progression, the ability of neoplastic cells to degrade the basement membrane and penetrate neighboring tissue (or blood vessels and lymph nodes) is an early event of the metastatic cascade. The Boyden chamber assay is one of the most prevalent methods implemented to measure the pro- or anti-invasive effects of drugs, investigate signaling pathways that modulate cell invasion, and characterize the role of extracellular matrix proteins in metastasis. However, the traditional protocol of the Boyden chamber assay has some technical challenges and limitations. One such challenge is that the endpoint of the assay involves photographing and counting stained cells (in multiple fields) on porous filters. This process is very arduous, requires multiple observers, and is very time-consuming. Our improved protocol for the Boyden chamber assay involves lysis of the dye-stained cells and reading the absorbance using an ELISA reader to mitigate this challenge. We believe that our improved Boyden chamber methodology offers a standardized, high-throughput format to evaluate the efficacy of various drugs and test compounds in influencing cellular invasion in normal and diseased states. We believe that our protocol will be useful for researchers working in the fields of immunology, vascular biology, drug discovery, cancer biology, and developmental biology. Key features • Measurement of tumor invasion using human cancer cells. • Ability to measure the pro-invasive/anti-invasive activity of small molecules and biological modifiers. • Measurement of chemotaxis, chemokines, trafficking of immune cells, and proteolytic activity of matrix metalloproteinases, lysosomal hydrolysates, collagenases, and plasminogen activators in physiological and pathological conditions. • Investigation of the role of extracellular matrix proteins in the crosstalk between endothelial, epithelial, muscle, or neuronal cells and their adjacent stroma.

The Flavoring Agent Ethyl Vanillin Induces Cellular Stress Responses in HK-2 Cells.

Flavored e-cigarettes are a popular alternative to cigarette smoking; unfortunately, the extrapulmonary effects are not well-characterized. Human proximal tubule cells were cultured for 24 or 48 h with 0-1000 µM ethyl vanillin (ETH VAN) and cytotoxicity evaluated. Mitochondrial health was significantly diminished following 48 h of exposure, accompanied by significantly decreased spare capacity, coupling efficiency, and ATP synthase expression. ETH VAN at 24 h inhibited glycolysis. The endoplasmic reticulum (ER) stress marker C/EBP homologous protein (CHOP) was increased at 100 µM relative to 500-1000 µM. The downstream proapoptotic marker cleaved caspase-3 subsequently showed a decreasing trend in expression after 48 h of exposure. The autophagy biomarkers microtubule-associated proteins 1A/1B light chain 3 (LC3B-I and LC3B-II) were measured by Western blot. LC3B-II levels and the LC3B-II/LC3B-I ratio increased at 24 h, which suggested activation of autophagy. In contrast, by 48 h, the autophagy biomarker LC3B-II decreased, resulting in no change in the LC3B-II/LC3B-I ratio. Mitophagy biomarker PTEN-induced putative kinase 1 (PINK1) expression decreased after 48 h of exposure. The downstream marker Parkin was not significantly changed after 24 or 48 h. These findings indicate that the flavoring ETH VAN can induce energy pathway dysfunction and cellular stress responses in a renal model.

Urologic care of nonagenarians: A retrospective chart review.

INTRODUCTION: Nonagenarians represent a rapidly growing patient population in Canada with unique health concerns. With the goal of preparing urologists to manage this complicated patient populations in the future, we sought to characterize referral patterns, diagnoses, investigations, treatments, and associated complications in a cohort of nonagenarians. Our second goal was to review anticholinergic burden (ACB) and rates of anticoagulation in this patient population and to assess the risk of hematuria in those who were anticoagulated. METHODS: This was a single-center, retrospective chart review of a sample of nonagenarians referred to our tertiary care centre between 2009 and 2017. Demographic information, referral patterns, investigations, treatment plans, and outcomes were assessed. We assessed medication lists to calculate ACB scores at the time of referral, in addition to rates of anticoagulation use. RESULTS: Data was collected for 154 nonagenarians. Hematuria was the most common reason for referral (n=43, 27.9%). Urinary retention and lower urinary tract symptoms (LUTS) were seen in 22 and 36 patients, respectively. The majority of patients underwent routine investigations; however, treatment decisions were frequently based on age and frailty. Mild, moderate and severe ACB scores were seen in 76.6%, 9.33%, and 14.0%, respectively. Of those referred for hematuria, 78.1% were on anticoagulation therapy. CONCLUSIONS: The most common reasons for urologic referral of nonagenarians include hematuria and LUTS. Most nonagenarians are offered routine investigations, and many are offered minor interventions for common benign and malignant urologic diagnoses. When treating nonagenarians, an individualized patient-centered care approach is likely most appropriate.

The e-liquid flavoring cinnamaldehyde induces cellular stress responses in human proximal tubule (HK-2) kidney cells.

Flavored e-liquid use has become popular among e-cigarette users recently, but the effects of such products outside the lung are not well characterized. In this work, acute exposure to the popular flavoring cinnamaldehyde (CIN) was performed on human proximal tubule (HK-2) kidney cells. Cells were exposed to 0-100 µM CIN for 24-48 h and cellular stress responses were assessed. Mitochondrial viability via MTT assay was significantly decreased at 20 µM for 24 and 48 h exposure. Seahorse XFp analysis showed significantly decreased mitochondrial energy output at 20 µM by 24 h exposure, in addition to significantly reduced ATP Synthase expression. Seahorse analysis also revealed significantly decreased glycolytic function at 20 µM by 24 h exposure, suggesting inability of glycolytic processes to compensate for reduced mitochondrial energy output. Cleaved caspase-3 expression, a mediator of apoptosis, was significantly increased at the 24 h mark. C/EBP homologous protein (CHOP) expression, a mediator of ER-induced apoptosis, was induced by 48 h and subsequently lost at the highest concentration of 100 µM. This decrease was accompanied by a simultaneous decrease in its downstream target cleaved caspase-3 at the 48 h mark. The autophagy marker microtubule-associated protein 1 A/1B light chain 3 (LC3B-I and LC3B-II) expression was significantly increased at 100 µM by 24 h. Autophagy-related 7 (ATG7) protein and mitophagy-related proteins PTEN-induced putative kinase 1 (PINK1) and PARKIN expression were significantly reduced at 24 and 48 h exposure. These results indicate acute exposure to CIN in the kidney HK-2 model induces mitochondrial dysfunction and cellular stress responses.

The E-liquid flavoring vanillin alters energy and autophagic pathways in human proximal tubule (HK-2) epithelial cells.

The use of flavored e-liquids in electronic nicotine delivery systems (ENDS) has become very popular in recent years, but effects of these products have not been well characterized outside the lung. In this study, acute exposure to the popular flavoring vanillin (VAN) was performed on human proximal tubule (HK-2) kidney cells. Cells were exposed to 0-1000 µM VAN for 24 or 48 h and cellular stress responses were determined. Mitochondrial viability using MTT assay showed a significant decrease between the control and 1000 µM group by 48 h. Seahorse XFp analysis showed significantly increased basal respiration, ATP production, and proton leak after 24 h exposure. By 48 h exposure, these parameters remained significantly increased in addition to non-mitochondrial respiration and maximal respiration. Glycolytic activity after 24 h exposure showed significant decreases in glycolysis, glycolytic capacity, glycolytic reserve, and non-glycolytic acidification. The autophagy markers microtubule-associated protein 1A/1B light chain 3 (LC3B-I and LC3B-II) were probed via western blotting. The ratio of LC3B-II/LC3B-I was significantly increased after 24 h exposure to VAN, but by 48 h this ratio significantly decreased. The mitophagy marker PINK1 showed an increasing trend at 24 h, and its downstream target Parkin was significantly increased between the control and 750 µM group only. Finally, the oxidative stress marker 4-HNE was significantly decreased after 48 h exposure to VAN. These results indicate that acute exposure to VAN in the kidney HK-2 model can induce energy and autophagic changes within the cell.

Examining the impact of postoperative opioid use on length of hospital stay following radical cystectomy.

INTRODUCTION: Radical cystectomy (RC) is associated with high rates of morbidity, prolonged hospital stay, and increased opioid use for postoperative pain management; however, the relationship between postoperative opioid use and length of stay (LOS ) remains uncharacterized. This study serves to investigate the association between postoperative opioid use and length of hospital stay after RC. The relationship between patient and surgical factors on LOS was also characterized. METHODS: We retrospectively reviewed all patients between 2009 and 2019 who underwent RC at our institution. Patient and perioperative variables were analyzed to determine the relationship between postoperative opioid use and LOS using multivariable linear regression analysis. RESULTS: We identified 240 patients for study inclusion with a median age of 70.0 years. Median LOS was 10.0 days, with median daily mg morphine equivalent use of 57.5 for patients. Daily mg morphine equivalent use was significantly associated with an increased LOS, as were previous pelvic radiation, postoperative ileus, and higher Clavien-Dindo grade complication during admission (all p<0.05). Median LOS increased by one day for each increase of 13.2 daily mg morphine equivalents received. CONCLUSIONS: Increased daily opioid use was associated with increased length of hospital stay after RC. Non-opioid-based pain management approaches may be effective in reducing LOS after RC.

Anticancer Activity of Region B Capsaicin Analogs.

The heterocyclic vanilloid compound capsaicin is responsible for the spicy and pungent flavor of chili peppers. Several convergent studies have shown that capsaicin suppresses the growth of multiple human cancers. Apart from capsaicin, natural and synthetic capsaicin-like compounds display growth suppressive activity in human cancers. The pharmacophore of capsaicin is comprised of three regions, namely region A (the aromatic ring), region B (the amide bond), and region C (the side chain). The present manuscript describes the isolation and synthesis of capsaicin analogs which have structural modifications in region B of the molecule. Furthermore, the pharmacokinetic properties, anticancer activity of region B capsaicin analogs, as well as the signaling pathways (underlying the growth-inhibitory effects of region B capsaicin analogs) have also been described. The discovery of novel, second-generation region B capsaicin analogs may foster the hope of innovative nutrition-based combination therapies in human cancers.

Clinical utility of routine postoperative serial hemoglobin measurements in patients undergoing radical cystectomy for urothelial carcinoma.

INTRODUCTION: Routine measurements of serum hemoglobin (sHgb) are common after abdominal surgery; however, prolonged measurements may be associated with patient anxiety, increased costs, and longer hospitalization without clinical benefit. The objective of this study was to determine the utility of routine sHgb measurements after radical cystectomy (RC) and factors associated with transfusion of packed red blood cell (pRB C) beyond postoperative day (POD ) 2. METHODS: We retrospectively reviewed patients who underwent RC between 2009 and 2019 at a single academic tertiary care center. The number of sHgb measurements for each patient was examined and pRB C transfusion rates were calculated. Multivariable logistic regression was used to determine factors associated with transfusion beyond POD 2. RESULTS: The median number of sHgb measurements per patient during admission was nine (interquartile range [IQR] 7, 25). Overall, 69/240 (28.7%) patients received a postoperative transfusion, including 46/240 (19.2%) patients receiving a transfusion beyond POD 2. Among patients with a sHgb ≥100 g/L on POD 2, 7/85 (8.2%) went on to receive a transfusion beyond this day compared with 39/155 (25.2%) patients with sHgb <100 g/L. On multivariable analysis, risk factors associated with pRB C transfusion beyond POD 2 included older age, lower sHgb on POD 2, and longer length of stay in hospital. CONCLUSIONS: Transfusion of pRB Cs beyond POD 2 was found to be common; however, patients with sHgb ≥100 g/L on POD 2 were at low risk of requiring subsequent transfusion. Discontinuing further routine sHgb checks in these patients may serve to decrease patient anxiety, healthcare costs, and delays in hospital discharge.

The NXDC-MEN-301 Study on 5-ALA for Meningiomas Surgery: An Innovative Study Design for the Assessing the Benefit of Intra-Operative Fluorescence Imaging.

BACKGROUND: 5-aminolevulinic acid (5-ALA; GleolanTM, NX Development Corps., Lexington, USA) is approved for fluorescence-guided resections of suspected malignant gliomas. Experience has demonstrated that meningiomas also show fluorescence, which may be a useful surgical adjunct. We present an innovative design for a multi-center, prospective study to determine the clinical safety and potential benefit of fluorescence-guided resection of meningiomas with utmost bias reduction. METHODS: All patients with suspected meningioma (all grades) receive GleolanTM 20 mg/kg 2-4 h prior to surgery supported by fluorescence excitation from a blue light source (Blue400, Zeiss Meditech, Oberkochen, Germany; FL400, Leica Microsystems, Heerbrugg, Switzerland). Surgeons are asked whether a residual tumor can be observed to fluoresce under blue light (BL) after the tumor is no longer recognizable using conventional illumination at the end of surgery. In addition, when faced with tissues of uncertain tissue type (so-called "indeterminate" tissue), this study records how often surgeons make a correct decision based on fluorescence and how this influences surgical strategy. The primary endpoint is the percentage of patients in whom one of these two benefits are observed. Other endpoints include the diagnostic accuracy of fluorescence compared to white light (WL) versus correlative histology. For bias reduction, pertinent data are derived from surgical videos reviewed by independent reviewers blinded to surgeons' assessments of tissue type and fluorescence status. Data will be included from approximately 100 study participants completing the study at approximately 15 centers in the United States, Germany, and Austria. RESULTS: As of May 2022, 88 patients have completed the study. No adverse safety signal has been detected. CONCLUSIONS: Preliminary data confirm the feasibility of our study design. Accrual is targeted for completion in the third quarter of 2022.

Utility of Postoperative Serial Renal Function Monitoring in Patients Undergoing Radical Cystectomy for Urothelial Carcinoma.

PURPOSE: The aim of this study is to examine the rates of clinical actions (CAs) as a result of serial creatinine (SCr) values and to examine postoperative SCr trends to assess the utility of SCr measurements in radical cystectomy (RC) patients. METHODS: We performed a retrospective chart review using our institution's database on all patients who underwent radical cystectomy for urothelial carcinoma (UC) from 2009 to 2019. Preoperative and all postoperative inpatient creatinine values were recorded. Minor CAs included fluid boluses, fluid rate changes, and medication changes. Major CAs included OR take-backs for stent repositioning, nephrostomy tube placement, nephrology consultation, and hemodialysis. RESULTS: A total of 238 RCs were performed with a resultant 2952 SCr measurements. The median number of SCr measurements per patient was 9 (interquartile range, IQR 7) with median length of hospital stay of 10 days (IQR 9 days). There were 92 minor and 12 major CAs as a result of 3% and 0.44% of SCr measurements, respectively. All major CAs were seen in patients experiencing complicated postoperative course. The median postoperative day with the highest creatinine was day 2. Predictors of postoperative CAs included preoperative renal dysfunction and obesity. CONCLUSION: SCr measurements remain a clinically valuable tool in postoperative management. Nonetheless, this present study suggests that prolonged SCr monitoring is of limited clinical utility. As such, discontinuing SCr checks after postoperative day 3 in patients experiencing uncomplicated postoperative course is safe and may lead to both cost savings and decreased patient discomfort.

Anti-cancer activity of sustained release capsaicin formulations.

Capsaicin (trans-8-methyl-N-vanillyl-6-noneamide) is a hydrophobic, lipophilic vanilloid phytochemical abundantly found in chili peppers and pepper extracts. Several convergent studies show that capsaicin displays robust cancer activity, suppressing the growth, angiogenesis and metastasis of several human cancers. Despite its potent cancer-suppressing activity, the clinical applications of capsaicin as a viable anti-cancer drug have remained problematic due to its poor bioavailability and aqueous solubility properties. In addition, the administration of capsaicin is associated with adverse side effects like gastrointestinal cramps, stomach pain, nausea and diarrhea and vomiting. All these hurdles may be circumvented by encapsulation of capsaicin in sustained release drug delivery systems. Most of the capsaicin-based the sustained release drugs have been tested for their pain-relieving activity. Only a few of these formulations have been investigated as anti-cancer agents. The present review describes the physicochemical properties, bioavailability, and anti-cancer activity of capsaicin-sustained release agents. The asset of such continuous release capsaicin formulations is that they display better solubility, stability, bioavailability, and growth-suppressive activity than the free drug. The encapsulation of capsaicin in sustained release carriers minimizes the adverse side effects of capsaicin. In summary, these capsaicin-based sustained release drug delivery systems have the potential to function as novel chemotherapies, unique diagnostic imaging probes and innovative chemosensitization agents in human cancers.

Rodent models of ketamine-induced cystitis.

AIMS: Long-term or recreational use of ketamine affects the urinary system and can result in ketamine-induced cystitis (KIC). Rodent models of KIC are important to study KIC pathophysiology and are paramount to the future development of therapies for this painful condition. This review aims to provide a summary of rodent models of KIC, focusing on disease induction, experimental methods, and pathological features of the model. METHOD: A literature search was performed using the National Center for Biotechnology Information (NCBI) Pubmed database up to March 2021. 20 articles met the inclusion criteria and were finally selected. RESULTS: There are considerable variations in the rodent models used for studying KIC in terms of the strain of the animal being used; dose, duration, and route of ketamine administration to induce KIC, and assessment of pathological features. CONCLUSION: KIC remains difficult to fully recapitulate in humans. Improved characterization of KIC models and the experimental parameters and meticulous discussion on translational limitations are required to improve the translational value of research using rodent models of KIC.

Urological outcomes in nonagenarians with prostate cancer.

INTRODUCTION: Nonagenarians represent a growing patient population. Herein, we report on the largest cohort of Canadian nonagenarian patients, to our knowledge, with prostate cancer. METHODS: A retrospective chart of 44 nonagenarian men diagnosed with localized or metastatic prostate cancer between 2006 and 2019 was performed. Diagnoses were based on pathological specimens or the presence of a high prostate-specific antigen (PSA >20) or abnormal digital rectal exam (DRE) in the setting of metastatic disease on imaging. Patient demographics, presenting complaints, and treatments required were included in the analysis. A descriptive statistical analysis was performed. RESULTS: The median patient age at time of referral was 91.1 years (interquartile range [IQR] 90.2-92.9). The median PSA at time of referral was 54.0 (IQR 18.2-142.6). Metastatic disease was present in 55% of patients at time of diagnosis (n=24). Most patients required at least one urological intervention (n=35). There were 56.8% of patients who received androgen deprivation therapy (ADT) as part of their treatment regime (n=25). Half (50%) of patients were managed with androgen receptor axis-targeted agents (ARAT), as well as ADT (n=22). Five patients (11.4%) underwent surgical castration. Death due to any cause was noted in 52.3% of patients (n=23) throughout the study period, with the median age at death being 94.4 years (IQR 92.3-97.0). Death due to prostate cancer was noted in 18.2% of patients (n=8). CONCLUSIONS: This study highlights common presenting complaints for nonagenarian patients with prostate cancer and that many require urological intervention despite advanced age. Future studies should address patient-reported quality-of-life outcomes in the nonagenarian population with prostate cancer.

Long-term outcomes of sacral neuromodulation for lower urinary tract dysfunction: A 23-year experience.

AIMS: To evaluate the long-term outcomes of sacral neuromodulation (SNM), and patient characteristics that may predict long-term success or complications. METHODS: A single-center retrospective cohort study was performed of all patients who underwent SNM testing and implantation. Outcome results, resolution of symptoms, and device removal were reported. Multivariable logistic regression was used to identify predictors of success. Cox proportional hazards model was used to identify predictors for device removal. RESULTS: Four hundred and thrity four patients underwent SNM test phase of which 241 (median age 48.0 years, 91.7% [221/241] female) had device implantation and were followed up for median [range] time of 4.0 (3 months-20.5 years) years. Multivariable logistic regression showed that male gender (odds ratio: 0.314; 95% confidence interval: 0.164-0.601, p = .0005) was independently associated with decreased peripheral nerve evaluation success. At final follow-up for patients who originally had device implantation, median (interquartile range) percent of symptoms resolution of all patients was 60.0% (0%-90%) and 69.3% (167/241) had SNM successful outcomes. Cox proportional hazards model showed no difference for time to SNM device removal with respect to patient age, gender, or diagnosis. 69.3% (167/241) patients had at least 1 surgical re-intervention. The most common reason at first surgical re-intervention was lead change only (26.3%, 44/167). CONCLUSION: SNM is a minimally invasive procedure with good long-term success rates. There is a high revision rate but overall, SNM has a good safety profile and excellent long-term outcomes.

Experimental Cannabinoid 2 Receptor Activation by Phyto-Derived and Synthetic Cannabinoid Ligands in LPS-Induced Interstitial Cystitis in Mice.

Interstitial cystitis (IC) is a chronic bladder disorder with unclear etiology. The endocannabinoid system has been identified as a key regulator of immune function, with experimental evidence for the involvement of cannabinoid receptors in bladder inflammation. This study used intravital microscopy (IVM) and behavioral testing in lipopolysaccharide-induced IC, to investigate the anti-inflammatory analgesic effects of a natural dietary sesquiterpenoid, beta-caryophyllene (BCP), which is present in cannabis among other plants, and has reported agonist actions at the cannabinoid 2 receptor (CB2R). BCP's anti-inflammatory actions were compared to the synthetic CB2R-selective cannabinoid, HU308, and to an FDA-approved clinical treatment (dimethyl sulfoxide: DMSO). IVM data revealed that intravesical instillation of BCP and/or HU308 significantly reduces the number of adhering leukocytes in submucosal bladder venules and improves bladder capillary perfusion. The effects of BCP were found to be comparable to that of the selective CB2R synthetic cannabinoid, HU308, and superior to intravesical DMSO treatment. Oral treatment with BCP was also able to reduce bladder inflammation and significantly reduced mechanical allodynia in experimental IC. Based on our findings, we believe that CB2R activation may represent a viable therapeutic target for IC, and that drugs that activate CB2R, such as the generally regarded as safe (GRAS) dietary sesquiterpenoid, BCP, may serve as an adjunct and/or alternative treatment option for alleviating symptoms of inflammation and pain in the management of IC.

Monoacylglycerol lipase inhibition as potential treatment for interstitial cystitis.

Interstitial cystitis is a chronic inflammatory condition of the urinary bladder with an unclear etiology. Currently, there are no widely accepted long-term treatment options available for patients with IC, with the European Association of Urology (EAU, 2017 guidelines), American Urology Association (AUA, 2014 guidelines), and the Royal College of Obstetricians and Gynaecologists (RCOG, 2016 guidelines) all suggesting various different conservative, pharmacological, intravesical, and surgical interventions. The endocannabinoid system represents a potential target for IC treatment and management. Activation of cannabinoid receptor 2 (CBR2) with various agonists has previously been shown to reduce leukocyte differentiation and migration, in addition to inhibiting the release of pro-inflammatory cytokines at the site of inflammation. These receptors have been identified in the detrusor and sensory nerves of the urothelium in various mammalian species, including humans. We hypothesize that by inhibiting the enzymes responsible for the catabolism of endogenous cannabinoids locally, bladder concentrations of CBR2 agonists will increase, particularly 2-arachidonyl glycerol, resulting in a diminished inflammatory response.

Current Practices in the Surgical Management of Female Stress Urinary Incontinence: A Survey of Canadian Urologists and Gynecologists.

INTRODUCTION: We assessed the practices of urologists and gynecologists who manage stress urinary incontinence surgically to examine the impact of the FDA (U.S. Food and Drug Administration) and/or Health Canada statements on pelvic floor mesh. We also determined how urologists and gynecologists manage recurrent stress urinary incontinence and complications of mesh mid urethral slings. METHODS: We conducted an online survey of urologists and gynecologists who were members of the Canadian Urological Association or Society of Obstetricians and Gynaecologists of Canada. RESULTS: Mid urethral sling was the most common surgery for stress urinary incontinence performed by urologists and gynecologists (100% vs 84%, p=0.0002). The majority of respondents (87%, 119 of 137) were aware of the FDA and/or Health Canada statements and 66% of physicians altered the way they counseled patients before mid urethral sling surgery. An equal proportion of urologists and gynecologists altered their surgical management of stress urinary incontinence due to patient concerns (31% vs 36%) and due to FDA and/or Health Canada statements (16% vs 13%). Repeat mid urethral sling was the most common method of treating recurrent stress urinary incontinence and urologists were more likely than gynecologists to manage complications of mid urethral sling (58% vs 41%, p=0.0286). Chronic pain (33%) and vaginal mesh erosion (26%) were the most common concerns overall. CONCLUSIONS: Mid urethral sling was reported as the most commonly performed surgery for stress urinary incontinence by urologists and gynecologists after the FDA and Health Canada statements. Both groups altered their surgical practices most commonly due to patient concerns, indicating that negative media attention is impacting the way in which urologists and gynecologists practice when surgically managing stress urinary incontinence in Canada. Variation exists between urologists and gynecologists when it comes to managing complications related to mid urethral sling.