Sacral Tarlov perineurial cysts: a systematic review of treatment options.

Tarlov perineurial spinal cysts (TCs) are an underrecognized cause of spinal neuropathic symptoms. TCs form within the sensory nerve root sleeves, where CSF extends distally and can accumulate pathologically. Typically, they develop at the sacral dermatomes where the nerve roots are under the highest hydrostatic pressure and lack enclosing vertebral foramina. In total, 90% of patients are women, and genetic disorders that weaken connective tissues, e.g., Ehlers-Danlos syndrome, convey considerable risk. Most small TCs are asymptomatic and do not require treatment, but even incidental visualizations should be documented in case symptoms develop later. Symptomatic TCs most commonly cause sacropelvic dermatomal neuropathic pain, as well as bladder, bowel, and sexual dysfunction. Large cysts routinely cause muscle atrophy and weakness by compressing the ventral motor roots, and multiple cysts or multiroot compression by one large cyst can cause even greater cauda equina syndromes. Rarely, giant cysts erode the sacrum or extend as intrapelvic masses. Disabling TCs require consideration for surgical intervention. The authors' systematic review of treatment analyzed 31 case series of interventional percutaneous procedures and open surgical procedures. The surgical series were smaller and reported somewhat better outcomes with longer term follow-up but slightly higher risks. When data were lacking, authorial expertise and case reports informed details of the specific interventional and surgical techniques, as well as medical, physical, and psychological management. Cyst-wrapping surgery appeared to offer the best long-term outcomes by permanently reducing cyst size and reconstructing the nerve root sleeves. This curtails ongoing injury to the axons and neuronal death, and may also promote axonal regeneration to improve somatic and autonomic sacral nerve function.

Robotic assisted proximal dorsal urethral diverticulectomy.

INTRODUCTION AND HYPOTHESIS: Urethral diverticula are rare but clinically significant entities among female patients. Ventrally located, mid-to distal, simple or horseshoe diverticula are most commonly observed and are usually repaired via a transvaginal approach with varying levels of difficulty but high success rates. Dorsally (anteriorly) located urethral diverticula are more challenging to repair secondary to the need to access the side of the urethra opposite the vaginal lumen, abutting the external urethral sphincter. Unique proximal anatomy in the case presented led to careful consideration of the surgical options. METHODS: We present a review of techniques reported in the literature and a video demonstrating our technique for transabdominal robot-assisted laparoscopic excision of a large, dorsal, very proximally located, crescenteric urethral diverticulum in a patient who initially presented with urosepsis. RESULTS: Robotic-assisted excision of the urethral diverticulum was accomplished in 3:27 h with an estimated blood loss of 50 cc. Vaginal counter-incision was not necessary. The patient's postoperative course was uneventful. Postoperative voiding cystourethrogram prior to suprapubic catheter removal revealed a well-healed repair without extravasation. At 6-month follow-up, she denied any de novo lower urinary tract symptoms such as urinary incontinence, post-void dribbling, urinary tract infection or urinary hesitancy. CONCLUSIONS: Dorsal urethral diverticulum in women, particularly when very proximal, can present a diagnostic and surgical challenge for reconstructive pelvic surgeons. The robotic approach to urethral diverticulectomy is feasible for a proximal dorsal urethral diverticulum which lies cephalad to the pubic symphysis. This or other laparoscopic applications may also be considered as an adjunct to the standard vaginal approach for complex urethral diverticuli with a proximal dorsal component.

Pentosan Polysulfate Maculopathy: What Urologists Should Know in 2020.

OBJECTIVE: To conduct a review of current literature to assess whether an association exists between Pentosan Polysulfate Sodium and the development of macular disease, as it is the only oral medication approved by the Food and Drug Administration for the management of interstitial cystitis. MATERIALS AND METHODS: A systematic review was conducted by the authors separately, with review methods established prior to the conduct of the review. Databases searched included PubMed, Ovid, Medline, EBSCO, and Google Scholar. A search was conducted for the terms "Pentosan Polysulfate Maculopathy," "Pentosan Polysulfate Retinopathy," and "Interstitial Cystitis Maculopathy." All papers reporting on primary data were included. There were no study sponsors. RESULTS: A total of 14 papers reporting on primary data were identified. Most papers reported on the development of macular disease in the setting of chronic pentosan polysulfate sodium exposure. No randomized controlled trials have been performed to date and data was insufficient to perform a meta-analysis. Nevertheless, patients with interstitial cystitis were more likely to receive a diagnosis of maculopathy after several years of the medication use. CONCLUSION: Although the nature of the published studies renders them prone to confounders, currently available data suggest an increased risk for developing maculopathy after years of pentosan polysulfate sodium use. In light of this, and the marginal effectiveness of the medication for the average individual, we suggest that education be provided as to the possible association and that regular ophthalmic evaluation be recommended for patients who are continued on chronic Pentosan Polysulfate Sodium.

Estrogen replacement is protective to the effect of in vitro hypoxia on female rabbit bladder and pelvic floor contractile response.

Purpose: To explore the effect of estrogen replacement on pelvic floor and bladder contractile response to electrical field stimulation, following in vitro hypoxia in an animal model of surgical menopause. Materials and Methods: Twelve female adult rabbits were divided into three groups: control, ovariectomy, and ovariectomy with estradiol replacement. At 4 weeks animals were euthanized. Bladder, coccygeus, and pubococcygeus were isolated. Tissues were equilibrated with oxygenated Tyrodes containing glucose and stimulated with electrical field stimulation. Tissues were then stimulated under hypoxic conditions for 1 hour using nitrogenated Tyrodes without glucose. Tissues were then re-oxygenated for 2 hours and stimulated. Results: Pelvic floor required 10 times the stimulation duration (power) to achieve maximum contraction at 2 g baseline tension (10 ms duration) when compared to bladder (1 ms duration). Maximal tension generated was significantly greater for bladder than pelvic floor. Coccygeus and pubococcygeus were significantly less sensitive to the effects of hypoxia and had stable contractile response to field stimulation throughout the hour of hypoxia. Hypoxia resulted in progressive and rapid decline of bladder contractile strength. Following hypoxia, pelvic floor contractile recovery was superior to bladder. Improvement in the contractile response of both bladder and pelvic floor, during the period of post-hypoxia re-oxygenation, was significantly greater in ovariectomy animals treated with estradiol replacement. Conclusions: Replacement of estradiol at time of ovariectomy reduced oxidative stress on tissue and was protective to the effects of hypoxia on pelvic floor and bladder contractile function.

Spontaneous voiding is surprisingly recoverable via outlet procedure in men with underactive bladder and documented detrusor underactivity on urodynamics.

AIMS: To identify clinical and urodynamic factors leading to spontaneous voiding in men with detrusor underactivity (DU) and suspected bladder outlet obstruction who underwent an outlet de-obstruction procedure. METHODS: We identified 614 men who underwent an outlet procedure at our institution from 2005 to 2014. Men were stratified by bladder contractility index (BCI). The primary outcome was spontaneous voiding after surgery. Data were analyzed in Statistical analysis system software. RESULTS: Of the 131 men who underwent preoperative urodynamics, 122 (mean age 68 years) had tracings available for review. DU (BCI < 100) was identified in 54% (66 of 122), of whom only 68% (45 of 66) voided spontaneously before surgery, compared with 82% (46 of 56) of men with BCI ≥ 100. At a mean follow-up of 6.4 months postoperatively, 79% (52 of 66) of men with DU were able to void spontaneously, compared with 96% (54 of 56) of men with BCI ≥ 100. In men with a BCI < 100 unable to void before surgery, 57% (12 of 21) recovered spontaneous voiding after surgery. On logistic regression for the outcome postoperative spontaneous voiding, significant preoperative characteristics, and urodynamic factors included preoperative spontaneous voiding (odds ratio [OR] = 9.460; 95% confidence interval [CI] = 2.955-30.289), increased maximum flow rate (Qmax; OR = 1.184; 95% CI = 1.014-1.382), increased detrusor pressure at maximum flow (Pdet@Qmax; OR = 1.032; 95% CI = 1.012-1.052), DU with BCI < 100 (OR = 0.138; 95% CI = 0.030-0.635), and obstruction with bladder outlet obstruction index > 40 (OR = 5.595; 95% CI = 1.685-18.575). CONCLUSION: Outlet de-obstruction improves spontaneous voiding in men with DU and may benefit men who do not meet the urodynamic threshold for obstruction.

Can magnetic resonance imaging differentiate among transurethral bulking agent, urethral diverticulum, and periurethral cyst?

PURPOSE: To evaluate magnetic resonance imaging findings that differentiate among periurethral bulking agents (primarily collagen), urethral diverticulum, and periurethral cyst. METHODS: We searched our radiologic database retrospectively from 2001 to 2017 for periurethral cystic lesions, identifying a total of 50 patients with 68 lesions. Final diagnoses in 68 lesions were bulking agents (27), urethral diverticula (29), and periurethral cysts (12). Two abdominal radiologists, blinded to clinical history, independently evaluated T1, T2, and post-contrast images. The readers assessed number, morphological features, location, connection to urethra and mass effect, signal intensity, and enhancement for each lesion. Fisher exact test and logistic regression analysis were performed for each univariate significant feature. The operative and pathologic reports were the reference standard. RESULTS: Magnetic resonance imaging features found more often in bulking agents versus urethral diverticulum were multiple lesions (P = 0.011), upper or upper-mid-urethral location (P ≤ 0.0001), lack of internal fluid/fluid level (P = 0.002), no urethral connection (P = 0.005), T1 isointensity, and T2 mild hyperintensity compared to muscles but lower T2 signal than urine (P < 0.0001). Most cases of urethral diverticula and periurethral cysts were detected at mid- and lower urethra. Urethral diverticula were larger than bulking agents and periurethral cysts (P = 0.005 and P = 0.023) (mean diameter = 24, 16, 15 mm, respectively). Most bulking agents (93%) and urethral diverticula (90%) showed mass effect on urethra, while periurethral cysts (75%) did not (P < 0.0001). CONCLUSION: Signal intensity and lesion characterization on magnetic resonance imaging can significantly differentiate bulking agent from urethral diverticulum and periurethral cyst. Radiologists should consider differential diagnosis of a bulking agent, especially when distinguishing characteristics described here are present to prevent incorrect diagnosis and ultimately unnecessary surgical intervention.

Surgery for female SUI: The ICI algorithm.

INTRODUCTION: Stress urinary incontinence (SUI) is common in women and can significantly impact quality of life. METHODS: This is a review of the 6th International Consultation on Incontinence (ICI) chapter analyzing level of evidence on surgical treatment of SUI as well as the consensus algorithm that resulted from the detailed work in the committee report as of April 2017. Included studies in this review were selected to highlight the algorithm for management. RESULTS: Non-operative and surgical treatment options exist; conservative therapies comprise first line management, but if SUI remains bothersome, surgical treatment should be considered. Bulking agents offer a minimally invasive option with moderate short-term success rates. The most commonly performed surgical treatments for SUI are mid-urethral and pubovaginal slings, with high cure rates and patient satisfaction. Retropubic suspension is a more traditional but widely accepted procedure. Single incision sling, adjustable sling, or artificial urinary sphincter may be appropriate in carefully selected patients. CONCLUSIONS: The choice of surgical procedure should be made only after a thorough discussion and shared decision between the patient and surgeon regarding risks, benefits, and alternatives. A trial of conservative therapy should be conducted where relevant. Referral to a specialist should be considered in women with a more complex presentation.

The Clinical Role of LASER for Vulvar and Vaginal Treatments in Gynecology and Female Urology: An ICS/ISSVD Best Practice Consensus Document.

In this best practice document, we propose recommendations for the use of LASER for gynecologic and urologic conditions such as vulvovaginal atrophy, urinary incontinence, vulvodynia, and lichen sclerosus based on a thorough literature review. Most of the available studies are limited by their design; for example, they lack a control group, patients are not randomized, follow-up is short term, series are small, LASER is not compared with standard treatments, and most studies are industry sponsored. Because of these limitations, the level of evidence for the use of LASER in the treatment of these conditions remains low and does not allow for definitive recommendations for its use in routine clinical practice. Histological evidence is commonly reported as proof of tissue regeneration after LASER treatment. However, the histological changes noted can also be consistent with reparative changes after a thermal injury rather than necessarily representing regeneration or restoration of function. The use of LASER in women with vulvodynia or lichen sclerosus should not be recommended in routine clinical practice. There is no biological plausibility or safety data on its use on this population of women. The available clinical studies do not present convincing data regarding the efficacy of LASER for the treatment of vaginal atrophy or urinary incontinence. Also, although short-term complications seem to be uncommon, data concerning long-term outcomes are lacking. Therefore, at this point, LASER is not recommended for routine treatment of the aforementioned conditions unless part of well-designed clinical trials or with special arrangements for clinical governance, consent, and audit.

The clinical role of LASER for vulvar and vaginal treatments in gynecology and female urology: An ICS/ISSVD best practice consensus document.

BACKGROUND: The clinical role of LASER for vulvar and vaginal treatments in gynecology and female urology is controversial. AIMS: In this best practice document, we propose recommendations for the use of LASER for gynecologic and urologic conditions such as vulvovaginal atrophy, urinary incontinence, vulvodynia, and lichen sclerosus based on a thorough literature review. MATERIALS & METHODS: This project was developed between January and September 2018. The development of this document followed the ICS White Paper Standard Operating Procedures. RESULTS: Most of the available studies are limited by their design; for example they lack a control group, patients are not randomized, follow up is short term, series are small, LASER is not compared with standard treatments, and studies are industry sponsored. Due to these limitations, the level of evidence for the use of LASER in the treatment of these conditions remains low and does not allow for definitive recommendations for its use in routine clinical practice. Histological evidence is commonly reported as proof of tissue regeneration following LASER treatment. However, the histological changes noted can also be consistent with reparative changes after a thermal injury rather than necessarily representing regeneration or restoration of function. The use of LASER in women with vulvodynia or lichen sclerosus should not be recommended in routine clinical practice. There is no biological plausibility or safety data on its use on this population of women. DISCUSSION: The available clinical studies do not present convincing data regarding the efficacy of LASER for the treatment of vaginal atrophy or urinary incontinence. Also, while short-term complications seem to be uncommon, data concerning long-term outcomes are lacking. CONCLUSION: At this point, LASER is not recommended for routine treatment of the aforementioned conditions unless part of well-designed clinical trials or with special arrangements for clinical governance, consent, and audit.

Management of Postoperative Lower Urinary Tract Symptoms (LUTS) After Pelvic Organ Prolapse (POP) Repair.

PURPOSE OF REVIEW: Pelvic organ prolapse (POP) is a common condition for which approximately 200,000 US women annually undergo surgical repair [Am J Obstet Gynecol 188:108-115, 2003]. After surgical correction, persistent or new lower urinary tract symptoms (LUTS) can be present. We provide guidance on the current tools to predict, counsel, and subsequently handle postoperative LUTS. The current literature is reviewed regarding LUTS diagnosis and management in the setting of prolapse surgery with an emphasis on newer developments in this area. RECENT FINDINGS: 1. More severe stages of prolapse are positively correlated with obstructive symptoms [Am J Obstet Gynecol 185:1332-1337, 2001], but not with other LUTS [Adv Urol 2013:5673753, 2013, Eur J Obstet Gynecol Reprod Biol 177:141-145, 2014, Am J Obstet Gynecol 199:683, 2008, Int Urogynecol J 21:1143-1149, 2010]. 2. One-week ambulatory pessary trial is an effective way to approximate postoperative results-one study correctly predicted persistent urgency and frequency in addition to occult stress urinary incontinence in 20% of study population [Obstet Gynecol Int 2012:392027, 2012]. 3. No preoperative overactive bladder (OAB) symptom was the best predictor for the absence of de novo OAB symptoms postoperatively [Int Urogynecol J 21:1143-1149, 2010]. 4. Urge incontinence patients respond favorably to sacral neuromodulation [Neurourol Urodyn 26: 29-35, 2007], botulinum toxin, and anticholinergic therapy [Res Rep Urol 8:113-122, 2016 , N Engl J Med, 367:1803-1813, 2012]. 5. Primary bladder outlet obstruction (BOO) can be treated effectively with alpha antagonists or anticholinergics, timed voiding, and pelvic physiotherapy as first-line therapy. Counseling regarding postoperative LUTS is key when planning POP surgery. A thorough understanding of patient history is crucial to successful repair. Patients with significant preoperative symptoms, history of neurologic disease, pelvic floor dysfunction, bladder neck obstruction, or higher stages of anterior wall prolapse may be higher risk for postoperative LUTS. UDS with or without reduction and an ambulatory pessary trial can help prognosticate. Patients will likely maintain a positive therapeutic relationship postoperatively for LUTS if counseled preoperatively.

Surgical Management of Female Voiding Dysfunction.

Surgical intervention for female voiding dysfunction is common, involving a single or multifaceted approach affecting multiple organ systems in the pelvis. Surgical success relies on knowledge of surgical history, anatomic approaches, and judicious use of supports or materials. Owing to the varied repairs used over the last few decades, it is important for the general surgeon to understand both current and historic approaches. This understanding will help in planning future pelvic surgery as well as in evaluating current ramifications of prior surgery.

A Novel Cystometric Model of Pelvic Floor Dysfunction After Rabbit Pelvic Floor Noxious Electrical Stimulation.

OBJECTIVES: Although a relationship between pelvic floor dysfunction and lower urinary tract symptoms is described in the literature, the mechanism and pathways need further characterization. We developed an animal model of pelvic floor dysfunction after noxious stimulation of the pubococcygeus (PC) muscle. METHODS: Fifteen female adult rabbits were evaluated with cystometry (CMG) and electromyography (EMG) recordings from the PC muscle. Cystometry/EMG was performed before and after treatment animal (n = 11) received noxious pelvic floor electrical stimulation through the PC EMG electrode, and controls (n = 4) underwent sham needle placement. Two animals underwent S3 dorsal rhizotomy to demonstrate that the observed results required afferent innervation. RESULTS: Voiding changes were demonstrated in 9 of 11 rabbits after stimulation. Most of the rabbits (7/9) exhibited a prolonged-dysfunctional voiding pattern with larger capacity (mean, 17 mL [SEM, ±8 mL]), longer intercontractile interval (227% [SEM, ±76%]) and duration (163% [SEM, ±20%]), and increased postvoid residual (24 mL [SEM, ±6 mL]). The remaining dysfunctional rabbits (2/9) exhibited an overactive-dysfunctional voiding pattern with lower capacity (-26 mL [SEM, ±6 mL]), shortened intercontractile interval (16% [SEM, ±9%]) and duration (56% [SEM, ±30%]), and decreased postvoid residual (-27 mL [SEM, ±6 mL]). Nonresponder rabbits (2/11) were relatively unchanged in their micturition cycles after stimulation. Rhizotomy animals were acontractile and filled until overflow incontinence occurred. CONCLUSIONS: Using noxious electrical stimulation of the pelvic musculature, we were able to produce an animal model of pelvic floor dysfunction in most rabbits as hallmarked by a larger bladder capacity, an increased intercontractile interval, and prolonged contraction duration.

Noxious electrical stimulation of the pelvic floor and vagina induces transient voiding dysfunction in a rabbit survival model of pelvic floor dystonia.

PURPOSE: Existing data supports a relationship between pelvic floor dysfunction and lower urinary tract symptoms. We developed a survival model of pelvic floor dysfunction in the rabbit and evaluated cystometric (CMG), electromyographic (EMG) and ambulatory voiding behavior. MATERIALS AND METHODS: Twelve female adult virgin rabbits were housed in metabolic cages to record voiding and defecation. Anesthetized CMG/EMG was performed before and after treatment animals (n=9) received bilateral tetanizing needle stimulation to the pubococcygeous (PC) muscle and controls (n=3) sham needle placement. After 7 days all animals were subjected to tetanizing transvaginal stimulation and CMG/EMG. After 5 days a final CMG/EMG was performed. RESULTS: Of rabbits that underwent needle stimulation 7 of 9 (78%) demonstrated dysfunctional CMG micturition contractions versus 6 of 12 (50%) after transvaginal stimulation. Needle stimulation of the PC musculature resulted in significant changes in: basal CMG pressure, precontraction pressure change, contraction pressure, interval between contractions and postvoid residual; with time to 3rd contraction increased from 38 to 53 minutes (p=0.008 vs. prestimulation). Vaginal noxious stimulation resulted in significant changes in: basal CMG pressure and interval between contractions; with time to 3rd contraction increased from 37 to 46 minutes (p=0.008 vs. prestimulation). Changes in cage parameters were primarily seen after direct needle stimulation. CONCLUSIONS: In a majority of animals, tetanizing electrical stimulation of the rabbit pelvic floor resulted in voiding changes suggestive of pelvic floor dysfunction as characterized by a larger bladder capacity, longer interval between contractions and prolonged contraction duration.

Female stress urinary incontinence and the mid-urethral sling: is obstruction necessary to achieve dryness?

BACKGROUND: Recently, the American Urogynecologic Society and Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction released position statements on the use of mid-urethral slings. The statement offers that the polypropylene mesh mid-urethral sling (retropubic and transobturator) is now the recognized worldwide standard of care for the surgical treatment of stress urinary incontinence. The purpose of the current manuscript is to examine whether the polypropylene mesh mid-urethral sling should be the standard of care. METHODS: Data for this review were acquired by a systematic search of the medical literature. RESULTS: The Trial of Mid-Urethral Slings found that retropubic and transobturator slings were associated with a significant rate of adverse events, despite being comprised of surgeons from high-volume, experienced centers. Stress urinary incontinence is not just a urethral disease due to intrinsic sphincteric deficiency. It can also be related to urethral hypermobility, which in turn is caused by anterior vaginal wall laxity. Often both hypermobility and intrinsic sphincter deficiency coexist. Recognizing the role of anterior vaginal wall support is important to understanding the role of procedures (such as Burch or needle suspension procedures) which have the potential of correcting stress incontinence without affecting voiding parameters. CONCLUSIONS: As a discipline, we need to conceptualize stress incontinence due to urethral hypermobility or intrinsic sphincter deficiency as separate entities and design our procedures to restore the underlying suspected pathology.

Long-term outcomes and patient satisfaction of continent catheterizable limb and augmentation cystoplasty simultaneous with salvage prostatectomy.

AIMS: We evaluated the long-term outcomes of augmentation cystoplasty and continent catheterizable limb formation in patients who underwent simultaneous salvage prostatectomy. METHODS: Twelve men who underwent salvage prostatectomy with augmentation cystoplasty and either an appendicovesicostomy or Monti ileovesicostomy between October 2000 and February 2003 were assessed for long-term surgical complications, reoperations, continence rates, and patient satisfaction using the Incontinence Symptom Index (ISI) questionnaire and a self-designed catheterization questionnaire. RESULTS: In addition to bladder augmentation, six patients underwent appendicovesicostomy, four had a Monti ileovesicostomy and two a spiral Monti ileovesicostomy. There were no intraoperative complications or surgical-related deaths. Four patients required revision surgery (33%) at a mean of 39 months. Minor revisions were performed for stomal stenosis in two patients with stomal relocation in two patients. Ten of 12 patients were dry (83.3%) with a catheterization frequency of between 3 and 8 hr. At a mean follow-up of 61 months (SD = 20.51), the mean ISI severity score was 1.86 (SD = 3.54) and the mean ISI bother score was 1 (SD 0.74). The majority (86%) would choose to undergo the surgery again. CONCLUSIONS: Although surgically challenging and associated with significant morbidity, salvage prostatectomy with concomitant bladder augmentation and continent catheterizable reconstruction is a feasible and effective means of obtaining adequate long-term urinary continence, while preserving the native bladder. In comparison to similar historical patients with catheterizable limbs only, fewer of the augmented patients needed antimuscarinic medication and delayed augmentation was not necessary. Complications do not increase over time and the continence rates are stable.

Pelvic ischemia is measurable and symptomatic in patients with coronary artery disease: a novel application of dynamic contrast-enhanced magnetic resonance imaging.

INTRODUCTION: Pelvic ischemia can manifest as vascular-mediated erectile dysfunction (ED) and lower urinary tract symptoms (LUTS), and is associated with cardiac ischemia. AIMS: We aimed to develop a dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) technique to measure pelvic perfusion in benign tissue. METHODS: Nine men with coronary artery disease (CAD) were compared with nine without. Images were acquired at 3T with T1-weighted DCE-MRI for perfusion. Two-compartment pharmacokinetic modeling was employed to fit signal enhancement from prostate, corpus cavernosal, and spongiosal tissues. MAIN OUTCOME MEASURES: Perfusion parameters and validated pelvic symptom scores were compared. RESULTS: The mean International Index of Erectile Function (IIEF) total score was worse in CAD (41.3 +/- 19.7) vs. controls (59.4 +/- 14.9, P = 0.04). The IIEF erectile function domain score trended to worse in CAD (13.7 +/- 9.7) vs. controls (22.0 +/- 9.9, P = 0.09). The mean total International Prostate Symptom Score (IPSS) trended to worse in CAD patients (13.2) than controls (7.0) (P = 0.10). Magnetic resonance perfusion analysis demonstrated lower mean maximal percent enhancement to P < 0.0001 in the CAD group vs. controls for all the following comparisons: prostate in CAD (22.4 +/- 0.4) vs. controls (26.3 +/- 0.1); cavernosal tissue in CAD (9.3 +/- 0.2) vs. controls (16.6 +/- 0.8); and spongiosal tissue in CAD (20.6 +/- 1.2) vs. controls (24.0 +/- 0.6). Comparison of mean wash-in rates in the unit of 10(-3)/second was also highly significant (P < 0.0001 for all tissues): prostate in CAD (574.0 +/- 18.0) was lower than controls (1,035.0 +/- 29.0); slower wash-in rates were seen in CAD cavernosal (58.0 +/- 4.0 vs. 139.0 +/- 9.0 in controls) and spongiosal tissue (134.0 +/- 6.0 vs. 278.0 +/- 12.0 in controls). CONCLUSION: These initial data demonstrate that pelvic perfusion can be measured in noncancerous tissues, and that perfusion correlates with validated measures of ED and LUTS.

Robotically assisted excision of ovarian vein for intermittent ureteral obstruction.

With the increasing popularity of robotically assisted procedures, new indications for robotically assisted surgery are being examined. Although open and laparoscopic surgical management of intermittent ureteral obstruction from ovarian vein syndrome has been reported previously, we report the first use of robotic assistance for ureterolysis and ovarian vein excision.

Diagnostic discordance of electromyography (EMG) versus voiding cystourethrogram (VCUG) for detrusor-external sphincter dyssynergy (DESD).

AIMS: Detrusor sphincter dyssynergia (DSD) is defined as: "a detrusor contraction concurrent with an involuntary contraction of the urethral and/or periurethral striated muscle." In neurogenic etiology, this usually refers to involuntary contraction of the external striated sphincter and has classically been termed detrusor-external sphincter dyssynergia (DESD). There is currently no consensus regarding diagnosis [specifics of electromyographic (EMG) or voiding cystourethrographic (VCUG) determination], and little data on how well these modalities correlate. We explore the diagnostic congruence for DESD between needle EMG and VCUG in the neurogenic population. METHODS: Consecutive studies performed by a single urodynamicist at a major neurologic center were reviewed. Presence of DESD was determined by increased wire needle EMG activity and/or by dilated bladder neck and proximal urethra during detrusor contraction, in the absence of valsalva or attempt to inhibit voiding. Minimal acceptable criterion for agreement between the two tests was set at 70%. RESULTS: Fourty nine patients were diagnosed with DESD, had a videourodynamic study available, and had no history of sphincterotomy or stent. Binomial testing demonstrated significant disagreement (P < 0.000) in observed proportions. There was 60% agreement (28 patients) and 40% disagreement (21 patients) between EMG and VCUG for diagnosis of DESD. CONCLUSIONS: We found significant disagreement between needle EMG and VCUG for a positive diagnosis of DESD. A combination of EMG and VCUG may identify more cases of DESD than either modality alone and underscores the need for more strict criteria when defining this entity from a urodynamic standpoint.