To mesh or not mesh "apical prolapse," that is the question!

Surgical approaches for pelvic organ prolapse have evolved over the last 30 years and is a popular topic for debate, particularly when discussing apical prolapse. Transvaginal native tissue repairs remain the mainstay of POP surgeries, however, transabdominal approaches continue to evolve. Use of interposition material, such as synthetic polypropylene mesh, is the standard when performing an abdominal sacrocolpopexy, however, use of autologous fascia can be considered. This debate article provides an overview of this subject and highlights the value of different approaches to apical prolapse. The authors were asked to support their approach in various scenarios including:extremes of age, prior hysterectomy and intact uterus, desire to avoid mesh, sexual activity, and presence of comorbidities. In discussing common patient scenarios, ultimate decision making on specific POP surgeries is determined by patient preference and goals.

Troubleshooting Interstim Sacral Neuromodulation Generators to Recover Function.

PURPOSE OF REVIEW: Sacral neuromodulation (SNM) is being used to treat lower urinary tract symptoms (LUTS) with growing popularity among clinicians in multiple specialties. As this therapy becomes more common in the USA and Europe, urologists will encounter more patients implanted with SNM generators. RECENT FINDINGS: Over time, it has recently been understood that up to 53% will develop pain at the implant site as reported by Groen et al. (J Urol 186:954, 2011) and 3-38% will lose effective stimulation as reported by Al-zahrani et al. (J Urol 185:981, 2011) and White et al. (Urology 73:731, 2009). There is a paucity of troubleshooting methodology in the literature, apart from revision surgery, to salvage the SNM generator. In fact, it has been suggested that one contemporary series' failure rate is lower than some historic series because of the ability to reprogram devices as reported by Siegel et al. (J Urol 199:229, 2018). Standard algorithms for such reprogramming efforts are lacking in the literature and may salvage some patients otherwise destined for surgical revision or addition of multimodal therapy to achieve acceptable symptom control. It is possible to troubleshoot and thereby salvage many SNM generators, saving patients from surgical revision in many cases and increasing the number of patients with persistent benefit from SNM. The algorithms presented in this manuscript represent a systematic strategy for reprogramming and troubleshooting SNM generators.

Commentary on "Prognostic effect of carcinoma in situ in muscle-invasive urothelial carcinoma patients receiving neoadjuvant chemotherapy."

BACKGROUND: Carcinoma in situ (CIS) is a poor prognostic finding in urothelial carcinoma. However, its significance in muscle-invasive urothelial carcinoma (MIUC) treated with neoadjuvant chemotherapy (NAC) is uncertain. We assessed the effect of CIS found in pretreatment transurethral resection of bladder tumor (TURBT) biopsies on the pathologic and clinical outcomes. MATERIALS AND METHODS: Subjects with MIUC treated with NAC before cystectomy were identified. The pathologic complete response (pCR) rates stratified by TURBT CIS status were compared. The secondary analyses included tumor response, progression-free survival (PFS), overall survival (OS), and an exploratory post hoc analysis of patients with pathologic CIS only (pTisN0) at cystectomy. RESULTS: A total of 137 patients with MIUC were identified. TURBT CIS was noted in 30.7% of the patients. The absence of TURBT CIS was associated with a significantly increased pCR rate (23.2% vs. 9.5%; odds ratio = 4.08; 95% CI: 1.19-13.98; P = 0.025). Stage pTisN0 disease was observed in 19.0% of the TURBT CIS patients. TURBT CIS status did not significantly affect the PFS or OS outcomes. Post hoc analysis of the pTisN0 patients revealed prolonged median PFS (104.5 vs. 139.9 months; P = 0.055) and OS (104.5 vs. 152.3 months; P = 0.091) outcomes similar to those for the pCR patients. CONCLUSION: The absence of CIS on pretreatment TURBT in patients with MIUC undergoing NAC was associated with increased pCR rates, with no observed differences in PFS or OS. Isolated CIS at cystectomy was frequently observed, with lengthy PFS and OS durations similar to those for pCR patients. Further studies aimed at understanding the biology and clinical effect of CIS in MIUC are warranted.

Conditional Electrical Stimulation in Animal and Human Models for Neurogenic Bladder: Working Toward a Neuroprosthesis.

Sacral neuromodulation has had a tremendous impact on the treatment of urinary incontinence and lower urinary tract symptoms for patients with neurologic conditions. This stimulation does not use real-time data from the body or input from the patient. Incorporating this is the goal of those pursuing a neuroprosthesis to enhance bladder function for these patients. Investigators have demonstrated the effectiveness of conditional (also called closed-loop) feedback in animal models as well as limited human studies. Dorsal genital nerve, pudendal nerve, S3 afferent nerve roots, S1 and S2 ganglia have all been used as targets for stimulation. Most of these have also been used as sources of afferent nerve information using sophisticated nerve electrode arrays and filtering algorithms to detect significant bladder events and even to estimate the fullness of the bladder. There are problems with afferent nerve sensing, however. Some of these include sensor migration and low signal to noise ratios. Implantable pressure sensors have also been investigated that have their own unique challenges, such as erosion and sensor drift. As technology improves, an intelligent neuroprosthesis with the ability to sense significant bladder events and stimulate as needed will evolve.

The Worldwide Economic Impact of Neurogenic Bladder.

Costs of neurogenic bladder vary widely and depend on a number of factors including severity of disease, symptomatology, patient insurance, and devices required. Recognition of how each treatment strategy will impact the patient financially could help guide selection of treatment as well as improve compliance with the chosen regimen. We have attempted to provide an overview of long term cost considerations for the neurogenic bladder patient. Armed with this information, the practitioner can better help the patient select a bladder care regimen that balances the desire to both minimize symptoms now and preserve urinary tract integrity for the future, yet still remain cost effective.

A GENERIC PACKAGING TECHNIQUE USING FLUIDIC ISOLATION FOR LOW-DRIFT IMPLANTABLE PRESSURE SENSORS.

This paper reports on a generic packaging method for reducing drift in implantable pressure sensors. The described technique uses fluidic isolation by encasing the pressure sensor in a liquid-filled medical-grade polyurethane balloon; thus, isolating it from surrounding aqueous environment that is the major source of baseline drift. In-vitro tests using commercial micromachined piezoresistive pressure sensors show an average baseline drift of 0.006 cmH2O/day (0.13 mmHg/month) for over 100 days of saline soak test, as compared to 0.101 cmH2O/day (2.23 mmHg/month) for a non-fluidic-isolated one soaked for 18 days. To our knowledge, this is the lowest reported drift for an implantable pressure sensor.

Quality of life in T1-3N0 prostate cancer patients treated with radiation therapy with minimum 10-year follow-up.

PURPOSE: To describe patient-reported quality of life using a validated survey in a cohort of patients who are long-term survivors of definitive radiotherapy for T1-3N0 prostate cancer. METHODS AND MATERIALS: Survivors of a previously reported cohort of prostate cancer patients treated with staging pelvic lymphadenectomy and definitive radiotherapy between November 1974 and August 1988 were queried using a questionnaire incorporating the RAND 36-Item Health Survey and the University of California, Los Angeles Prostate Cancer Index. Responses were reviewed and analyzed. Of the 146 N0 patients, 88 have survived for 10 years postdiagnosis. Fifty-six (64%) of these patients were still alive with valid addresses and were mailed copies of the questionnaires, of which 46 (82%) responded. Median potential follow-up from date of diagnosis was 13.9 years, with a median age of responders of 80 years. RESULTS: The mean sexual function score was 15.4, with a bother score of 42. The mean urinary function score was 65, with a bother score of 61. The mean bowel function score was 72.6, with a bother score of 64.8. The amount of patient bother reported in the sexual category is similar to that previously reported for cohorts of prostate cancer patients undergoing radiotherapy or observation. This is despite the fact that sexual function was similar to that previously reported for patients postprostatectomy. Patient-reported function and bother scores in urinary and bowel categories were somewhat more severe than a previously reported radiotherapy cohort with shorter follow-up. CONCLUSIONS: With long follow-up, most patients who underwent radiotherapy for prostate cancer in the era described exhibit somewhat worse bladder, bowel, and erectile function than recently published controls without prostate cancer. In this cohort of older men with long follow-up, erectile function is similar to reported prostatectomy series. However, patient bother related to erectile function is similar to that of controls in earlier published radiotherapy series. Worse urinary and bowel function may be due to progressive symptoms with aging and longer follow-up, or to the radiotherapy techniques performed during the era in question.

Impact of body weight on urinary electrolytes in urinary stone formers.

OBJECTIVES: Obesity increases the risk of developing chronic medical conditions such as diabetes mellitus, hypertension, and coronary artery disease. We performed a retrospective review of a large data base on urinary stones to determine if differences are found in urine and serum chemistries among obese and nonobese stone-forming patients. The effect of body weight on stone recurrence among urinary stone formers was also determined. METHODS: A national data base containing serum biochemical profiles, 24-hour urine specimens, and standardized questionnaires was retrospectively evaluated from 5942 consecutive patients with urinary stone disease. Stone-forming patients were classified by body weight: nonobese men, less than 100 kg and nonobese women, less than 85 kg; intermediate men, 100 to 120 kg and intermediate women, 85 to 100 kg; and obese men, more than 120 kg and obese women, more than 100 kg. RESULTS: Obese stone formers comprised 6.8% (n = 404) of the patient population. The mean weight in the nonobese and obese groups was 81 kg versus 134 kg, respectively, for men and 64 kg versus 112 kg, respectively, for women. Obese patients represented 3.8% of the male and 12.6% of the female population. Obese patients had increased urinary excretion of sodium, calcium, magnesium, citrate, sulfate, phosphate, oxalate, uric acid, and cystine; obesity was associated with increased urinary volumes and urine osmolality compared with the nonobese patients. Obese men had increased concentration of urinary sodium, oxalate, uric acid, sulfate, and phosphate when corrected for urinary volume. Obese women had increased concentrations of sodium, uric acid, sulfate, phosphate, and cystine. The mean number of stone episodes in nonobese versus obese men was similar (3.55 and 3.56), whereas mean stone episodes were 2.93 and 3.38 (P = 0.045) for nonobese versus obese women. CONCLUSIONS: Among known stone formers, obesity is associated with unique changes in both serum and urinary chemistries. These changes are associated with an increased incidence of urinary stone episodes in obese women but not in obese men.

Transplantation of a cadaveric polycystic kidney in a patient with autosomal dominant polycystic kidney disease: long-term outcome.

INTRODUCTION: Kidneys from donors affected by autosomal dominant polycystic kidney disease (ADPKD) were considered unusable for transplantation. To the best of our knowledge, seven cases worldwide have now been described in the English literature since 1967 suggesting such donor organs may be acceptable under certain conditions. Most of these reports have only short-term follow-up. METHODS: We provide a review of these patients and share our experience with an ADPKD patient who had a cadaveric ADPKD transplant and has been closely followed for 10 years. RESULTS: During the 10-year period, the patient had three transplant biopsies without complication. This creatinine is currently 1.2 mg/dL. Serial computed tomography imaging indicated that the cystic disease slowly progressed during this time period. He eventually developed intractable pain in his native left kidney and underwent a laparoscopic nephrectomy. CONCLUSIONS: Normal functioning cadaveric kidneys that show early signs of polycystic kidney disease should be considered acceptable for renal donation. These organs provide the recipient a safe, reasonable period of graft survival and have not been shown to cause adverse effects.

Is the Diabetic Bladder a Neurogenic Bladder? Evidence from the Literature.

Diabetes can often cause LUTS. This has been called diabetic cystopathy by many authors, but no concise grouping of symptoms for this condition has been agreed upon. The etiology of diabetic cystopathy remains unknown, but evidence from the literature strongly suggests a neurologic etiology as the primary factor, with other factors such as polyuria, damage to muscle from oxidative stress, and urothelial factors possibly contributing. Once a standard definition for diabetic cystopathy can be agreed upon, prospective, longitudinal studies will play a key role in the generation of hypotheses for the causes of diabetic cystopathy. Animal models will help test these hypotheses and possibly provide strategies for prevention.

An implantable pressure sensing system with electromechanical interrogation scheme.

In this paper, we report on the development of an implantable pressure sensing system that is powered by mechanical vibrations in the audible acoustic frequency range. This technique significantly enhances interrogation range, alleviates the misalignment issues commonly encountered with inductive powering, and simplifies the external receiver circuitry. The interrogation scheme consists of two phases: a mechanical vibration phase and an electrical radiation phase. During the first phase, a piezoelectric cantilever acts as an acoustic receiver and charges a capacitor by converting sound vibration harmonics occurring at its resonant frequency into electrical power. In the subsequent electrical phase, when the cantilever is not vibrating, the stored electric charge is discharged across an LC tank whose inductor is pressure sensitive; hence, when the LC tank oscillates at its natural resonant frequency, it radiates a high-frequency signal that is detectable using an external receiver and its frequency corresponds to the measured pressure. The pressure sensitive inductor consists of a planar coil (single loop of wire) with a ferrite core whose distance to the coil varies with applied pressure. A prototype of the implantable pressure sensor is fabricated and tested, both in vitro and in vivo (swine bladder). A pressure sensitivity of 1 kHz/cm H2O is achieved with minimal misalignment sensitivity (26% drop at 90° misalignment between the implanted device and acoustic source; 60% drop at 90° misalignment between the implanted device and RF receiver coil).

Neuromodulation for Neurogenic Bladder.

Although neuromodulation is well established for the treatment of non-neurogenic lower urinary tract symptoms, recent literature supports its use in the patient having LUTS associated with a neurologic condition. Sacral neuromodulation, in particular, may see new use as a modality to facilitate neurologic remodeling in spinal cord injured patients as well as children. As a therapeutic option, sacral neuromodulation and dorsal genital nerve stimulation may one day become more effective and more efficient utilizing the concept of closed-loop feedback, where electro-neurogram and bladder pressure data are incorporated into stimulation routines. In addition, some older therapies are reviewed that have recently demonstrated success in this patient population.

Computational models for detection of endocrinopathy in subfertile males.

The observation that men with sperm density greater than 10 million/ml had low probability of endocrinopathy led to a refinement in the evaluation of subfertility. Using statistical methods, we sought to provide a more accurate prediction of which patients have an endocrinopathy, and to report the outcome as the odds of having disease. In addition, by examining the parameters that influenced the model significantly, the underlying pathophysiology might be better understood. Records of 1035 men containing variables including testis volume, sperm density, motility as well as the presence of endocrinopathy were randomized into 'training' and 'test' data sets. We modeled the data set using linear and quadratic discriminant function analysis, logistic regression (LR) and a neural network. Wilk's regression analysis was performed to determine which variables influenced the model significantly. Of the four models investigated, LR and a neural network performed the best with receiver operating characteristic areas under the curve of 0.93 and 0.95, respectively, correlating to a sensitivity of 28% and a specificity of 99% for the LR model, and a sensitivity and specificity of 56 and 97% for the neural network model. Reverse regression yielded P-values for the testis volume and sperm density of <0.0001. The neural network and LR models accurately predicted the probability of an endocrinopathy from testis volume, sperm density and motility without serum assays. These models may be accessed via the Internet, allowing urologists to select patients for endocrinologic evaluation at http://www.urocomp.org.

Outcomes for surgical management of orchalgia in patients with identifiable intrascrotal lesions.

OBJECTIVE: The outcome of surgery for relief of orchalgia in patients with identifiable intrascrotal pathology is not well defined. We evaluated the success of commonly performed surgical procedure indicated for pain relief in patients with specific intrascrotal lesions. METHODS: Surgical cases performed for relief of painful scrotal pathology were reviewed, including ligation of internal spermatic vein, hydrocelectomy, spermatocelectomy, and orchiopexy for suspected intermittent torsion. Relief of pain as reported to the physician and time for return to full activity were determined. Pain relief was compared to a 50% placebo rate using Fisher's exact test. RESULTS: Eigthy-five of 151 patients (56%) undergoing surgery for pain relief had complete data and adequate follow-up for analysis. Of 40 patients who had ligation of the internal spermatic vein, 30 (75%) were relieved of pain (p = 0.037). All 19 patients with painful hydroceles and 16 of 17 (94%) with spermatoceles were relieved of pain (p < 0.001). Of 9 patients undergoing scrotal orchiopexy for suspected intermittent torsion, 8 (89%) were pain-free (p < 0.001). CONCLUSION: Surgical management of specific intrascrotal lesions is highly effective.

Gross hematuria secondary to renal vein hypertension from unilateral retroperitoneal fibrosis.

We report the first case of localized, unilateral, idiopathic retroperitoneal fibrosis encasing the left renal vein, which resulted in secondary renal vein hypertension. The patient presented with sudden and dramatic gross hematuria. Surgical release and excision of the surrounding localized retroperitoneal fibrosis resulted in prompt resolution of the hematuria.

Comparison of flaps versus grafts in proximal hypospadias surgery.

PURPOSE: We analyzed the complication rate in patients who underwent proximal hypospadias repair using preputial skin as a flap or free graft. MATERIALS AND METHODS: We retrospectively reviewed the records of 142 patients who underwent proximal hypospadias repair. Repairs were subdivided into tubed and onlay repairs within the flap and free graft groups. We analyzed postoperative complications, including fistulas, proximal strictures, diverticula and meatal stenosis. RESULTS: Median patient age at followup was 11.3 months and median followup was 9.4 months. Two-thirds of the repairs were performed with free grafts. A proximal stricture developed in 8 and 0 patients who underwent free tubed graft and free onlay repair, respectively (p = 0.047). Otherwise there was no significant difference in the complication rate of the various types of repair. Of the 43 patients who had stricture, fistula or meatal stenosis 29 (67%) presented more than 1 year after surgery. CONCLUSIONS: In repairs performed with free grafts there is a significantly higher proximal stricture rate when a tube rather than an onlay is used. Otherwise we noted no significant difference in the complication rates of flaps and grafts used to repair proximal hypospadias. A significant number of complications presented more than 1 year postoperatively and they may even present as late as 4 years. This finding suggests that longer followup may be necessary to assess completely the outcome of proximal hypospadias surgery.

The fate of 10-year clinically recurrence-free survivors after definitive radiotherapy for T1-3N0M0 prostate cancer.

We recently reported the outcome of 168 patients treated with pelvic lymphadenectomy and definitive radiation therapy. This report is a subanalysis of those patients (pts) who were clinically without evidence of disease (NED) 10 years after a negative staging pelvic lymphadenectomy and definitive radiation therapy for prostate cancer. One hundred of our original cohort of 168 patients had at least ten year follow-up. 76 patients had pathologically negative lymph nodes and had not received hormonal therapy. Forty-two N0 patients with sufficient follow-up were alive and clinically NED 10 years post-operatively. Distribution by disease stage at diagnosis was: Stage A2: 12 pts; Stage B: 19 pts; Stage B2/C: 6 pts; Stage C: 5 pts. Median follow-up was 13.3 years, with a minimum follow-up of 10 years. Of the 42 patients clinically NED at 10 years, 5 pts died subsequently without PSA data, remaining clinically NED a median of 13 y 3 m postoperatively; 37 patients were alive and without evidence of disease off all therapy at 10 years post-operatively. Bone scans were performed on 8 of the 9 patients with PSA over 4.0 ng/ml or on hormonal therapy. These revealed a single patient with diffuse but asymptomatic bone metastases. Ultrasound-guided sextant biopsies were performed on one 78-year-old patient with elevated PSA 19 years post-operatively, revealing an asymptomatic local recurrence. Patients who survive clinically NED for 10 years have a low likelihood of clinical failure, even in the presence of PSA values between 4.0 and 10 ng/ml. In these patients, PSA trends are of greater utility than absolute values.

Second primary malignancies in T1-3N0 prostate cancer patients treated with radiation therapy with 10-year followup.

PURPOSE: The risk of patients with prostate cancer to have second primary malignancies is unclear. Population and autopsy based studies have shown no increased risk, which is at variance with several institutional analyses. A retrospective review was performed with comparison to expected cancer data from the Connecticut Tumor Registry. MATERIALS AND METHODS: Records of a cohort of prostate cancer patients treated with staging pelvic lymphadenectomy and definitive radiotherapy between November 1, 1974 and July 7, 1987 were reviewed. Median potential followup from date of diagnosis was 10.9 years. RESULTS: Of the 164 patients 150 (91.5%) had followup to death or to August 1995, with data available in part on 4 of the remaining patients. In 43 patients 51 second primary malignancies developed. Increased frequency of lymphomas, and kidney, bladder and rectal lesions (all p < 0.001) was observed concurrently with diagnosis of prostate cancer, although this may be due to bias since full staging for the prostate cancer may have led to their diagnosis. An increased frequency of renal lesions in the 1 to 4-year followup period (p = 0.032) also was observed. Two sarcomas and a leukemia were putatively radiation induced but their frequency was not significantly different from the comparison baseline. CONCLUSIONS: Much of the apparent increase in second primary malignancies associated with prostate cancer noted by some authors may be attributed to bias in the staging process. Renal cancers may occur more frequently in patients with prostate cancer but the distribution of these lesions is inconsistent with a field defect mechanism of cancer induction.