Pelvic Organ Prolapse in Female Patients Presenting to Transitional Urology Care Clinic.

PURPOSE: Patients with congenital genitourinary abnormalities are growing into adulthood and their expectations, especially in the areas of sexual function and fertility are creating unforeseen challenges for health care providers. We review the incidence and management of pelvic organ prolapse at our Transitional Urology Clinic. MATERIALS AND METHODS: This study is a retrospective chart review of the presentation and treatment of patients with clinically bothersome pelvic organ prolapse seen at our tertiary Transitional Urology Clinic during 2012 to 2015. RESULTS: Seven patients with a mean age of 22.8 years presented to our clinic with clinically bothersome prolapse. Four patients had myelomeningocele, 2 had sacral agenesis and 1 had bladder exstrophy. All were on self-catheterization. Three patients were sexually active and 1 had an intact uterus and desired fertility. Bothersome symptoms included vaginal bulge in 6 cases, difficult vaginal intercourse in 1 and difficult catheterization in 1. For the leading edge of Bp (anterior compartment) prolapse the median POP-Q (Pelvic Organ Prolapse Quantification System) stage was 3 (range 1 to 3), for Bp (posterior compartment) prolapse it was 1 (range 0 to 3) and for C (vaginal vault or cervical) prolapse it was 2 (range 1 to 3). Management included pessary in 1 case, hysterectomy with bilateral uterosacral ligament suspension in 4, sacrocolpopexy in 1 and observation in 1. Mean followup was 17.6 months (range 1 to 92). One of the 5 patients treated with surgical intervention had recurrence in the anterior compartment and vaginal vault. CONCLUSIONS: Females with congenital genitourinary anomalies present with pelvic organ prolapse at a much younger age and a more advanced stage. There is a paucity of literature on the epidemiology, presentation and management of pelvic organ prolapse in this patient population.

The Single-Incision Sling to Treat Female Stress Urinary Incontinence: A Dynamic Computational Study of Outcomes and Risk Factors.

Dynamic behaviors of the single-incision sling (SIS) to correct urethral hypermobility are investigated via dynamic biomechanical analysis using a computational model of the female pelvis, developed from a female subject's high-resolution magnetic resonance (MR) images. The urethral hypermobility is simulated by weakening the levator ani muscle in the pelvic model. Four positions along the posterior urethra (proximal, midproximal, middle, and mid-distal) were considered for sling implantation. The α-angle, urethral excursion angle, and sling-urethra interaction force generated during Valsalva maneuver were quantitatively characterized to evaluate the effect of the sling implantation position on treatment outcomes and potential complications. Results show concern for overcorrection with a sling implanted at the bladder neck, based on a relatively larger sling-urethra interaction force of 1.77 N at the proximal implantation position (compared with 0.25 N at mid-distal implantation position). A sling implanted at the mid-distal urethral location provided sufficient correction (urethral excursion angle of 23.8 deg after mid-distal sling implantation versus 24.4 deg in the intact case) with minimal risk of overtightening and represents the optimal choice for sling surgery. This study represents the first effort utilizing a comprehensive pelvic model to investigate the performance of an implanted sling to correct urethral hypermobility. The computational modeling approach presented in the study can also be used to advance presurgery planning, sling product design, and to enhance our understanding of various surgical risk factors which are difficult to obtain in clinical practice.

Robotic Intracorporeal Continent Cutaneous Urinary Diversion: Primary Description.

The purpose is to present the first report and describe our novel technique for intracorporeal continent cutaneous diversion after robotic cystectomy. After completion of robot-assisted cystectomy using a standard six-port transperitoneal technique, three additional ports are placed, and the robot is redocked laterally over the patient's right side in the modified lateral position. Our technique replicates step-by-step the principles of the open approach. Ileocolonic anastomosis, ureteroenteral anastomoses, and construction of a hand-sewn right colonic pouch are all performed intracorporeally. Tapering of efferent ileal limb and reinforcement of the ileocecal valve are performed via the extraction site, while the stoma is matured through a prospective port site. Successful robotic intracorporeal creation of a modified Indiana pouch was achieved. Operative time for diversion was 3 hours, with negligible blood loss, and without any intraoperative complications. No major (Clavien III-V) 90-day complications were observed. At a follow-up of 1 year, the patient continues to catheterize without difficulty. We demonstrate the first description of robotic intracorporeal continent cutaneous urinary diversion after robot-assisted cystectomy. We present a systematic minimally invasive approach, replicating the principles of open surgery, which is technically feasible and safe with a good functional result.

Increased pathology in lungs of mice after infection with an alpha-crystallin mutant of Mycobacterium tuberculosis: changes in cathepsin proteases and certain cytokines.

Latency and reactivation are a significant problem that contributes to the incidence, transmission and pathogenesis of tuberculosis. The mechanisms involved in these processes, at the level of both the bacillus and the host, are poorly understood. In Mycobacterium tuberculosis the alpha-crystallin (acr) gene has been linked to latency, because it is highly expressed during hypoxic growth conditions. Deletion of the acr gene in M. tuberculosis H37Rv (Deltaacr strain) was previously shown to reduce the intracellular growth of bacilli in macrophages; however, its impact on pathogenesis in vivo was unknown. This study demonstrated that infection of C57BL6 mice with Deltaacr results in lung bacillary loads 1-2 log units higher in comparison to parental H37Rv. Haematoxylin/eosin staining of lungs revealed exacerbated pathology characterized by extensive obliteration of alveolar air spaces by granulomatous inflammation. RT-PCR analysis and immunostaining of lungs showed that infection with either H37Rv or Deltaacr results in the differential expression of lysosomal cathepsin proteases. A slight increase in the expression of the matrix-degrading acidic-type cathepsins B, D and H was noted in Deltaacr-infected mice and was associated with clusters of macrophages within lung granulomas. Deltaacr-infected mice also showed high serum levels of TNF-alpha, IFN-gamma and G-CSF, suggesting that Acr may play a role in modulating the host response to infection.

Susceptibility to Cryptosporidium parvum infections in cytokine- and chemokine-receptor knockout mice.

To determine the role of cytokines and a chemokine receptor in the susceptibility to, and outcome of, infection, 4 different knockout mice (IL-4, IL-10, IL-12, and CCR5) were infected with Cryptosporidium parvum and monitored for infection intensity by collection of fecal pellets from individual mice. Because adult immunocompetent mice are refractory to infection, wild-type mice on the same background as the knockout mice (C57BL/6) were used as a negative control. No infection was detected over a 4-wk time period in IL-4, IL-10, and CCR5 knockout mice inoculated with 106 oocysts. IL-12 knockout mice inoculated with as little as 100 oocysts shed up to 10,000 oocysts/100 microl of feces on the peak infection day (day 8) and were able to fully recover by 2 wk after infection. IL-12 is an important inducer of IFN-gamma, which probably accounted for susceptibility to infection. Previous studies using IFN-gamma knockout mice have shown strain-related differences in infection intensity and outcome, with increased parasite loads and decreased survival among IFN-gamma knockout mice on a C57BL/6 background compared with those on a BALB/c background. Similar results were observed in IL-12 knockout mice on a BALB/c background, which exhibited little or no infection, despite higher levels of inoculation (10(6) oocysts/mouse).