An analysis of urodynamic parameters in diabetic and nondiabetic women.

OBJECTIVES: Diabetes is highly prevalent worldwide, with an estimated 536 million living with diabetes in 2021, and that number projected to increase to 783 million by 2045. Diabetic bladder dysfunction is thought to affect up to 60%-90% of individuals with diabetes and can significantly impact quality of life. Despite the prevalence of diabetic bladder dysfunction, the exact pathophysiological mechanism, and resulting clinical presentation, remains debated. Our objective was to compare urodynamic parameters between diabetic and nondiabetic women, assessing the impact of various markers of diabetes severity on bladder function. METHODS: A retrospective chart review was conducted on female patients aged 18 and above who underwent urodynamic studies at a single tertiary care university hospital system from 2014 to 2020. Patients were categorized based on diabetes status, and diabetes severity including duration of disease, hemoglobin A1c levels, insulin dependence, and markers of end-organ dysfunction. Urodynamic variables, including compliance, bladder voided efficiency, bladder contractility index, postvoid residual, maximum flow rate, capacity, voided volume, and detrusor overactivity, were assessed by two independent reviewers. Statistical analyses were performed to assess the impact of diabetes and diabetic severity on urodynamic parameters. RESULTS: A total of 652 female patients were included in the study, of which, 152 (23.3%) had diabetes, with an average duration of diagnosis of 82.3 months. Diabetic women were older and had higher body mass index compared to nondiabetic women. Diabetic retinopathy and neuropathy were present in 18% and 54.6% of diabetic patients, respectively. Significant differences in urodynamic parameters were observed between diabetic and nondiabetic women, with diabetic women showing higher rates of detrusor overactivity (p = 0.01), particularly associated with increasing BMI (p = 0.03). However, classic markers of diabetes severity including duration, as well as markers of end-organ damage, showed mixed associations with urodynamic changes. CONCLUSIONS: Despite the prevalence of diabetic bladder dysfunction and its impact on patient quality of life, the exact mechanisms and clinical presentation remain elusive. Our study highlights the significant differences in urodynamic parameters between diabetic and nondiabetic women, emphasizing the need for further research into the relationship between diabetes and diabetic bladder dysfunction.

Radiation exposure during sacral neuromodulation lead placement: Multi-institutional descriptive study.

OBJECTIVES: Fluoroscopy has significantly improved lead placement and decreased surgical time for implantable sacral neuromodulation (SNM). There is a paucity of data regarding radiation and safety of fluoroscopy during SNM procedures. Our study aims to characterize fluoroscopy time and dose used during SNM surgery across multiple institutions and assess for predictors of increased fluoroscopy time and radiation dose. METHODS: Electronic medical records were queried for SNM procedures (Stage 1 and full implant) from 2016 to 2021 at four academic institutions. Demographic, clinical, and intraoperative data were collected, including fluoroscopy time and radiation dose in milligray (mGy). The data were entered into a centralized REDCap database. Univariate and multivariate analysis were performed to assess for predictive factors using STATA/BE 17.0. RESULTS: A total of 664 procedures were performed across four institutions. Of these, 363 (54.6%) procedures had complete fluoroscopy details recorded. Mean surgical time was 58.8 min. Of all procedures, 79.6% were performed by Female Pelvic Medicine and Reconstructive Surgery specialists. There was significant variability in fluoroscopy time and dose based on surgical specialty and institution. Most surgeons (76.4%) were considered "low volume" implanters. In a multivariate analysis, bilateral finder needle testing, surgical indication, surgeon volume, and institution significantly predicted increased fluoroscopy time and radiation dose (p < 0.05). CONCLUSIONS: There is significant variability in fluoroscopy time and radiation dose utilized during SNM procedures, with differences across institutions, surgeons, and subspecialties. Increased radiation exposure can have harmful impacts on the surgical team and patient. These findings demonstrate the need for standardized fluoroscopy use during SNM procedures.

Changes in patient reported outcome measures after treatment for female urethral stricture.

INTRODUCTION: There is a paucity of patient reported outcome measure (PROM) data for women with urethral strictures. To address this gap, we aim to evaluate change in PROM among women who underwent surgery for a stricture. METHODS: American Urological Association Symptom Index (AUA-SI) and Urogenital Distress Inventory (UDI-6) data from a multi-institutional retrospective cohort study of women treated for urethral stricture was assessed. RESULTS: Fifty-seven women had either AUA-SS or UDI-6 and 26 had baseline and postoperative data for either. Most women underwent urethroplasty (77%) and the majority (73%) remained stricture free at median follow-up of 21 months (interquartile range [IQR] 7-37). The median baseline AUA-SI was 21 (IQR 12-28) and follow-up was 10 (IQR 5-24). After treatment, there was a median decrease of 12 (IQR -18 to -2) in AUA-SI (p = 0.003). The median AUA Quality of life (QOL) score at baseline and follow-up were 6 (IQR 4-6) and 3 (IQR 2-5), respectively. There was a median AUA-QOL improvement of 2 points (-5,0; p = 0.007) from a baseline 5 (unhappy) to 3 (mixed). Median UDI-6 scores were 50 (IQR 33-75) at baseline and 17 (IQR 0-39), at follow-up. After treatment, there was a median decrease of 19 (-31 to -11; p = 0.01). CONCLUSION: Women with urethral strictures have severe lower urinary tract symptoms which improved after surgery. This study substantiates the claims that recognizing and treating women with urethral stricture disease greatly improves lower urinary tract symptoms and QOL.

Treatment of urethral stricture disease in women: A multi-institutional collaborative project from the SUFU research network.

AIM: Female urethral stricture disease is rare and has several surgical approaches including endoscopic dilations (ENDO), urethroplasty with local vaginal tissue flap (ULT) or urethroplasty with free graft (UFG). This study aims to describe the contemporary management of female urethral stricture disease and to evaluate the outcomes of these three surgical approaches. METHODS: This is a multi-institutional, retrospective cohort study evaluating operative treatment for female urethral stricture. Surgeries were grouped into three categories: ENDO, ULT, and UFG. Time from surgery to stricture recurrence by surgery type was analyzed using a Kaplan-Meier time to event analysis. To adjust for confounders, a Cox proportional hazard model was fit for time to stricture recurrence. RESULTS: Two-hundred and ten patients met the inclusion criteria across 23 sites. Overall, 64% (n = 115/180) of women remained recurrence free at median follow-up of 14.6 months (IQR, 3-37). In unadjusted analysis, recurrence-free rates differed between surgery categories with 68% ENDO, 77% UFG and 83% ULT patients being recurrence free at 12 months. In the Cox model, recurrence rates also differed between surgery categories; women undergoing ULT and UFG having had 66% and 49% less risk of recurrence, respectively, compared to those undergoing ENDO. When comparing ULT to UFG directly, there was no significant difference of recurrence. CONCLUSION: This retrospective multi-institutional study of female urethral stricture demonstrates that patients undergoing endoscopic management have a higher risk of recurrence compared to those undergoing either urethroplasty with local flap or free graft.

Where Are We Headed with Neuromodulation for Overactive Bladder?

Overactive bladder (OAB) affects millions of people around the world and decreases quality of life for those affected. Over the past two decades, significant advances in treatment have transformed the lives of those with OAB. Sacral neuromodulation (SNM), posterior tibial nerve stimulation (PTNS), and dorsal genital nerve stimulation are the most effective contemporary treatment modalities. New techniques and bio-sensing schemes offer promise to advance therapy beyond what is currently available. Current neuromodulation techniques do 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. Dorsal genital nerve, pudendal nerve, S3 afferent nerve roots, and S1 and S2 ganglia have all been used as targets for stimulation. Some of these have also been used as sources of afferent nerve information to detect significant bladder events and even to estimate the fullness of the bladder. As technology improves, an intelligent neuroprosthesis with the ability to sense significant bladder events may revolutionize treatment of OAB.

An Universal packaging technique for low-drift implantable pressure sensors.

Monitoring bodily pressures provide valuable diagnostic and prognostic information. In particular, long-term measurement through implantable sensors is highly desirable in situations where percutaneous access can be complicated or dangerous (e.g., intracranial pressure in hydrocephalic patients). In spite of decades of progress in the fabrication of miniature solid-state pressure sensors, sensor drift has so far severely limited their application in implantable systems. In this paper, we report on a universal packaging technique for reducing the sensor drift. The described method isolates the pressure sensor from a major source of drift, i.e., contact with the aqueous surrounding environment, by encasing the sensor in a silicone-filled medical-grade polyurethane balloon. In-vitro soak tests for 100 days using commercial micromachined piezoresistive pressure sensors demonstrate a stable operation with the output remaining within 1.8 cmH2O (1.3 mmHg) of a reference pressure transducer. Under similar test conditions, a non-isolated sensor fluctuates between 10 and 20 cmH2O (7.4-14.7 mmHg) of the reference, without ever settling to a stable operation regime. Implantation in Ossabow pigs demonstrate the robustness of the package and its in-vivo efficacy in reducing the baseline drift.

Gender and Racial Diversity among U.S. Urology Residency Programs and Efforts to Improve It: You Can't Be What You Can't See.

INTRODUCTION: The U.S. urology workforce lacks ethnic and gender diversity. Few programs exist to increase diversity, and little is known on their effectiveness. We assessed the landscape of specific programs designed to increase underrepresented in medicine (URiM) and female student participation in the U.S. Urology Match, and understand the concerns and attitudes of those students. METHODS: To better understand urology-specific programs, we sent an 11-item survey to all 143 urology residency programs. To better understand the concerns and attitudes of URiM and female students participating in the U.S. Urology Match, we sent a 12-item survey to the students who participated in the Match from 2017 to 2021. Lastly, we evaluated trends in match rate using Match data from 2019 to 2021. RESULTS: Among programs, 43% responded to our survey. Most residency programs offer a wide array of initiatives to increase their diversity, with unconscious bias training being the most frequent (78.7%). Programs with at least 1 female faculty member were associated with increased recruitment of female residents over time (p=0.047). A similar trend was seen in programs with URiM faculty. Among students, 10.5% responded to our survey, of whom 79.2% were unaware of any programs at their institution geared toward URiM or female students. Match data revealed that women were more likely to match (p=0.002), and URiM students were less likely to match (p <0.001) compared to the overall Match rate. CONCLUSIONS: Urology programs are making substantial efforts to improve diversity, but the message is lacking reach. Having a diverse faculty did make a difference in programs' ability to diversify.

Sacral neuromodulation for refractory urge incontinence is less effective following spinal surgery.

Patients with neurogenic disorders and voiding dysfunction have been reported to respond poorly to sacral neuromodulation. We report on our experience in treating voiding symptoms with sacral neuromodulation after spinal surgery. The medical charts of patients evaluated for sacral neuromodulation from 2000-2008 were retrospectively reviewed. Indications, need for explantation, and clinical success (>50% symptom improvement) were recorded. The cohort of patients who had undergone prior spinal surgery was compared to patients with no history of spinal surgery or neurological disease. Thirty-two patients with a history of spinal surgery and 136 with no history of neurologic disease underwent sacral neuromodulation testing. Twenty men and women (62.5%) from the spinal surgery group ultimately underwent permanent implantation. Seventeen of the 32 patients were diagnosed with urge incontinence, of whom 52.9% reported a successful outcome at a mean of 2.3 years of follow-up, compared to an 80.3% success rate in patients with no history of spinal surgery (p=0.018). Sixteen of 32 carried a diagnosis of urgency/frequency with 62.5% success at last follow-up, compared 73.9% (p=0.35) of those without a history of spinal surgery or neurological disease. Thirteen of 32 patients diagnosed with urinary retention experienced a 61.5% long-term success rate, compared with 63.6% for those without spinal surgery and urinary retention. Six of 20 (30.0%) in the spinal surgery group were explanted at a mean time of 2.9 years, compared with 27 of 102 (26.5%) of the non-neurologic patients. Clinical success can be achieved using sacral neuromodulation in patients with voiding dysfunction and a history of spinal surgery; however, those with urge incontinence are less likely to report significant improvement.

Securing Mesh with Delayed Absorbable Suture Does Not Increase Risk of Prolapse Recurrence After Robotic Sacral Colpopexy.

Introduction and Objective: Nonabsorbable monofilament suture is traditionally used to secure vaginal mesh for robot-assisted sacral colpopexy (RASC) but can become exposed postoperatively requiring invasive vaginal removal. Polydioxanone delayed absorbable suture may avoid this. We sought to determine the objective and subjective impact of suture choice for mesh fixation. Materials and Methods: A cohort study was undertaken using a prospective registry and subjects were grouped based on type of suture at the time of RASC. Apical failure was defined as C point descent of >2 cm, anterior compartment failure was defined as pelvic organ prolapse quantification (POP-Q) Ba point of >0, and posterior compartment failure was defined as Bp point of >0. Patient-reported outcomes included urogenital distress inventory (UDI)-6 and QoL. Two-tailed t-test and chi-squared were used for analysis. Results: A total of 119 women underwent RASC between 2009 and 2016. Patients had similar preoperative characteristics (Table 1). All POP-Q, UDI-6, and quality of life (QoL) scores improved postoperatively (Tables 1 and 2). Apical failure was noted in 0, anterior failure was noted in 7 (average Ba +1.1 cm in failures), and posterior failure was noted in 4 (mean Bp +1.0 cm) at 16 months' follow-up. Failures in the anterior compartment were much more common in the nonabsorbable monofilament cohort (Table 2). Failures in the apical and posterior compartments were not significantly different between groups. Nine suture erosions were noted in the nonabsorbable monofilament cohort, five requiring excision in the clinic and two in the operating room. Two suture erosions were noted in the delayed absorbable cohort, 0 required excision. Postoperative UDI-6 and QoL scores did not vary significantly between groups (5.3 ± 4.0 vs 5.1 ± 4.0, p = not significant (NS), 2.8 ± 2.0 vs 2.8 ± 2.2, p = NS). [Table: see text] [Table: see text] Conclusion: Securing mesh with delayed absorbable monofilament did not appear to increase risk of failure in patients undergoing RASC and eliminates the need for suture excision postoperatively.

Robotic Sacral Colpopexy Using Autologous Fascia Lata Compared with Mesh.

Objective: The objective is to compare robotic sacral colpopexy (RSC) utilizing autologous fascia lata with RSC with synthetic mesh in the treatment of pelvic organ prolapse (POP). Methods: We performed a prospective nonrandomized case comparison trial at a single institution. We compared RSC utilizing either synthetic mesh or autologous fascia lata in women with symptomatic POP, stages II through IV. The primary outcome was anatomic prolapse recurrence determined by the Pelvic Organ Prolapse Quantification (POP-Q) examination. Secondary outcomes included patient-reported outcomes such as the Urogenital Distress Inventory-6 (UDI-6) and Incontinence Impact Questionnaire-7 (IIQ-7). Complications were also recorded and categorized using the Clavien-Dindo (CD) system. The hypothesis is that autologous fascia lata would provide equivalent anatomic and patient-reported outcomes compared with mesh while eliminating mesh-related complications. Results: Sixty-four women underwent RSC with 19 (29.7%) receiving fascia lata graft. The overall operative time was greater in the fascia lata group with mean fascia lata harvest time of 24.8 ± 7.4 minutes. Intragroup comparisons of the fascia and mesh groups demonstrated significant improvement in pelvic measurements as well as patient-reported outcomes. Intergroup comparison demonstrated equivalent success rates at 12.1 ± 8.7 months follow-up. There was one apical failure in the fascia lata RSC group; however, the difference was not statistically significant (p = 0.30). Significant complications in the fascia lata harvest group included two CD-II and one CD-IIIb. In the mesh group there was one mesh erosion requiring surgical excision (CD-IIIb). Conclusion: This is the first comparison between RSC with autologous fascia lata and mesh. Short-term anatomic outcomes were similar with autologous fascia lata use without the risk of mesh erosion. Morbidity from graft harvest site was not trivial. These results emphasize the need for a randomized controlled trial.

Long-term outcomes of urgency-frequency syndrome due to painful bladder syndrome treated with sacral neuromodulation and analysis of failures.

PURPOSE: We present our long-term experience with sacral neuromodulation devices placed in patients with painful bladder syndrome to determine whether the benefit decreases over time. MATERIALS AND METHODS: Between January 2000 and July 2004, 32 women and 7 men with interstitial cystitis/painful bladder syndrome in whom previous conventional therapy failed underwent sacral neuromodulation test stimulation. Before 2003 a percutaneous test lead was placed in the clinic setting. After 2003 a quadripolar permanent lead was placed in the operating room. Permanent generators were implanted if the patient had more than 50% relief from the presenting complaint, which was defined as urinary or pelvic pain, urgency, or urinary frequency. Long-term outcomes included battery depletion, device malfunction, infection or loss of benefit as well as any change in need for medications. RESULTS: Of 39 patients 22 went from test stimulation to permanent generator implantation. There were significant differences in short-term but not long-term outcomes between the 2 methods of test stimulation. Of 33 patients undergoing percutaneous nerve evaluation 13 (39.4%) met the criteria for permanent generator implantation, while 9 of 11 (81.8%) evaluated with the quadripolar lead met these criteria (p = 0.015). Long-term success between the groups was similar at 92.3% (12 of 13) vs 77.8% (7 of 9) (p = 0.329) during an average followup of 59.9 months. Eleven (50.0%) devices required explantation. Of 22 patients 3 (13.6%) lost benefit over time. CONCLUSIONS: These patients appear to respond best to permanent quadripolar lead placement but long-term results do not appear to be independently affected by the method of test stimulation. Loss of benefit over time is not common.

Sacral neuromodulation in diabetic patients: success and complications in the treatment of voiding dysfunction.

AIMS: We compared success rates, subsequent complications, and possible indications for success of sacral neuromodulation (SNM) for urinary voiding dysfunction in diabetic and non-diabetic patients. METHODS: Thirty-two diabetic patients (mean age 61.8 years, range 27-83) with urge incontinence, urgency-frequency syndrome, and/or urinary retention refractory to non-surgical treatment were retrospectively evaluated along with 211 non-diabetic patients (mean age 54.1 years, range 20-86) with similar symptoms. All patients who experienced >or=50% reduction in urinary symptoms following a 7- to 21-day test period went on to permanent SNM device implantation. RESULTS: No significant difference was found with respect to successful conversion rates from the test period to permanent implantation between diabetic and non-diabetic patients. Long-term success rates at a mean followup of 29.3 months following permanent device implantation for diabetic patients were 69.2% of those with urge incontinence, 85.7% of those with urgency-frequency, and 66.7% of those with urinary retention. The non-diabetic cohort had success rates of 67.0% for urge incontinence, 67.8% for urgency/frequency, and 58.2% for urinary retention (P = 0.823, 0.157, and 0.631, respectively). No patient experienced intraoperative complications. Nine of 24 (37.5%) devices were explanted postoperatively in diabetic patients compared with 36 of 141 (25.5%) in non-diabetic patients (P = 0.224). The number of explants due to infection was higher in diabetic patients (16.7%) versus non-diabetic patients (4.3%; P = 0.018). CONCLUSIONS: No difference in long-term success rates was seen in diabetic patients when compared with similar, non-diabetic patients. Diabetic patients did, however, have a higher incidence of device explantation due to infection.

Prostatitis: diagnosis and treatment.

Prostatitis ranges from a straightforward clinical entity in its acute form to a complex, debilitating condition when chronic. It is often a source of frustration for the treating physician and patient. There are four classifications of prostatitis: acute bacterial, chronic bacterial, chronic prostatitis/chronic pelvic pain syndrome, and asymptomatic. Diagnosis of acute and chronic bacterial prostatitis is primarily based on history, physical examination, urine culture, and urine specimen testing pre- and post-prostatic massage. The differential diagnosis of prostatitis includes acute cystitis, benign prostatic hyperplasia, urinary tract stones, bladder cancer, prostatic abscess, enterovesical fistula, and foreign body within the urinary tract. The mainstay of therapy is an antimicrobial regimen. Chronic pelvic pain syndrome is a more challenging entity, in part because its pathology is poorly understood. Diagnosis is often based on exclusion of other urologic conditions (e.g., voiding dysfunction, bladder cancer) in association with its presentation. Commonly used medications include antimicrobials, alpha blockers, and anti-inflammatory agents, but the effectiveness of these agents has not been supported in clinical trials. Small studies provide limited support for the use of nonpharmacologic modalities. Asymptomatic prostatitis is an incidental finding in a patient being evaluated for other urologic problems.

Buccal mucosal graft urethroplasty in the treatment of urethral strictures: experience using the two-surgeon technique.

At our institution, the majority of buccal mucosal graft urethroplasties are performed using a two-team approach with an otolaryngologic surgeon. We report our two-surgeon experience with buccal mucosal grafting for reconstruction of all anterior urethral strictures. Twenty-four men underwent autologous buccal mucosal graft urethroplasty between October 2001 and September 2008 for recurrent urethral stricture disease. Twenty-two underwent a single-stage repair and two underwent a two-stage repair. Medical charts were retrospectively reviewed for demographics, comorbidities, etiology, location and length of stricture, and prior interventions in order to identify predictors of buccal urethroplasty success, defined as no evidence of stricture recurrence. All patients underwent retrograde urethrogram and cystoscopy. Operative and anesthesia times were evaluated. We determined an overall success rate of 83.3% (20 of 24 cases). Mean anesthesia time for single-stage urethroplasty was 155 min and mean operative time was 123 min. One of the two two-stage urethroplasties experienced stricture recurrence (50%). The single-stage buccal graft success rate was 86.4% (19 of 22 cases). Two of the four who developed recurrent stricture disease that required intervention had undergone a previous mesh urethroplasty. Complications developed in four of 24 patients (16.6%), including superficial wound infection (one), superficial wound dehiscence (two), and abscess/fistula formation requiring reoperation (one). The buccal mucosa is an ideal tissue for both single- and two-stage substitution urethroplasty for patients with recurrent stricture disease. Our two-surgeon technique minimizes anesthesia and operative times, and contributes to the overall high success rate and relatively low complication rate.

Traumatic urethral injury without pelvic fracture in an adult female.

A 23-year-old female was involved in a motor vehicle collision with multiple injuries, including a right acetabular fracture, but no pelvic fracture. Urology consultation was obtained due to difficulty placing a urethral catheter. Examination revealed a longitudinal urethral tear with vaginal laceration extending 2 cm from the urethral meatus proximally toward the bladder neck. The longitudinal urethral tear was repaired primarily. Traumatic female urethral injury in the absence of a pelvic fracture is an exceedingly rare occurrence.

Ossabaw Pig Demonstrates Detrusor Fibrosis and Detrusor Underactivity Associated with Oxidative Stress in Metabolic Syndrome.

Metabolic Syndrome (MetS) has detrimental effects on the bladder, including detrusor underactivity. The progression and mechanism of disease are poorly understood. A swine model for diabetic bladder dysfunction (DBD) was established because of the pig's human-sized bladder and its ability to develop MetS by dietary modification alone. The hypothesis of this study is that this swine model will demonstrate oxidative stress associated with MetS, which contributes to both bladder fibrosis and detrusor underactivity (DU). Ossabaw pigs underwent dietary modification consisting of a hypercaloric, atherogenic diet for 10 mo to induce MetS, and were compared with a group of control (lean) pigs. Urodynamic studies were performed in both groups to confirm DU. Thiobarbituric acid reactive substances (TBARS) detected in the urine were used to measure oxidative stress activity in the urinary tract, and urinary IL17a was used to detect profibrotic activity. MetS was confirmed by assessing body weight, blood pressure, glucose tolerance, total cholesterol, and triglycerides. The MetS group exhibited an increase in the relative levels of urinary TBARS and IL17a. Bladder pressures at capacity were lower in the MetS group, suggesting DU. Histologic analysis of a cohort of control (lean) and MetS pigs revealed that as compared with the control pigs, the MetS pigs had significantly more collagen in the muscularis layer, but not in the submucosa or mucosa layer. In conclusion, the Ossabaw pig model for diet-induced MetS is associated with oxidative stress and profibrotic activity in the bladder, which results in DU. This has previously been shown in mice and rats, but never in pigs. This novel model will better represent human MetS and DBD because the mechanism and size of the pig bladder more closely resemble that of a human, resulting in a more valid model and facilitating further study into the signaling mechanisms responsible for this impairment.

Contribution of renal innervation to hypertension in rat autosomal dominant polycystic kidney disease.

The kidney has both afferent (sensory) and efferent (sympathetic) nerves that can influence renal function. Renal innervation has been shown to play a role in the pathogenesis of many forms of hypertension. Hypertension and flank pain are common clinical manifestations of autosomal dominant (AD) polycystic kidney disease (PKD). We hypothesize that renal innervation contributes to the hypertension and progression of cystic change in rodent PKD. In the present study, the contribution of renal innervation to hypertension and progression of renal histopathology and dysfunction was assessed in male Han:SPRD-Cy/+ rats with ADPKD. At 4 weeks of age, male offspring from crosses of heterozygotes (Cy/+) were randomized into either 1) bilateral surgical renal denervation, 2) surgical sham denervation control, or 3) nonoperated control groups. A midline laparotomy was performed to allow the renal denervation (i.e., physical stripping of the nerves and painting the artery with phenol/alcohol). Blood pressure (tail cuff method), renal function (BUN) and histology were assessed at 8 weeks of age. Bilateral renal denervation reduced the cystic kidney size, cyst volume density, systolic blood pressure, and improved renal function (BUN) as compared with nonoperated controls. Operated control cystic rats had kidney weights, cyst volume densities, systolic blood pressures, and plasma BUN levels that were intermediate between those in the denervated animals and the nonoperated controls. The denervated group had a reduced systolic blood pressure compared with the operated control animals, indicating that the renal innervations was a major contributor to the hypertension in this model of ADPKD. Renal denervation was efficacious in reducing some pathology, including hypertension, renal enlargement, and cystic pathology. However, sham operation also affected the cystic disease but to a lesser extent. We hypothesize that the amelioration of hypertension in Cy/+ rats was due to the effects of renal denervation on the renin angiotensin system.

Robotic Sacral Colpopexy.

INTRODUCTION AND OBJECTIVE: Robot-assisted sacral colpopexy (RASC) is a fast growing approach for surgeons treating patients with advanced stage pelvic organ prolapse (POP). Open abdominal sacral colpopexy has been the gold standard for advanced POP but requires longer hospital stays and a much larger incision. The indications, preoperative preparation, operative positioning, and operative steps are detailed, and an accompanying video shows the approach. METHODS: RASC can be broken down into 11 steps and the reader will be able to reference the article to the corresponding portion of the video. RESULTS: A total of 119 women underwent RASC between 2009 and 2016. Patients had similar preoperative characteristics. All POP-Q, UDI-6, and quality of life scores improved postoperatively. Apical failure was noted in 0, anterior failure was noted in 7 (average Ba +1.1 cm in failures), and posterior failure was noted in 4 (mean Bp +1.0 cm) patients at 15.6 months' follow-up. A total of 11 suture erosions were noted in five patients requiring excision in the clinic and 2 patients in the operating room. Four suture erosions were managed with observation. Two mesh exposure events were noted. CONCLUSION: Outcomes for robotic sacral colpopexy are like those of open abdominal sacral colpopexy.