RESUMEN
AIMS: Small fiber neuropathy/polyneuropathy (SFN) has been found to be present in 64% of complex (refractory or multisystem) chronic pelvic pain (CPP) patients. The small fiber dysfunction seen in SFN can negatively impact autonomic control of micturition in addition to pain. This study investigated the clinical association of autonomic dysfunction (detrusor underactivity and primary bladder neck obstruction [BNO]) on video urodynamics (VUDS) with SFN in patients with CPP. METHODS: This was a retrospective observational study, querying data from patients with complex CPP. Inclusion criteria were: the presence of complex (refractory or multisystem) CPP, and completion of both (1) subspecialty autonomic neurology evaluation for SFN and (2) high-quality VUDS performed according to ICS standards. Autonomic bladder dysfunction (BNO or detrusor underactivity) on VUDS was compared to the presence of SFN. RESULTS: Thirty-two female patients with complex CPP met criteria. Of the 32, 23 (72%) were found to have SFN. Patient with autonomic bladder dysfunction (BNO or detrusor underactivity) were more likely to have SFN (OR = 9.5 [95% CI: 1.641, 55.00], p = 0.007). Post-void residual volume was higher in the SFN group (p = 0.011 [95% CI: 13.12, 94.0]) and symptoms of urge urinary incontinence were more likely to be present (p = 0.000 [95% CI: -3.4, -1.25]). CONCLUSIONS: Patients with complex CPP with autonomic bladder dysfunction are more likely to have SFN. This suggests patients with complex CPP should be considered for diagnosis and treatment of SFN, particularly if BNO or detrusor underactivity is noted on VUDS evaluation.
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Polineuropatías , Obstrucción del Cuello de la Vejiga Urinaria , Femenino , Humanos , Dolor Pélvico , Polineuropatías/complicaciones , Estudios Retrospectivos , Vejiga Urinaria , UrodinámicaRESUMEN
PURPOSE OF REVIEW: The purpose of this paper is to review the most recent literature on non-surgical therapeutic options for chronic pelvic pain in females. RECENT FINDINGS: Chronic pelvic pain can arise from virtually any organ system in the human body. If a precise etiology is identified, the management of chronic pelvic pain can be tailored accordingly. In some cases, patients with chronic pelvic pain can remain without a specific diagnosis. In these circumstances, adequate symptom control can still be achieved even if no underlying disorder is found. Although chronic pelvic pain is often a difficult disorder to manage, several non-surgical management options exist. Employing a multidisciplinary approach, most patients can achieve adequate symptom relief, usually without the need for surgical intervention.
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Dolor Crónico , Dolor Pélvico , Enfermedad Crónica , Dolor Crónico/etiología , Dolor Crónico/terapia , Femenino , Humanos , Dolor Pélvico/etiología , Dolor Pélvico/terapiaRESUMEN
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.
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Divertículo , Procedimientos Quirúrgicos Robotizados , Enfermedades Uretrales , Trastornos Urinarios , Divertículo/cirugía , Femenino , Humanos , Masculino , Uretra , Enfermedades Uretrales/cirugíaRESUMEN
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.
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Incontinencia Urinaria de Esfuerzo/cirugía , Procedimientos Quirúrgicos Urológicos/métodos , Femenino , Humanos , Cabestrillo Suburetral , Esfínter Urinario ArtificialRESUMEN
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.
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Vejiga Urinaria de Baja Actividad/cirugía , Vejiga Urinaria/cirugía , Micción , Procedimientos Quirúrgicos Urológicos/métodos , Anciano , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Recuperación de la Función , Resultado del Tratamiento , Obstrucción del Cuello de la Vejiga Urinaria/complicaciones , Obstrucción del Cuello de la Vejiga Urinaria/cirugía , Vejiga Urinaria de Baja Actividad/complicaciones , UrodinámicaRESUMEN
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.
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Ginecología/métodos , Terapia por Láser/métodos , Urología/métodos , Enfermedades Vaginales/terapia , Vulva , Consenso , Femenino , Humanos , Láseres de Estado SólidoRESUMEN
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.
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Terapia por Láser/métodos , Enfermedades Vaginales/terapia , Enfermedades de la Vulva/terapia , Adolescente , Adulto , Niño , Femenino , Humanos , Persona de Mediana Edad , Guías de Práctica Clínica como Asunto , Adulto JovenRESUMEN
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.
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Síntomas del Sistema Urinario Inferior/terapia , Prolapso de Órgano Pélvico/cirugía , Consejo , Femenino , Humanos , Síntomas del Sistema Urinario Inferior/etiología , Cuidados Preoperatorios , Factores de Riesgo , Obstrucción del Cuello de la Vejiga Urinaria/etiología , Obstrucción del Cuello de la Vejiga Urinaria/terapia , UrodinámicaRESUMEN
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.
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Cabestrillo Suburetral , Incontinencia Urinaria de Esfuerzo/cirugía , Urodinámica/fisiología , Procedimientos Quirúrgicos Urológicos/métodos , Femenino , Humanos , Diseño de Prótesis , Incontinencia Urinaria de Esfuerzo/fisiopatologíaAsunto(s)
Consenso , Ginecología , Trastornos del Suelo Pélvico/diagnóstico , Diafragma Pélvico/fisiopatología , Sociedades Médicas , Procedimientos Quirúrgicos Urológicos/normas , Urología , Femenino , Humanos , Medición de Resultados Informados por el Paciente , Trastornos del Suelo Pélvico/fisiopatología , Trastornos del Suelo Pélvico/cirugía , Estados Unidos , Urodinámica/fisiologíaRESUMEN
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.
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Quistes de Tarlov , Humanos , Axones , Raíces Nerviosas Espinales/diagnóstico por imagen , Raíces Nerviosas Espinales/cirugía , Columna Vertebral , Quistes de Tarlov/complicaciones , Quistes de Tarlov/diagnóstico por imagen , Quistes de Tarlov/cirugíaRESUMEN
OBJECTIVE: Bladder dysfunction after nerve injury has a variable presentation, and extent of injury determines whether the bladder is spastic or atonic. The authors have proposed a series of 3 nerve transfers for functional innervation of the detrusor muscle and external urethral sphincter, along with sensory innervation to the genital dermatome. These transfers are applicable to only cases with low spinal segment injuries (sacral nerve root function is lost) and largely preserved lumbar function. Transfer of the posterior branch of the obturator nerve to the vesical branch of the pelvic nerve provides a feasible mechanism for patients to initiate detrusor contraction by thigh adduction. External urethra innervation (motor and sensory) may be accomplished by transfer of the vastus medialis nerve to the pudendal nerve. The sensory component of the pudendal nerve to the genitalia may be further enhanced by transfer of the saphenous nerve (sensory) to the pudendal nerve. The main limitations of coapting the nerve donors to their intrapelvic targets are the bifurcation or arborization points of the parent nerve. To ensure that the donor nerves had sufficient length and diameter, the authors sought to measure these parameters. METHODS: Twenty-six pelvic and anterior thigh regions were dissected in 13 female cadavers. After the graft and donor sites were clearly exposed and the branches identified, the donor nerves were cut at suitable distal sites and then moved into the pelvis for tensionless anastomosis. Diameters were measured with calipers. RESULTS: The obturator nerve was bifurcated a mean ± SD (range) of 5.5 ± 1.7 (2.0-9.0) cm proximal to the entrance of the obturator foramen. In every cadaver, the authors were able to bring the posterior division of the obturator nerve to the vesical branch of the pelvic nerve (located internal to the ischial spine) in a tensionless manner with an excess obturator nerve length of 2.0 ± 1.2 (0.0-5.0) cm. The distance between the femoral nerve arborization and the anterior superior iliac spine was 9.3 ± 1.8 (6.5-15.0) cm, and the distance from the femoral arborization to the ischial spine was 12.9 ± 1.4 (10.0-16.0) cm. Diameters were similar between donor and recipient nerves. CONCLUSIONS: The chosen donor nerves were long enough and of sufficient caliber for the proposed nerve transfers and tensionless anastomosis.
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Transferencia de Nervios , Humanos , Femenino , Vejiga Urinaria/cirugía , Vejiga Urinaria/inervación , Estudios de Factibilidad , Nervios Espinales , CadáverRESUMEN
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.
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Cistitis Intersticial/tratamiento farmacológico , Degeneración Macular/inducido químicamente , Poliéster Pentosan Sulfúrico/efectos adversos , Humanos , Degeneración Macular/diagnóstico , Degeneración Macular/epidemiología , Prevalencia , Urólogos/educaciónRESUMEN
BACKGROUND: Secondary to the complex care, involved specialty providers, and various etiologies, chronic pelvic pain patients do not receive holistic care. OBJECTIVE: To compare our general and neuromodulation cohorts based on referrals, diagnosis, and therapy and describe our neuromodulation patients. METHODS: A multidisciplinary team was established at our center. The intake coordinator assessed demographics and facilitated care of enrolled patients. Outcomes were compared using minimal clinical important difference of current Numerical Rating Scale (NRS) between patients with neuropathic pain who received neuromodulation and those who did not. The neuromodulation cohort completed outcome metrics at baseline and recent follow-up, including NRS score (best, worst, and current), Oswestry Disability Index (ODI), Beck Depression Inventory, and Pain Catastrophizing Scale. RESULTS: Over 7 yr, 233 patients were referred to our consortium and 153 were enrolled. A total of 55 patients had neuropathic pain and 44 of those were managed medically. Eleven underwent neuromodulation. A total of 45.5% patients of the neuromodulation cohort were classified as responders by minimal clinically important difference compared to 26.6% responders in the control cohort at most recent follow-up (median 25 and 33 mo, respectively). Outcome measures revealed improvement in NRS at worst (P = .007) and best (P = .025), ODI (P = .014), and Pain Catastrophizing Scale Rumination (P = .043). CONCLUSION: Eleven percent of patients were offered neuromodulation. There were more responders in the neuromodulation cohort than the conservatively managed neuropathic pain cohort. Neuromodulation patients showed significant improvement at 29 mo in NRS best and worst pain, disability, and rumination. We share our algorithm for patient management.
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Dolor Crónico/terapia , Neuralgia/terapia , Dimensión del Dolor/métodos , Grupo de Atención al Paciente , Dolor Pélvico/terapia , Estimulación Eléctrica Transcutánea del Nervio/métodos , Adulto , Anciano , Anciano de 80 o más Años , Dolor Crónico/diagnóstico , Estudios de Cohortes , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Neuralgia/diagnóstico , Dolor Pélvico/diagnóstico , Encuestas y Cuestionarios , Resultado del Tratamiento , Adulto JovenRESUMEN
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.
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Cistostomía , Neoplasias de los Genitales Masculinos/cirugía , Ileostomía , Recurrencia Local de Neoplasia , Satisfacción del Paciente , Prostatectomía , Cateterismo Urinario , Incontinencia Urinaria/prevención & control , Anciano , Cistostomía/efectos adversos , Neoplasias de los Genitales Masculinos/patología , Neoplasias de los Genitales Masculinos/fisiopatología , Neoplasias de los Genitales Masculinos/radioterapia , Humanos , Ileostomía/efectos adversos , Masculino , Persona de Mediana Edad , Antagonistas Muscarínicos/uso terapéutico , Prostatectomía/efectos adversos , Reoperación , Terapia Recuperativa , Encuestas y Cuestionarios , Factores de Tiempo , Resultado del Tratamiento , Incontinencia Urinaria/etiología , Incontinencia Urinaria/fisiopatología , UrodinámicaRESUMEN
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.
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Estradiol/farmacología , Terapia de Reemplazo de Estrógeno , Estrógenos/farmacología , Hipoxia , Contracción Muscular/efectos de los fármacos , Diafragma Pélvico/fisiología , Vejiga Urinaria/efectos de los fármacos , Vejiga Urinaria/fisiología , Animales , Femenino , Hipoxia/fisiopatología , Técnicas In Vitro , ConejosRESUMEN
Women with urinary urgency and frequency may also have pelvic floor muscle spasm. Transvaginal biofeedback (TVBF) and electrical stimulation (EStim) is a treatment modality that has been used to treat vaginismus and chronic pelvic pain. In this study, TVBF/EStim was evaluated in women with pelvic floor muscle spasm associated with urinary symptoms. Fifty-two women underwent therapy with TVBF/EStim and reported a mean symptom improvement of 64.5%.
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Terapia Conductista/métodos , Biorretroalimentación Psicológica , Terapia por Estimulación Eléctrica/métodos , Diafragma Pélvico/fisiopatología , Espasmo/fisiopatología , Trastornos Urinarios/fisiopatología , Trastornos Urinarios/terapia , Adulto , Anciano , Femenino , Humanos , Persona de Mediana Edad , Proyectos Piloto , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
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.
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Quistes/diagnóstico por imagen , Divertículo/diagnóstico por imagen , Imagen por Resonancia Magnética/métodos , Enfermedades Uretrales/diagnóstico por imagen , Incontinencia Urinaria de Esfuerzo/diagnóstico por imagen , Incontinencia Urinaria de Esfuerzo/terapia , Adulto , Anciano , Anciano de 80 o más Años , Colágeno/uso terapéutico , Medios de Contraste , Diagnóstico Diferencial , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios RetrospectivosRESUMEN
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.
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Enfermedad Coronaria/diagnóstico , Aumento de la Imagen/métodos , Procesamiento de Imagen Asistido por Computador/métodos , Impotencia Vasculogénica/diagnóstico , Isquemia/diagnóstico , Angiografía por Resonancia Magnética/métodos , Pelvis/irrigación sanguínea , Anciano , Medios de Contraste , Puente de Arteria Coronaria , Enfermedad Coronaria/cirugía , Gadolinio DTPA , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/diagnóstico , Estudios ProspectivosRESUMEN
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.