Early sacral neuromodulation ameliorates urinary bladder function and structure in complete spinal cord injury minipigs.

AIMS: To determine the effects of early sacral neuromodulation (SNM) and pudendal neuromodulation (PNM) on lower urinary tract (LUT) function, minipigs with complete spinal cord injury (cSCI) were analyzed. SNM and PNM have been proposed as therapeutic approaches to improve bladder function, for example after cSCI. However, further evidence on efficacy is required before these methods can become clinical practice. METHODS: Eleven adults, female Göttingen minipigs with cSCI at vertebral level T11-T12 were included: SNM (n = 4), PNM (n = 4), and SCI control (SCIC: n = 3). Tissue from six healthy minipigs was used for structural comparisons. Stimulation was started 1 week after cSCI. Awake urodynamics was performed on a weekly basis. After 16 weeks follow-up, samples from the urinary bladder were taken for analyses. RESULTS: SNM improved bladder function with better capacities and lower detrusor pressures at voiding and avoided the emergence of detrusor sphincter dyssynergia (DSD). PNM and untreated SCI minipigs had less favorable outcomes with either DSD or constant urinary retention. Structural results revealed SCI-typical fibrotic alterations in all cSCI minipigs. However, SNM showed a better-balanced distribution of smooth muscle to connective tissue with a trend towards the reduced progression of bladder wall scarring. CONCLUSION: Early SNM led to an avoidance of the emergence of DSD showing a more physiological bladder function during a 4 month follow-up period after cSCI. This study might pave the way for the clinical continuation of early SNM for the treatment of neurogenic LUT dysfunction after SCI.

A new technique for minimal invasive complete spinal cord injury in minipigs.

BACKGROUND: The aim of this study was to develop a minimal invasive complete spinal cord injury (SCI) minipig model for future research applications. The minipig is considered a translationally relevant model for SCI research. However, a standardized minimal invasive complete SCI model for pigs has not yet been established. METHODS: Adult Göttingen minipigs were anesthetized and placed in extended prone position. After initial computed tomography (CT) scan, the skin was incised, a needle placed in the epidural fatty tissue. Using the Seldinger technique, a guidewire and dilators were introduced to insert the balloon catheter to Th12. After confirmation of the level Th11/Th12, the balloon was inflated to 2 atm for 30 min. The severity of the lesion was followed by CT and by MRI, and by immunohistochemistry. Function was assessed at the motor and sensory level. RESULTS: Duration of procedure was about 60 min including the 30-min compression time. The balloon pressure of 2 atm was maintained without losses. The lesion site was clearly discernible and no intradural bleeding was observed by CT. Neurological assessments during the 4-month follow-up time showed consistent, predictable, and stable neurological deficits. Magnetic resonance imaging analyses at 6 h and 4 weeks post SCI with final immunohistochemical analyses of spinal cord tissue underlined the neurological outcomes and proved SCI completeness. CONCLUSIONS: We have established a new, minimal invasive, highly standardized, CT-guided spinal cord injury procedure for minipigs. All risks of the open surgery can be excluded using this technique. This CT-guided SC compression is an excellent technique as it avoids long surgery and extensive trauma and allows a feasible inter-animal comparison.

Structural Changes of the Urinary Bladder After Chronic Complete Spinal Cord Injury in Minipigs.

PURPOSE: The aim of this study was to determine the structural changes of the urinary bladder after chronic spinal cord injury (SCI) in minipigs with the primary focus on the analysis of urinary bladder wall proteins and their quantitative distribution. METHODS: Seven Göttingen minipigs (adult, female) underwent a complete spinal cord transection. Follow-up time was 4 months during which the bladder was drained by frequent single catheterisation and data from the bladder diary and daily urine strip test were collected. Samples from the urinary bladder were taken, fixed in 4% paraformaldehyde and stained for histological analyses. Bladder wall thickness, single tissue quantities/distributions, types I and III collagen, and elastin quantifications were performed. Comparisons to healthy urinary bladder tissue of age-matched minipigs were performed for statistical analyses. RESULTS: No urinary tract infections were observed in our SCI minipig collective during follow-up. A trend towards a reduction in bladder volumes and an increase in incontinence periods were seen. The bladder wall thickness significantly increased after chronic SCI. Furthermore, bladder wall composition was severely altered by a significant loss of smooth muscle tissue and a significant increase in connective tissue. Elastic fibres were reduced in number and altered in their structural appearance after SCI. Type I collagen was significantly increased, while type III collagen was significantly decreased after SCI. CONCLUSIONS: Chronic SCI highlighted that the urinary bladder wall undergoes fibrotic events with reduced contractile and elastic properties due to changes of the bladder wall protein composition. These changes show in detail how SCI severely influences the urinary bladder wall composition and depicts the similarities between minipigs and humans.

New laparoscopic approach to the pudendal nerve for neuromodulation based on an anatomic study.

AIMS: The aim was to develop a new laparoscopic technique for placement of a pudendal lead. METHODS: Development of a direct, feasible and reliable minimal-invasive laparoscopic approach to the pudendal nerve (PN). Thirty-one embalmed human specimens were dissected for the relevant anatomic structures of the pelvis. Step-by-step documentation and analysis of the laparoscopic approach in order to locate the PN directly in its course around the medial part of the sacrospinous ligament and test this approach for feasibility. Landmarks for intraoperative navigation towards the PN as well as the possible position of an lead were selected and demonstrated. RESULTS: The visible medial umbilical fold, the intrapelvine part of the internal pudendal artery, the coccygeus muscle and the sacrospinous ligament are the main landmarks. The PN traverses the medial part of the sacrospinous ligament dorsally, medially to the internal pudendal artery. The medial part of the sacrospinous ligament has to be exposed in order to display the nerve. An lead can be placed ventrally on the nerve or around it, depending on the lead type or shape. CONCLUSIONS: A precise and reliable identification of the PN by means of laparoscopy is feasible with an easy four-step approach: (1) identification of the medial umbilical fold; (2) identification of the internal iliac artery; (3) identification of the internal pudendal artery and incision of the coccygeus muscle ('white line', arcuated line); and (4) exposition of the medial part of the sacrospinous ligament to display the PN.

Laparoscopic Radical Cystectomy and Ileal Neobladder for Muscle Invasive Bladder Cancer in Combination with One Stage Prophylactic Laparoscopic Sacrospinal Fixation to Avoid Future Pelvic Organ Prolapse.

BACKGROUND: Women who undergo cystectomy with orthotopic ileal neobladder are more likely to have urinary retention and neocystocele mainly because of anatomical reasons than stress urinary incontinence. The risk is even higher in case of neurologic comorbidities, as in case of our patient. CASE PRESENTATION: We present a laparoscopic mesh insertion for sacrospinal colposuspension to prevent a neocystocele and pelvic organ prolapse in combination with laparoscopic radical cystectomy in a female patient suffering from bladder cancer and chronic episodic multiple sclerosis. After a 30-month follow-up, the patient is continent and voids without residual urine. A dynamic MR of the pelvis shows a minimal rectocele without any evidence of a cystocele. CONCLUSION: Laparoscopic cystectomy combined with sacrospinal mesh fixation is technically feasible and could be an option to prevent neocystocele for female patients.

Natural Orifice Transluminal Endoscopic Surgery-Assisted Laparoscopic Transvesical Bladder Diverticulectomy: Feasibility Study, Points of Technique, and Case Series with Medium-Term Follow-Up.

OBJECTIVES: To demonstrate the feasibility of our novel natural orifice transluminal endoscopic surgery (NOTES)-assisted approach with medium-term follow-up. PATIENTS AND METHODS: From March 2012, we included all patients who presented to our clinic with symptomatic or complicated retentive bladder diverticula secondary to long-standing infravesical obstruction. After managing the primary cause, we proceeded in all cases to our novel NOTES-assisted approach. We followed up the patients with abdominal ultrasonography at 6 weeks and 12 months postoperatively. Success was determined as subjective relief of the symptoms and objective disappearance of the diverticula in postoperative retrograde cystogram (RGC). RESULTS: Between March 2012 and August 2014, eight diverticula were treated using our new technique. The surgery was uneventful. The mean operative time was 134.25 ± 44.92 minutes. Blood loss was minimal (>50 mL). Retrograde cystography was performed on the 10th postoperative day. The introduction of the needle holder through the urethral natural orifice (NOTES) facilitated a more optimal direction of the needle holder for suturing the bladder wall due to its parallel position in relation to the trigone and posterolateral walls. This renders this step easier compared with suturing the bladder wall through the transvesical laparoscopic ports. One case had a grade IIIa complication according to the Clavien-Dindo classification of surgical complications. The study is limited by the small number of cases. CONCLUSION: Laparoscopic transvesical bladder diverticulectomy is a promising and safe procedure with good outcomes. Using the urethra (NOTES assisted) as an extra access to the bladder facilitates diverticular traction and bladder suturing without the need for extra ports. This technique can also be applied together with the novel T-laparoendoscopic single-site surgery approach.