Intraoperative Retrograde Perfusion Sphincterometry to Evaluate Efficacy of Autologous Vas Deferens 6-Branch Suburethral Sling to Properly Restore Sphincteric Apparatus During Robot-Assisted Radical Prostatectomy.

OBJECTIVE: The aim of this study is to describe (urodynamically) the effect of the use of a 6-branch autologous suburethral sling, made with absorbable sutures and vas deferens, to support the bladder neck and urethra during robot-assisted laparoscopic prostatectomy (RALP) to improve early urinary continence (EUC) recovery. MATERIALS AND METHODS: Retrograde leak point pressure (RLPP) was intraoperatively evaluated, by means of retrograde perfusion sphincterometry (RPS), in 77 patients (mean age ± standard deviation [SD]: 65.64 ± 7.23 years, mean body mass index ± SD: 26.69 ± 3.89) scheduled to undergo RALP at our institution. RLPP was evaluated before (RLPPb) and after pneumoperitoneum induction (RLPPp). RLPP was then evaluated after urethrovesical anastomosis (RLPPa) and after proper sling tensioning (RLPPs), with the aim to obtain the same pressure as after pneumoperitoneum induction. EUC recovery, defined as the use of no pad, was assessed 10 days, 30 days, and 6 months after catheter removal. RESULTS: RPS and proper autologous 6-branch sling positioning were feasible in all patients, without perioperative complications and negligible impact on overall operative time. Pneumoperitoneum induction increased, similarly, RLPP in all patients. An important decrease of sphincteric capability was evident after prostate removal and the following urethrovesical anastomosis, while proper sling tensioning allowed for restoration of sphincteric apparatus capability to its presurgical status (mean RLPPs 40.84 cmH2O vs RLPPp 40.39 cmH2O, p = 0.942). EUC recovery within 10 days after catheter removal was achieved in 59 (77%) patients and progressively improved over time. CONCLUSIONS: RPS, intraoperatively performed during RALP, allows for precise evaluation of the impact of the surgical procedure on sphincteric apparatus competence. Moreover, the use of the 6-branch suburethral sling, in association with RPS, allows for restoration of the proper supporting system to the urethral sphincter, similar to the preoperative condition, offering the basis for EUC recovery after radical prostate surgery.

A Randomized Study of Intraoperative Autologous Retropubic Urethral Sling on Urinary Control after Robotic Assisted Radical Prostatectomy.

PURPOSE: We evaluated whether placement of a retropubic urethral sling fashioned from autologous vas deferens during robotic assisted radical prostatectomy would improve recovery of continence. MATERIALS AND METHODS: In a phase 2, single blind trial age stratified patients were randomized to undergo robotic assisted radical prostatectomy by multiple surgeons with or without sling placement. The outcomes were complete continence (0 urinary pads of any type) and near continence (0, an occasional or 1 pad per day) at 6 months, which was assessed by the Fisher exact test and logistic regression. The Kaplan-Meier method and the log rank test were used to evaluate time to continence. EPIC-UIN (Expanded Prostate Cancer Index Composite-Urinary Inventory) and I-PSS (International Prostate Symptom Score) 1, 3 and 6 months after catheter removal were evaluated by mixed models for repeated measures. RESULTS: Of 203 patients who were recruited 95 and 100 were randomized to undergo sling and no sling placement, respectively, and completed postoperative interviews. Six months after surgery the proportions reporting complete and near continence (66% and 87%, respectively) and times to complete and near continence were similar in the groups. Younger age was associated with a higher likelihood of complete continence (OR 1.74 per decreasing 5-year interval, 95% CI 1.23-2.48, p <0.01) and near continence (OR 2.18 per decreasing 5-year interval, 95% CI 1.21-3.92, p <0.01) adjusting for clinical, urinary and surgical factors. Adjusted EPIC-UIN and I-PSS scores changed with time but did not differ between the groups. No serious adverse events were observed. CONCLUSIONS: This trial failed to demonstrate a benefit of autologous urethral sling placement at robotic assisted radical prostatectomy on early return of continence at 6 months. Continence was related to patient age in adjusted models.

Retropubic Intracorporeal Placement of a Suburethral Autologous Sling During Robot-Assisted Radical Prostatectomy to Improve Early Urinary Continence Recovery: Preliminary Data.

BACKGROUND AND PURPOSE: Urinary continence (UC) recovery remains bothersome for patients even after robot-assisted radical prostatectomy (RARP). We describe the first retropubic suburethral autologous sling created and placed during RARP. The surgical technique and preliminary data regarding its effectiveness in improving early UC recovery are presented. PATIENTS AND METHODS: Between November 2013 and February 2014, 60 patients who underwent RARP at a single high-volume center were prospectively randomized into sling and nonsling groups. Early UC was assessed at 5 days (time of catheter removal), 10 days, and 30 days postoperatively by the daily number of pads used and the International Consultation on Incontinence Questionnaire-Urinary Incontinence-Short Form (ICIQ-UI-SF) score. Sling-related operative time and urethral erosion were also analyzed. Chi-square and independent sample t tests were used to investigate surgical and functional outcomes between groups. RESULTS: Complete data were available for all patients. Mean ± standard deviation (SD) numbers of pads used daily in nonsling and sling groups, respectively, were 1.9 ± 1.2 versus 1.7 ± 1.4 (P = 0.5) at 5 days, 1.8 ± 1.3 versus 1.3 ± 1.3 (P = 0.1) at 10 days, and 1.1 ± 1.2 versus 0.4 ± 0.8 (P = 0.01) at 30 days. At 1 month, mean ± SD ICIQ-UI-SF scores in nonsling and sling groups, respectively, were 4.8 ± 4.6 versus 1.8 ± 3.4 (P = 0.01); sling patients were associated with pad-free status (76% vs 46%, P = 0.03). The advantage in UC recovery was also observed in sling patients at 3, 6, and 12 months postoperatively. Surgical time did not differ between groups, and in sling patients, no cases of urethral erosion or uroflowmetry suggestive of urinary obstruction were found. Limitations included the small sample size and the lack of assessment of morphologic and urodynamic changes produced by the sling. CONCLUSIONS: The suburethral autologous sling is technically feasible and may improve early UC recovery after RARP. These preliminary results should be confirmed in a larger sample of patients.

Interpositional substitution of free vas deferens segment autografts in rat: feasibility and potential implications.

BACKGROUND: Insufficient vas length for performing a tension-free vasovasostomy is a problem occasionally encountered by microsurgeons. Herein we evaluated utilization of a non-vascularized vas deferens autograft in a rat model. METHODS: Segments of isolated vas deferens, 2.5 cm in length, were used as bilateral autografts in 15 rats. Each autograft was implanted between the two transected ends of vas deferens using end-to-end anastomosis. Fertility, sperm motility, and graft survival was evaluated and compared with the control group. RESULTS: At the end of the 3 months, 9/15 (60%) rats were able to breed successfully and 24 (80%) vas grafts were patent and viable. Large granulomata developed at the proximal anastomosis sites in 6 (20%) autografts that failed. Unilateral minimal fluid leakage was observed in 6 (20%) of the proximal (testicular end) anastomosis sites in those rats that were able to breed. Histological evaluations demonstrated that graft survival was associated with mild to severe changes in the structure of the vas autograft. On semen analysis 76% of the sperms in the experimental group had forward motility compared to 78% in the control group (p > 0.05). CONCLUSIONS: Vas autograft can successfully be performed in a rat model with ultimate breeding capability.

Comparison of different autogenous graft materials for reconstruction of large segment vas deferens defect: experimental study in rat.

PURPOSE: Vasectomy is one of the most common urological operations performed, and provides permanent contraception. Many vasectomized men ultimately seek vasectomy reversal because of unforeseen changes in lifestyle. Vasovasostomy has varying rates of success. In this study, we utilize vas deferens (VD), artery, and vein grafts to reconstruct 30% and 50%defects of the total vas deferens length. MATERIALS AND METHODS: Forty two male Wistar rats were divided into three groups as VD graft, carotid artery and external jugular vein transplantations. Each group was equally divided into 2 different subgroups according to the length of transplant material as 1.0 cm (n = 7) and 1.5 cm (n = 7). To evaluate whether these materials may be used for long segment vas deferens reconstruction, the patency rate, partial or total graft occlusion, and histologic examination of all specimens were examined. RESULTS: No patency was found in any of the grafts and many of them suffered destructive changes in anatomic structure. Sperm granulomas were determined around the testicular side anastomosis due to accumulated semen fluid which was in our belief, a result of aperistaltic zone caused by the grafts. CONCLUSION: When the poor results obtained in our study are put into perspective, vasoepididymostomy is the only treatment method to date for reconstruction of large segment vas deferens defects.

Experimental model of autoimmune orchitis with abdominal placement of donor's testes, epididymides, and vasa deferentia in recipient mice.

Haploid germ cells (spermatids and spermatozoa) develop in the testis after immune tolerance has been established. Therefore, they contain various autoimmunogenic antigens, but the testis is known to be an immunologically privileged organ. In particular, the blood-testis barrier formed by Sertoli cells protects autoimmunogenic haploid germ cells from attack by the autoimmune system. Experimental autoimmune orchitis (EAO), a breakdown of the testicular immune privilege leading to immunological male infertility, has been ordinarily induced in mice by immunization twice with testicular antigens+complete Freund's adjuvant (CFA)+Bordetella pertussis (BP). We previously found that two subcutaneous injections of viable syngeneic testicular germ cells induced murine EAO without the use of CFA+BP. In both EAO models, the lesions are characterized by spermatogenic disturbance with lymphocytic inflammation, and a second immunization with testicular antigens is critical for the disease induction. In the present study, we found that only one placement of a syngeneic donor's testes, epididymides and vasa deferentia (TEV) into the abdominal cavity or subcutaneous space was sufficient to induce EAO on the recipient's testes in mice. It was also noted that the placement of TEV induced only orchitis without epididymo-vasitis, while the serum autoantibodies were reactive with haploid germ cells existing throughout the TEV. Furthermore, the TEV placed in the abdominal cavity rather than the subcutaneous space was effective in inducing severe EAO, and the A/J strain was most susceptible to the TEV-induced EAO among the three strains examined. The model of EAO induced by the placement of the donor's TEV into the abdominal cavity in A/J mice will be helpful for the further analyses of testicular autoimmunity.

Reinnervation of transplanted vas deferens by cholinergic nerves normally supplying skeletal muscle.

The rat vas deferens was removed and either transplanted alongside the soleus muscle or into the bed of the soleus muscle that had previously been removed, and in this case the soleus nerve was connected to the transplant. The vas deferens reinnervated by the somatomotor nerve recovered the best. Contractions to transmural electrical stimulation could not be elicited from the denervated vas deferens, although noradrenaline and acetylcholine elicited contractions. The reinnervated vas deferens produced good contractile responses to transmural stimulation, and these were substantially reduced by a cholinergic muscarinic blocking agent, hyoscine, as compared to only a small reduction in the control vas deferens. Neostigmine potentiated the contraction of the transplanted vas deferens to a greater extent than that of the control. This indicated that a substantial component of the contractile response was produced by cholinergic fibres. Consistent with this was the finding that, while guanethidine blocked a greater proportion of the contraction in the control vas deferens, the contraction of the reinnervated transplant was less affected. Acetylcholine elicited a strong contraction in control vas deferens, but only a small response was obtained in the reinnervated transplant. However, the response to noradrenaline was greater in the transplant than in the control vas deferens. These results indicate that cholinergic nerves normally supplying skeletal muscle can reinnervate smooth muscle and that the alien somatomotor innervation altered the responsiveness of the smooth muscle of the vas deferens. Morphological studies confirm the shift from adrenergic to cholinergic fibres in the reinnervated vas deferens.

Fertility after homologous prepubertal testis transplantation in the dog.

Canine models of hereditary human diseases are widely used throughout the biomedical community, particularly when no suitable rodent model exists. In several models, the homozygote dogs die prior to puberty, or have substantially reduced fertility. Prepubertal transplantation of the testes was used to propagate the genotype of a mutant dog that would not otherwise have survived until puberty. The transplant recipient remained fertile 7 years postoperatively. To begin determining the factors necessary for successful function in testis transplants, prepubertal dogs that were dog leukocyte antigen (DLA) identical and disparate were examined for fertility and compared to the original transplant recipient as well as unoperated and sham-operated dogs. Immunosuppression was maintained with cyclosporine (CyA) and prednisone in the immediate postoperative period and CyA alone thereafter. The DLA-identical dogs demonstrated initial acceptance of the transplant, whereas one of two underwent chronic rejection. Both DLA-disparate dogs had subacute rejection prior to sexual maturity. These results demonstrate that homologous transplantation of prepubertal testes can be an effective method to preserve genotype in DLA-identical dogs. This model may also be useful for studying testis development and immunobiology.

The serotonin paradox: drug-receptor interaction in rat vas deferens

The contractile effect of serotonin was studied in rat vas deferens, in comparison with that of noradrenaline and tyramine, after reserpine treatment, surgical denervation, and transplantation to the colon. In reserpinized animals the effect of 5HT resembled that of tyramine, since it was strikingly reduced, in spite of a small residual effect, showing that in normal preparations the effects of 5HT and tyramine are predominantly duc to the release of endogenous noradrenaline. However, in denervated or transplanted vas deferens, in which the effect of tyramine is also abolished, the effect of 5HT was potentiated. It is suggested that after chronic, long lasting depletion of endogenous noradrenaline, there are alternate mechanisms that are generated to improve the contractile effect of 5HT, but not of tyramine. The nature of these mechanisms is still unknown.

Experimental vas replacement by either vas or a vascular graft.

An experimental model for vas replacement by transplantation of either vas or a vascular graft in attempt to restore patency in cases of a substance loss of vas that cannot be overcome by vasovasostomy was developed. Three transplant lengths, representing 10, 20 and 30% of the entire vas length, were used. The results showed an overall patency of 43% but for the transplant length representing 10% of the vas patency was achieved in approximately 75% of the cases regardless of the type of transplant used. Unpatency was usually due to occlusion of the proximal anastomosis, which in turn was considered to be due to a combination of unfavourable nutritional, neural and surgical factors. It is concluded that vas replacement by transplantation using either vas or a vascular graft is possible to perform experimentally and gives acceptable patency rates up to a transplant length of 10% of the entire vas length.

Reinnervation of the transplanted vas deferens: differential recovery of various biochemical and pharmacological parameters.

Biochemical and pharmacological parameters were used to follow the innervation characteristics of the rat was deferens transplanted (T) to the caecum. After about 5 months, a regeneration of autonomic nerves was clearly shown: first, by a complete recovery of neuronal uptake, indicated by: a) potentiation by cocaine of epinephrine (EPI) dose-response curves (T = 1.47 +/- 0.25, controls (C) = 1.50 +/- 0.14 log units); b) reversion to normal levels of pD2 values for norepinephrine (NE) and EPI (T = 6.6 +/- 0.1; 7.0 +/- 0.1, and C = 6.4 +/- 0.1; 6.9 +/- 0.1, respectively); second, a partial restoration of nerve terminals, and corresponding pools of NE, which was seen through histofluorescence and was indicated by a percent increase of: a) NE content, 47% (T = 3.8 +/- 0.8, C = 8.5 +/- 0.7 micrograms/g); b) dopamine-beta-hydroxylase (DBH) activity, 37% (T = 136 +/- 80, C = 364 +/- 15 nmol(hr.g); c) release of NE by 57 mM-potassium, 23% (T = 33.0 +/- 12.0, C = 147 +/- 14 ng/g. 5 min). Yet, two peculiarities of denervated organs remained practically unchanged even after 5-month transplantation: NE supersensitivity, measured by the relative responsiveness (rho) ratio (T = 0.96 +/- 0.02, C = 0.69 +/- 0.03), and tyramine-induced contraction, that was recovered by only 14% (T = 10.0 +/- 2.4, C = 72.0 +/- 3.5 mm). This differential recovery of the aforementioned parameters is discussed in the light of receptor mechanisms and functional changes following reinnervation.

[The elimination of extended defects of the ductus deferens]. / Ustranenie protiazhennykh defektov semiavynosiashchego protoka.

Based on their own experience gained in 12 reconstructive surgeries performed for iatrogenic lesions of the deferent duct in 8 patients the authors came to the conclusion that in the majority of patients an immediate vasovasostomy would be a failure or incompetence because of a significant tension of the tissues. To solve the faced problem, the authors proposed a technique of extra-anatomical (supra- and subpubic) anastomosis which enabled one to reduce the length of the duct by 9-19 cm. Transplantation of the duct's segments in the rat failed to demonstrate any benefit in case of homotransplantation of the duct's segments whereas autotransplants survived in 70 per cent of the cases and provided a 40 per cent recovery of the duct's patency. No signs of endoprosthetic effect on the transplantation outcomes were evident.

Transplant of a pediculate segment of vas deferens. Experimental study.

A new surgical technique has been used on white New Zealand rabbits. A segment of vas deferens was transplanted to the contralateral deferens with the intention of improving treatment for certain cases of infertility caused by obstruction. Evaluation of the technique was carried out by repeated seminograms, deferentovesiculography and histological studies of the transplanted deferens segment and the corresponding testicle. The viability of this surgical technique has been shown using the rabbit as an experimental specimen.

A model of an intraprostatic vas deferens in the rat.

The study of the effect of hormones in seminal fluid upon prostate tissue is hampered by the lack of a suitable model. Such a model is described in this paper, and its possible usefulness is discussed. The vas deferens of the rat is moved from its normal position into a surgical incision into the ventral prostate. Squamous metaplasia of epithelium in prostatic acini at early stages is replaced by cuboidal epithelium. At later stages, normal-appearing glandular epithelium is seen as close as 50 micrometers to the vas deferens. The structure of the vas deferens is not affected.

Brain tissue transplanted to the anterior chanber of the eye: 2. Fluorescence histochemistry of immature catecholamine- and 5-hydroxytryptamine neurons innervating the rat vas deferens.

Small pieces of the wall of the rat vas deferens were homologously transplanted to the anterior chamber of the eye together with small pieces of embryonic brain stem containing either developing noradrenaline (NA) cells of the locus coeruleus or 5-hydroxytryptamine (5-HT) neurons of the developing raphe system. The eyes of the recipients were sympathetically denervated. The double transplants became rapidly vascularized from the host iris. After 3 1/2 months the irides, together with their two transplants were analyzed by Falck-Hillarp fluorescent microscopy. Both the NA and the 5-HT neurons had survived and matured in the eye. Fluorescent varicose nerve terminals of the NA and 5-HT type respectively were found in all three potential receptor areas, i.e. within the CNS transplants, in the host irides and in the vas deferens transplants. In the latter, the newly formed monoamine nerve terminals arborized mainly within a well developed smooth muscle layer. The density of such new fibres was higher than or similar to that of the normally present sympathetic plexus in areas of the transplant close to the CNS transplant and lower in areas at a distance from the CNS transplant. It is concluded that immature central NA and 5-HT fibres are able to grow simultaneously into different types of sympathetically denervated smooth muscle tissues to form networks of fibres in the receptor organs resembling the normal sympathetic innervation.