Phospho-regulation, nucleotide binding and ion access control in potassium-chloride cotransporters.

Potassium-coupled chloride transporters (KCCs) play crucial roles in regulating cell volume and intracellular chloride concentration. They are characteristically inhibited under isotonic conditions via phospho-regulatory sites located within the cytoplasmic termini. Decreased inhibitory phosphorylation in response to hypotonic cell swelling stimulates transport activity, and dysfunction of this regulatory process has been associated with various human diseases. Here, we present cryo-EM structures of human KCC3b and KCC1, revealing structural determinants for phospho-regulation in both N- and C-termini. We show that phospho-mimetic KCC3b is arrested in an inward-facing state in which intracellular ion access is blocked by extensive contacts with the N-terminus. In another mutant with increased isotonic transport activity, KCC1Δ19, this interdomain interaction is absent, likely due to a unique phospho-regulatory site in the KCC1 N-terminus. Furthermore, we map additional phosphorylation sites as well as a previously unknown ATP/ADP-binding pocket in the large C-terminal domain and show enhanced thermal stabilization of other CCCs by adenine nucleotides. These findings provide fundamentally new insights into the complex regulation of KCCs and may unlock innovative strategies for drug development.

Clinical and Urodynamic results of the Argus T® sling in moderate and severe male stress urinary incontinence after radical prostatectomy - a 5 year prospective study.

PURPOSE: Sling as a therapeutic option for male stress urinary incontinence (SUI) has been reviewed in the last two decades, as it is a relatively simpliest surgery compared to artificial urinary sphincter and has the ability to modulate urethral compression. This study aims to evaluate the efficacy, rate of complications, quality of life and the effects on bladder emptying of the Argus T® compressive and ajustable sling in moderate and severe male SUI treatment. MATERIALS AND METHODS: Men eligible for stress urinary incontinence treatment after radical prostatectomy were recruited and prospectively evaluated, from March 2010 to November 2016. It was selected outpatient men with moderate and severe SUI, after 12 months of radical prostatectomy, who have failed conservative treatment. All patients had a complete clinical and urodynamic pre and post treatment evaluation, by means of clinical history, physical examination, urine culture, 1-hour pad test and ICIq-SF questionnaire. The UDS was performed after 12, 18 and 24 months postoperatively. RESULTS: Thirty-seven men underwent sling surgery, 19 patients (51.4%) with moderate and 18 (48.6%) with severe SUI. The minimum follow-up time was 5 years. Overall, we had a success rate of 56.7% at 60 months follow-up. After surgery, we did not observe significant changes in the urodynamic parameters evaluated during the follow-up. No patient had urodynamic bladder outlet obstruction (BOO) after sling implantation. Readjustment of the Argus T® sling was performed in 16 (41%) of the patients and 51% of the patients reported some adverse event. CONCLUSION: We demonstrate a long-term efficacy and safety of Sling Argus T® as an alternative to moderate and severe male SUI treatment. Furthermore, in our study bulbar urethra compression does not lead to bladder outlet obstruction.

Ceramide-1-Phosphate as a Potential Regulator of the Second Sodium Pump from Kidney Proximal Tubules by Triggering Distinct Protein Kinase Pathways in a Hierarchic Way.

Kidney proximal tubules are a key segment in the reabsorption of solutes and water from the glomerular ultrafiltrate, an essential process for maintaining homeostasis in body fluid compartments. The abundant content of Na+ in the extracellular fluid determines its importance in the regulation of extracellular fluid volume, which is particularly important for different physiological processes including blood pressure control. Basolateral membranes of proximal tubule cells have the classic Na+ + K+-ATPase and the ouabain-insensitive, K+-insensitive, and furosemide-sensitive Na+-ATPase, which participate in the active Na+ reabsorption. Here, we show that nanomolar concentrations of ceramide-1 phosphate (C1P), a bioactive sphingolipid derived in biological membranes from different metabolic pathways, promotes a strong inhibitory effect on the Na+-ATPase activity (C1P50 ≈ 10 nM), leading to a 72% inhibition of the second sodium pump in the basolateral membranes. Ceramide-1-phosphate directly modulates protein kinase A and protein kinase C, which are known to be involved in the modulation of ion transporters including the renal Na+-ATPase. Conversely, we did not observe any effect on the Na+ + K+-ATPase even at a broad C1P concentration range. The significant effect of ceramide-1-phosphate revealed a new potent physiological and pathophysiological modulator for the Na+-ATPase, participating in the regulatory network involving glycero- and sphingolipids present in the basolateral membranes of kidney tubule cells.

An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for the conservative and nonpharmacological management of female pelvic floor dysfunction.

Introduction and hypothesis There has been an increasing need for the terminology on the conservative management of female pelvic floor dysfunction to be collated in a clinically based consensus report. Methods This Report combines the input of members and elected nominees of the Standardization and Terminology Committees of two International Organizations, the International Urogynecological Association (IUGA) and the International Continence Society (ICS), assisted at intervals by many external referees. An extensive process of nine rounds of internal and external review was developed to exhaustively examine each definition, with decision-making by collective opinion (consensus). Before opening up for comments on the webpages of ICS and IUGA, five experts from physiotherapy, neurology, urology, urogynecology, and nursing were invited to comment on the paper. Results A Terminology Report on the conservative management of female pelvic floor dysfunction, encompassing over 200 separate definitions, has been developed. It is clinically based, with the most common symptoms, signs, assessments, diagnoses, and treatments defined. Clarity and ease of use have been key aims to make it interpretable by practitioners and trainees in all the different specialty groups involved in female pelvic floor dysfunction. Ongoing review is not only anticipated, but will be required to keep the document updated and as widely acceptable as possible. Conclusion A consensus-based terminology report for the conservative management of female pelvic floor dysfunction has been produced, aimed at being a significant aid to clinical practice and a stimulus for research.

An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for the conservative and nonpharmacological management of female pelvic floor dysfunction.

INTRODUCTION AND HYPOTHESIS: There has been an increasing need for the terminology on the conservative management of female pelvic floor dysfunction to be collated in a clinically based consensus report. METHODS: This Report combines the input of members and elected nominees of the Standardization and Terminology Committees of two International Organizations, the International Urogynecological Association (IUGA) and the International Continence Society (ICS), assisted at intervals by many external referees. An extensive process of nine rounds of internal and external review was developed to exhaustively examine each definition, with decision-making by collective opinion (consensus). Before opening up for comments on the webpages of ICS and IUGA, five experts from physiotherapy, neurology, urology, urogynecology, and nursing were invited to comment on the paper. RESULTS: A Terminology Report on the conservative management of female pelvic floor dysfunction, encompassing over 200 separate definitions, has been developed. It is clinically based, with the most common symptoms, signs, assessments, diagnoses, and treatments defined. Clarity and ease of use have been key aims to make it interpretable by practitioners and trainees in all the different specialty groups involved in female pelvic floor dysfunction. Ongoing review is not only anticipated, but will be required to keep the document updated and as widely acceptable as possible. CONCLUSION: A consensus-based terminology report for the conservative management of female pelvic floor dysfunction has been produced, aimed at being a significant aid to clinical practice and a stimulus for research.

Initial experience with sacral neuromodulation for the treatment of lower urinary tract dysfunction in Brazil.

OBJECTIVES: We report on the short-term outcomes of sacral neuromodulation (SNM) for treatment of idiopathic lower urinary tract dysfunction in Brazil (procedures performed before 2014). MATERIALS AND METHODS: Clinical data and surgical outcomes of patients who underwent SNM staged procedures were retrospective evaluated. Urological assessment included a focused medical history and physical examination, measurement of postvoid residual volumes, urodynamics, and bladder diaries. A successful test phase has been defined by improvement of at least 50% of the symptoms, based on bladder diaries. RESULTS: From January 2011 to December 2013, eighteen consecutive patients underwent test phase for SNM due to refractory overactive bladder (15 patients), non-obstructive chronic urinary retention (2 patients), and bladder pain syndrome/interstitial cystitis (1 patient). All patients underwent staged procedures at four outpatient surgical centers. Mean age was 48.3±21.2 (range 10-84 years). There were 16 women and 2 men. Median follow-up was 3 months. Fifteen patients (83.3%) had a successful test phase and underwent implantation of the pulse generator (IPG). Median duration of the test phase was 7 days (range 5-24 days). Mean age was 45.6±18.19 years in responders versus 61.66±34.44 years in non-responders (p=0.242). Mean operative time (test phase) was 99±33.12 min in responders versus 95±35 min for non-responders (p=0.852). No severe complications were reported. CONCLUSION: SNM is a minimally invasive treatment option for patients with refractory idiopathic lower urinary tract dysfunction. Our initial experience with staged technique showed that tined-lead electrodes yielded a high rate of responders and favorable clinical results in the short-term follow-up.

Overactive bladder - 18 years - Part I.

Overactive bladder syndrome is one of the lower urinary tract dysfunctions with the highest number of scientific publications over the past two decades. This shows the growing interest in better understanding this syndrome, which gathers symptoms of urinary urgency and increased daytime and nighttime voiding frequency, with or without urinary incontinence and results in a negative impact on the quality of life of approximately one out of six individuals - including both genders and almost all age groups. The possibility of establishing the diagnosis just from clinical data made patients' access to specialized care easier. Physiotherapy resources have been incorporated into the urological daily practice. A number of more selective antimuscarinic drugs with consequent lower adverse event rates were released. Recently, a new class of oral drugs, beta-adrenergic agonists has become part of the armamentarium for Overactive Bladder. Botulinum toxin injections in the bladder and sacral neuromodulation are routine modalities of treatment for refractory cases. During the 1st Latin-American Consultation on Overactive Bladder, a comprehensive review of the literature related to the evolution of the concept, epidemiology, diagnosis, and management was conducted. This text corresponds to the first part of the review Overactive Bladder 18-years.

Overactive bladder - 18 years - Part II.

Traditionally, the treatment of overactive bladder syndrome has been based on the use of oral medications with the purpose of reestablishing the detrusor stability. The recent better understanding of the urothelial physiology fostered conceptual changes, and the oral anticholinergics - pillars of the overactive bladder pharmacotherapy - started to be not only recognized for their properties of inhibiting the detrusor contractile activity, but also their action on the bladder afference, and therefore, on the reduction of the symptoms that constitute the syndrome. Beta-adrenergic agonists, which were recently added to the list of drugs for the treatment of overactive bladder, still wait for a definitive positioning - as either a second-line therapy or an adjuvant to oral anticholinergics. Conservative treatment failure, whether due to unsatisfactory results or the presence of adverse side effects, define it as refractory overactive bladder. In this context, the intravesical injection of botulinum toxin type A emerged as an effective option for the existing gap between the primary measures and more complex procedures such as bladder augmentation. Sacral neuromodulation, described three decades ago, had its indication reinforced in this overactive bladder era. Likewise, the electric stimulation of the tibial nerve is now a minimally invasive alternative to treat those with refractory overactive bladder. The results of the systematic literature review on the oral pharmacological treatment and the treatment of refractory overactive bladder gave rise to this second part of the review article Overactive Bladder - 18 years, prepared during the 1st Latin-American Consultation on Overactive Bladder.

Is there any difference in pelvic floor muscles performance between continent and incontinent women?

AIMS: To compare pelvic floor muscles (PFMs) performance in women with and without stress urinary incontinence (SUI) during endurance test. METHODS: It is a prospective case-control clinical trial. After determining PFM maximal voluntary contraction (MVC) by electromyography (EMG), women underwent endurance test, which consisted of consecutively PFM 1-sec fast contractions reaching MVC amplitude followed by 1-sec rest. Training time guided by Borg perceived exertion scale was noted. Heart rate (HR) behavior and EMG variables were assessed before and after training making a physiological analysis in both groups. RESULTS: A total of 56 women, mean age 52.19 years old, were evaluated (26 continent and 30 incontinent women). The time that SUI and continent women took to reach fatigue (Borg 10) was 9.1 ± 4.7 and 14.19 ± 8.32 min, respectively (P = 0.006). Confirming that all women performed similar effort during the test, analysis of variance with repeated measures showed that during the endurance test both groups presented similar increase in HR, showing detectable and significant increase from resting time to Borg 10 (P < 0.001). Besides, there was similar behavior in EMG for continent and SUI women, with a decrease from the baseline resting amplitude (P = 0.003 for SUI women and P = 0.006 for continent women). CONCLUSIONS: Women with SUI showed worse performance during an endurance test than continent women. It suggests that women have different capacity to perform PFM training. An initial evaluation based on PFM performance would help to define the best individualized PFM training.

Is there any change in pelvic floor electromyography during the first 6 months after radical retropubic prostatectomy?

UNLABELLED: The aim of this study is to determine electromyographic pelvic floor muscles activity during the first 6 months post RRP and its relationship to urinary continence. Thirty-eight men (mean age of 63.1 ± 5.7 year) with prostate cancer scheduled for open radical retropubic prostatectomy were evaluated. EXCLUSION CRITERIA: pelvic radiotherapy, systemic or neurologic diseases, pre-operative International Prostate Symptoms Score (IPSS) >7 and OABq ≥8. Surface electromyography (sEMG) evaluation, IPSS, Urinary Distress Inventory, Incontinence Impact Questionnaire, and Overactive Bladder Questionnaire-short form were applied before and at 1, 3, and 6 months after RRP. Six months after surgery, 18 men (47.4 %) presented urinary leakage. The sEMG evaluations within the first 6 months presented changes in fast contraction amplitude (p = 0.006), rest amplitude after fast contraction (p = 0.04), 10 s sustained contraction mean amplitude (p = 0.024) and final rest amplitude (p = 0.011). We observed that continent and incontinent patients as a group presented electromyographic changes during the first 6 months after radical prostatectomy that could be justified by the denervation/reinnervation of the external urethral sphincter. This finding is consistent with the adaptation of the pelvic floor musculature to the new urethral sphincter condition following surgery.

Acellular human glans extracellular matrix as a scaffold for tissue engineering: in vitro cell support and biocompatibility.

UNLABELLED: Diseases of the genitourinary tract can lead to significant damage. Current reconstructive techniques are limited by tissue availability and compatibility. This study aims to assess if the decellularized human glans can be used as a biomaterial for penile reconstruction. MATERIALS AND METHODS: Samples of the glans matrices were descellularized. We evaluate the presence of collagen type I and III, and elastic fibers. Biocompatibility assays were performed to assess the cytotoxic and non-cytotoxic interactions between the acellular matrix and 3T3 cells. The matrices were seeded with mesenchymal stem cells and were assessed for viability and integration of these cells. Biomechanical tests in native tissue, descellularized matrix and seeded matrix were performed to characterize their biomechanical properties. RESULTS: The tissue architecture of the decellularized matrix of human glans was preserved as well as the maintenance of the biomechanical and biological properties. The analyzes of glans seeded with mesenchymal stem cells revealed the integration of these cells to the matrices, and its viability during two weeks "in vitro". CONCLUSION: The decellularization process did not alter the biological and biomechanical characteristics of the human glans. When these matrices were seeded they were able to maintain the cells integrity and vitality.

Prostate-specific antigen testing in men between 40 and 70 years in Brazil: database from a check-up program.

OBJECTIVES: To evaluate the PSA in a large population of Brazilian men undergone to check up, and correlate the PSA cutoffs with prostate size and urinary symptoms. MATERIALS AND METHODS: This is a cross sectional study performed with men between 40 and 70 years undergone to check-up. All men were undergone to urological evaluation, digital rectal examination, prostate-specific antigen, and ultrasonography The exclusion criteria were men who used testosterone in the last six months, or who were using 5 alpha-reductase inhibitors. RESULTS: A total of 5015 men with an average age of 49.0 years completed the study. Most men were white and asymptomatic. The PSA in the three different aging groups were 0.9 ± 0.7 ng/dL for men between 40 and 50; 1.2 ± 0.5 ng/dL for men between 50 and 60; and 1.7 ± 1.5 ng/dL for men greater than 60 years (p=0.001). A total of 192 men had PSA between 2.5 and 4 ng/ml. From these men 130 were undergone to prostate biopsy. The predictive positive value of biopsy was 25% (32/130). In the same way, 100 patients had PSA > 4 ng/mL. From these men, 80 were undergone to prostate biopsy. In this group, the predictive positive value of biopsy was 40% (32/100). The Gleason score was 6 in 19 men (60%), 7 in 10 men (31%) and 8 in 3 men (9%). CONCLUSIONS: The PSA level of Brazilian men undergone to check up was low. There was a positive correlation with aging, IPSS and prostate size.

Uroflowmetry in a large population of Brazilian men submitted to a health check up program and its correlation with IPSS and prostate size.

PURPOSE: The aim of this study was to assess the uroflowmetry data in a large population of asymptomatic Brazilian men submitted to a health check up program and their correlation to IPSS and prostate size. MATERIALS AND METHODS: Asymptomatic men underwent a health check-up program between January and December 2012. The inclusion criteria were men between 40 and 70 years, IPSS ≤ 7, without bladder, prostate, urethral surgery, neurological diseases, urinary tract infection, PSA < 4.0 ng/dL and urinary volume higher than 150 mL. Urological assessment consisted of clinical history, IPSS, digital rectal examination (DRE), prostate specific antigen (PSA), urinalysis, ultrasonography and uroflowmetry. RESULTS: A total of 1041 asymptomatic men were included in this study. The average age was 49 years and average maximum flow rate was 17.4 mL/s. In spite of IPSS and prostate size increase with aging, they had a weak correlation with Qmax cutoffs (10 mL/s and 15 mL/s). A total of 85 men (8.3%) had more than 60 years, and even in this group, Qmax was higher than 15 mL/s. Out of 1041 men, 117 had IPSS less than 8 and Qmax less than 10 mL/s. CONCLUSIONS: In asymptomatic men there is a weak correlation between IPSS, prostate size and uroflowmetric data. The establishment of different normal cutoffs seems to be complicated and uroflowmetry data should be interpreted with caution in order to avoid misdiagnosis.

Quantification of ampicillin in bovine milk by coupled-column ultrahigh-performance liquid chromatography-tandem mass spectrometry.

This work reports the use of two-dimensional (2D) liquid chromatography system coupled with a tandem mass spectrometry for the quantification of ampicillin in bovine milk. A restrict access media column (RAM-BSA C(8) , 50 × 2.1 mm, Luna, 10 µm, 100 Å) was used in the first dimension in order to exclude macromolecules, while an ACQUITY UPLC BEH C(18) (50 × 2.1 mm, 1.7 µm) column was used in the second dimension. Three different channels of selected reaction monitoring (SRM) were used: 350 > 106 m/z, 350 > 160 m/z, and 350 > 192 m/z. The first transition was used for the quantification (higher intensity), and latter two for confirmation. The developed method is simple and requires a total analysis time of only 14 min/sample. The sample treatment involved only a centrifugation step for 20 min. The validated method has been successfully applied to monitor AMP residues in raw milk samples. To our knowledge, this is the first study to report the use of ultrahigh-performance liquid chromatography (UHPLC) in 2D configuration.

Development of a rabbit's urethral sphincter deficiency animal model for anatomical-functional evaluation.

OBJECTIVE: The aim of the study was to develop a new durable animal model (using rabbits) for anatomical-functional evaluation of urethral sphincter deficiency. MATERIALS AND METHODS: A total of 40 New Zealand male rabbits, weighting 2.500 kg to 3.100 kg, were evaluated to develop an incontinent animal model. Thirty-two animals underwent urethrolysis and 8 animals received sham operation. Before and at 2, 4, 8 and 12 weeks after urethrolysis or sham operation, it was performed cystometry and leak point pressure (LPP) evaluation with different bladder distension volumes (10, 20, 30 mL). In each time point, 10 animals (8 from the study group and 2 from the sham group) were sacrificed to harvest the bladder and urethra. The samples were evaluated by H&E and Masson 's Trichrome to determine urethral morphology and collagen/smooth muscle density. RESULTS: Twelve weeks after urethrolysis, it was observed a significant decrease in LPP regardless the bladder volume (from 33.7 ± 6.6 to 12.8 ± 2.2 cmH2O). The histological analysis evidenced a decrease of 22% in smooth muscle density with a proportional increase in the collagen, vessels and elastin density (p < 0.01). CONCLUSIONS: Transabdominal urethrolysis develops urethral sphincter insufficiency in rabbits, with significant decrease in LPP associated with decrease of smooth muscle fibers and increase of collagen density. This animal model can be used to test autologous cell therapy for stress urinary incontinence treatment.

Is the ultrasound-estimated bladder weight a reliable method for evaluating bladder outlet obstruction?

OBJECTIVE: • To evaluate the correlation between ultrasound-estimated bladder weight (UEBW) in patients with different degrees of bladder outlet obstruction (BOO). METHODS: • We evaluated 50 consecutive non-neurogenic male patients with lower urinary tract symptoms (LUTS) referred to urodynamic study (UDS). All patients self-answered the International Prostate Score Symptoms (IPSS) questionnaire. After the UDS, the bladder was filled with 150 mL to determine UEBW. • Patients with a bladder capacity under 150 mL, a previous history of prostate surgery or pelvic irradiation, an IPSS score <8, a bladder stone or urinary tract infection were excluded. • After a pressure-flow study, the Schafer linear passive urethral resistance relation nomogram was plotted to determine the grade of obstruction: Grades I-II/VI were defined as mild obstruction, Grades III-IV/VI as moderate obstruction, and Grades V-VI/VI as severe obstruction. RESULTS: • The UEBW was 51.7 ± 26.9, 54.1 ± 30.0 and 54.8 ± 28.2 in patients with mild, moderate and severe BOO, respectively (P= 0.130). The UEBW allowed us to define four groups: (i) UEBW <35 g; (ii) 35 g ≤ UEBW < 50 g; (iii) 50 g ≤ UEBW < 70 g; and (4) UEBW ≥ 70 g. • We did not find any differences in age, prostate weight, IPSS, PVR, cystometric bladder capacity, presence of detrusor overactive and degree of obstruction in the aforementioned groups. CONCLUSION: • Despite the fact that some studies have emphasized the value of UEBW as an efficient non-invasive method for evaluating lower urinary tract obstruction, our study suggests that UEBW does not present any individual correlation with LUTS or objective measurements of BOO.

Determining the variables associated to clean intermittent self-catheterization adherence rate: one-year follow-up study.

PURPOSE: To determine adherence rate and variables associate with patients' adherence to Clean Intermittent Self Catheterization (CISC). MATERIALS AND METHODS: Patients referred to CISC training program between July 2006 and May 2008, were prospectively evaluated with urodynamic, 3 days bladder diary (BD) and WHOQoL-brief questionnaire. After training to perform CISC, patients were evaluated at 2 weeks, monthly for 6 months and at 12 months with clinical visits and BD. Patients were considered adherent if they were performing at least 80% of the initial recommendation. RESULTS: Sixty patients (50.4 ± 19.9 years old) were trained to perform CISC (21 female and 39 male). Out of them, 30 (50%) had neurogenic and 30 (50%) had a non-neurogenic voiding dysfunction. The adherence rate at 6 and 12 months was 61.7%, 58%, respectively. Patients < 40 years old had adherence rate of 86%. Women and neurogenic patients had higher adherence rate than their counterparts (p = 0.024 and p = 0.016, respectively). In the WHOQoL-brief, patients that adhere to the program had a significant higher score on psychological and social relationships domains. There was not difference in pre and post training WHOQoL-brief scores. Educational background, marriage status, detrusor leak point pressure, Bladder Capacity, number of leakage episodes did not play a role on the adherence rate. CONCLUSION: Patients in CISC program present a reasonable adherence after one year. Women, neurogenic voiding dysfunction and patients under 40 years old were significantly more adherents. The psychological and social relationship status seems to positively interfere on adherence. CISC did not affect patient's QoL evaluated by WHOQoL-brief.

Ceramide-activated protein kinases A and C zeta inhibit kidney proximal tubule cell Na(+)-ATPase.

The basolateral membranes of kidney proximal tubule cells have (Na(+)+K(+))-ATPase and Na(+)-ATPase activities, involved in Na(+) reabsorption. We showed that ceramide (Cer) modulates protein kinase A (PKA) and protein kinase C (PKC), which are involved in regulating ion transporters. Here we show that ceramide, promotes 60% inhibition of Na(+)-ATPase activity (I(50) approximately 100nM). This effect was completely reversed by inhibiting PKA but did not involve the classic PKC signaling pathway. In these membranes we found the Cer-activated atypical PKC zeta (PKCzeta) isoform. When PKCzeta is inhibited, Cer ceases to inhibit the Na(+)-ATPase, allowing the cAMP/PKA signaling pathway to recover its stimulatory effect on the pump. There were no effects on the (Na(+)+K(+))-ATPase. These results reveal Cer as a potent physiological modulator of the Na(+)-ATPase, participating in a regulatory network in kidney cells and counteracting the stimulatory effect of PKA via PKCzeta.

Do we need new surgical techniques to repair vesico-vaginal fistulas?

INTRODUCTION AND HYPOTHESIS: The urogenital fistula is a devastating condition for women. Despite advances in medical care, the vesicovaginal fistula continues to be a distressful problem. Complex vesicovaginal fistulae repair may need tissue interposition. It can be achieved by vaginal or abdominal approach and depends on the surgeon's experience and local factors like size, location, and previous radiotherapy. The aim of this study was to demonstrate that using traditional approaches is possible and reasonable to treat any sort of vesicovaginal fistula. METHODS: Between January 2004 and August 2007, we treated 23 patients with complex urogenital fistulae. Of those with concomitant ureteral fistula requiring re-implantation or bladder augmentation, the vaginal approach was the first choice in 17 and abdominal approach in six. Patients were clinically evaluated at 1, 4, and 12 weeks postoperatively, then every 3 months in the first year. RESULTS: Seventeen women were treated by vaginal approach and six patients were treated by abdominal approach. Hysterectomy was the major etiology (73.9%). Ten patients (43.5%) had at least one previous abdominal surgery for fistulae repair without success before. In those patients with abdominal approach, the hospitalization was longer than vaginal approach (80.5+/-6 h versus 48+/-3 h). In both, there were no major intraoperative or postoperative complications; 13% developed urgency and 4% developed stress urinary incontinence. No patients have recurrence of fistulae (success rate 100%). CONCLUSIONS: Complex vesicovaginal fistulas are a big challenge for the urologist, and there is no gold standard surgical approach. The majority of complex vaginal fistula can be successfully managed by vaginal repair. As the vaginal approach is a minimally invasive procedure with low costs, easy learning curve, and high cure rates, new approaches must be carefully evaluated before being suggested as an alternative.