Applicability of vaginal energy-based devices in urogynecology: evidence and controversy

SUMMARY OBJECTIVE: This study aimed to analyze the evidence and controversies about the use of vaginal energy-based devices (laser and radiofrequency) for treatment of genitourinary syndrome of menopause, recurrent urinary tract infection, urinary incontinence, and genital prolapse through a literature review. METHODS: A search of literature databases (PubMed, Medline) was performed for publications in December 2022. Keywords included genitourinary syndrome of menopause, vaginal laxity, vaginal/vulvovaginal atrophy, urinary tract infection, urgency incontinence, frequency, urgency, stress urinary incontinence, genital prolapses AND energy-based devices, AND vaginal laser, AND vaginal radiofrequency, AND CO2 laser, AND Er:YAG laser. Publications in English from the last 7 years were reviewed and selected by the authors. RESULTS: The literature regarding vaginal energy-based devices in the treatment of urogynecological conditions is primarily limited to prospective case series with small numbers and short-term follow-up. Most of these studies showed favorable results, improvement of symptoms with low risk, or no mention of serious adverse events. Consensus statement documents from major medical societies suggest caution in recommending these therapies in clinical practice until more relevant data from well-designed studies become available. CONCLUSION: The potential of the vaginal laser and radiofrequency as a therapeutic arsenal for the evaluated urogynecological conditions is great, but qualified research must be done to prove their efficacy and long-term safety, define application protocols, and recommend the use of these technologies in clinical practice.

Testicular volume and Tanner stage: determinant factors for testicular torsion

ABSTRACT Objective To assess testicular volumes and sexual maturation in patients with testicular torsion. Methods A retrospective analysis of consecutively treated patients with testicular torsion between 2016 and 2018. Age, pubic hair staging (Tanner), and by ultrasonography, volume of the unaffected testis (in cubic centimeters) were evaluated either immediately before surgery or at the first postoperative visit. Patients with previous testicular disease, such as cryptorchidism, or with no records of testicular volume were excluded. The analysis included descriptive statistics and Bayesian regression. Results We treated 149 patients during the study period, and 141 (94.6%, median age 17.3 years) met the inclusion criteria. Median testicular volume was 13.0cm3 (interquartile range of 10.5-15.2), with similar right and left volumes (12.9cm3versus 13.3cm3; p=0.94). Sixty-five (46.1%) patients were Tanner stage IV, 17 (12.1%) stage III, and 59 (41.8%) stage V. Conclusion In this study, we were able to estimate volumes of testicular torsion, which aggregated around late puberty values (13.0cm3 for the whole dataset, 12.2cm3 for patients <25 years), suggesting that testicular hypermobility, due to congenital anatomical abnormalities, remains quiescent until the organ reaches a critical volume, after which torsion becomes possible. These findings provide a tentative explanation for the disease's age distribution.

Presentation delay, misdiagnosis, inter-hospital transfer times and surgical outcomes in testicular torsion: analysis of statewide case series from central Brazil

ABSTRACT Purpose To estimate statewide presentation delay, misdiagnosis rate, inter-hospital transfer times and testicular salvage for testicular torsion patients treated in our state's public health system. Patients and Methods Case series of consecutive testicular torsion patients treated in our state's public health system between 2012-2018. Predictors included presentation delay (time from symptoms to first medical assessment), facilitie's level-of-care (primary, secondary, tertiary), first diagnosis (torsion, epididymitis, other), Doppler-enhanced ultrasound request (Doppler-US) and inter-hospital transfer times, with surgical organ salvage as the main response. We used Bayesian regression to estimate the effect of first examining facilitie's level-of-care, first diagnosis, and Doppler-US on transfer time. Results 505 patients were included, most (298, 59%) with presentation delay >6 hours. Misdiagnosis at first examining facility raised transfer time from median 2.8 to 23.4 (epididymitis) and 37.9 hours (other) and lowered testicular salvage rates from 60.3% (torsion) to 10.7% (epididymitis) and 18.3% (other). Doppler-US had negligible effects on transfer time once controlling for misdiagnosis in the regression model. Although organ salvage in patients presenting before 6 hours at the tertiary facility was high (94.6%, and about 20% lower for those presenting at lower levels-of-care), the overall salvage rate was more modest (46%). Conclusion Our low overall testicular salvage rates originated from a large proportion of late presentations combined with long transfer times caused by frequent misdiagnoses. Our results indicate that efforts to improve salvage rates should aim at enhancing population-wide disease awareness and continuously updating physicians working at primary and secondary levels-of-care about scrotal emergencies.

Predicting urine output after kidney transplantation: development and internal validation of a nomogram for clinical use

ABSTRACT Purpose: To analyze pre-transplantation and early postoperative factors affecting post-transplantation urine output and develop a predictive nomogram. Patients and Methods: Retrospective analysis of non-preemptive first transplanted adult patients between 2001-2016. The outcomes were hourly diuresis in mL/Kg in the 1st (UO1) and 8th (UO8) postoperative days (POD). Predictors for both UO1 and UO8 were cold ischemia time (CIT), patient and donor age and sex, HLA I and II compatibility, pre-transplantation duration of renal replacement therapy (RRT), cause of ESRD (ESRD) and immunosuppressive regimen. UO8 predictors also included UO1, 1st/0th POD plasma creatinine concentration ratio (Cr1/0), and occurrence of acute cellular rejection (AR). Multivariable linear regression was employed to produce nomograms for UO1 and UO8. Results: Four hundred and seventy-three patients were included, mostly deceased donor kidneys' recipients (361, 70.4%). CIT inversely correlated with UO1 and UO8 (Spearman's p=-0.43 and −0.37). CR1/0 inversely correlated with UO8 (p=-0.47). On multivariable analysis UO1 was mainly influenced by CIT, with additional influences of donor age and sex, HLA II matching and ESRD. UO1 was the strongest predictor of UO8, with significant influences of AR and ESRD. Conclusions: The predominant influence of CIT on UO1 rapidly wanes and is replaced by indicators of functional recovery (mainly UO1) and allograft's immunologic acceptance (AR absence). Mean absolute errors for nomograms were 0.08 mL/Kg h (UO1) and 0.05 mL/Kg h (UO8).

Pro - inflammatory cytokines and metalloproteinase activation in polypropylene mesh implant in rat subcutaneous tissue

ABSTRACT Aims and Objectives: Polypropylene meshes have been increasingly adopted for correction of pelvic organ prolapse due to its lower recurrence rate when compared to surgeries without meshes. The study of the interaction of these materials with the host tissue may contribute to the development of materials with best biocompatibility and, consequently, less complication rates. Materials and Methods: The present study compares the inflammatory reaction of standard-weight (SW) and lightweight (LW) meshes (72 g/m216g/m2 respectively), implanted in the abdomen of 20 adult rats, which were euthanized in four or 30 days. Quantification of pro-inflammatory markers, IL-1 and TNF-α, and of metalloproteinases, MMP2 and MMP3, were carried out through immunohistochemistry with AxioVision® software. Results: There were no significant differences in the quantification of IL-1 and TNF-α in LW versus SW meshes. However, IL-1 quantification increased along time (30 days >4 days, p=0.0269). Also, MMP-2 quantification was similar to SW and LW and both presented a significant increase along time (30 days >4 days, p <0.0001). MMP-3 quantification also showed no difference between the SW and LW groups, but increased along time (30 days >4 days, p=0.02). Conclusions: Mesh's density did not influence the quantification of pro-inflammatory cytokines IL-1 and TNF-α and metalloproteinases 2 and 3. The increased expression of IL-1, MMP-2 and MMP-3 over time could represent a longstanding inflammatory response after PP mesh implantation. Possibly, the occurrence of adverse events following PP prosthetic implants can be influenced by other factors, not solely related to the amount of implanted material.

Host inflammatory response to polypropylene implants: insights from a quantitative immunohistochemical and birefringence analysis in a rat subcutaneous model

ABSTRACT Objectives To describe acute and sub acute aspects of histological and immunohistochemical response to PP implant in a rat subcutaneous model based on objective methods. Materials and Methods Thirty rats had a PP mesh subcutaneously implanted and the same dissection on the other side of abdomen but without mesh (sham). The animals were euthanized after 4 and 30 days. Six slides were prepared using the tissue removed: one stained with hematoxylin-eosin (inflammation assessment); one unstained (birefringence evaluation) and four slides for immunohistochemical processing: IL-1 and TNF-α (pro-inflammatory cytokines), MMP-2 (collagen metabolism) and CD-31 (angiogenesis). The area of inflammation, the birefringence index, the area of immunoreactivity and the number of vessels were objectively measured. Results A larger area of inflammatory reaction was observed in PP compared to sham on the 4th and on the 30th day (p=0.0002). After 4 days, PP presented higher TNF (p=0.0001) immunoreactivity than sham and no differences were observed in MMP-2 (p=0.06) and IL-1 (p=0.08). After 30 days, a reduction of IL-1 (p=0.010) and TNF (p=0.016) for PP and of IL-1 (p=0.010) for sham were observed. Moreover, area of MMP-2 immunoreactivity decreased over time for PP group (p=0.018). Birefringence index and vessel counting showed no differences between PP and sham (p=0.27 and p=0.58, respectively). Conclusions The implantation of monofilament and macroporous polypropylene in the subcutaneous of rats resulted in increased inflammatory activity and higher TNF production in the early post implant phase. After 30 days, PP has similar cytokines immunoreactivity, vessel density and extracellular matrix organization.

Leiomioma uretral durante a gravidez: relato de caso / Urethral leiomyoma during pregnancy: a case report

The authors report a case of urethral leiomyoma diagnosed during pregnancy, which was conservatively treated up to the 38th week, when the pregnancy was interrupted. Thirty days after delivery, exeresis of the lesion was performed from the upper border of the urethral meatus and sutured with interrupted delayed-absorbable suture. The patient evolved favorably and presented no lesion recurrence during three months of follow up.

Modelo pélvico sintético como uma ferramenta didática efetiva comparada à pelve cadavérica / A synthetic three-dimensional pelvic model as an effective didactic tool compared to cadaveric pelvis

A anatomia é considerada matéria essencial à educação médica. Aulas práticas com uso de componentes anatômicos manipuláveis são fundamentais ao ensino e à aprendizagem. O objetivo deste estudo foi avaliar o Modelo Sintético de Pelve (Masp) como ferramenta didática, comparada à pelve cadavérica (PC) tradicionalmente utilizada, bem como a satisfação dos estudantes em relação a ambos os métodos. Sessenta e sete estudantes receberam aula teórica após teste teórico preliminar (TTP). Foram randomizados em três grupos: G1 teve aula prática tradicional (APT); G2, aula prática com Masp (APM); e G3 não teve aula prática. Um teste final (TTF) foi aplicado a todos os grupos. G1 e G2 submeteram-se à avaliação do método (AM). A análise estatística foi realizada utilizando-se Anova (Análise de Variância) e teste não paramétrico Mann-Whitney. No TTF, G3 apresentou escores mais baixos do que G1 (p = 0,041) e G2 (p = 0,000). Não foi encontrada diferença estatisticamente significante entre G1 e G2 (p >0,05). G2 apresentou maior satisfação com o método (p = 0,001). Concluiu-se que PC e Masp provaram ser ferramentas didáticas efetivas e que G2 mostrou maior satisfação.

Anatomy is considered a fundamental subject of medical education. Practical classes which involve the use of manipulable anatomic components are essential to teaching and learning. The aim of this study was to evaluate the synthetic pelvic model (SPM) as a didactic tool, compared to the traditionally- -used cadaveric pelvis (CP), as well as student satisfaction in relation to both methods. Sixty-seven students were given a theory class following the preliminary theoretical test (PTT). The study sample was randomized in three groups: G1 had a traditional practical class (TPC); G2 had a practical class with SPM (PCS); and G3 had no practical class. A final test (FTT) was applied to all the groups. G1 and G2 were subjected to method evaluation (ME). Statistical analysis was conducted using analysis of variance (ANOVA) and the Mann-Whitney U test. In the FTT, G3 presented scores lower than G1 (p = 0.041) and G2 (p = 0.000). No statistically significant difference was found between G1 and G2 (p >0.05). G2 presented greater satisfaction with the method (p = 0.001). In conclusion, both CP and SPM proved to be effective didactic tools and student satisfaction was greater with G2.

A new experimental model for inducing interstitial cystitis by oxidative stress using intravesical instillation of a nitric oxide donor gel / Novo modelo experimental de indução de cistite intersticial por estresse oxidativo utilizando instilação intravesical de gel doador de óxido nítrico

Objective: The aim of this study was to develop an experimental model of inducing interstitial cystitis through intravesical instillation of a polymeric solution containing the NO donor S-nitrousglutathione (GSNO) and to compare it to the experimental interstitial cystitis induced by vesical instillation of protamine and potassium chloride. Methods: A total of 40 female Wistar rats were used and divided into four groups: 1 - ten rats treated with saline solution + GSNO; 2 - ten rats treated with saline solution + polymeric solution (without GNSO); 3 - ten rats treated with protamine sulphate + KCl; 4 - ten rats treated with protamine sulphate + GSNO. The rats received one application (five animals in each group) or three applications (five animals in each group) of the corresponding substance through intravesical instillation, and after six days (five animals in each group) or nine days (five animals in each group) they were euthanized and their bladders were removed for macroscopic evaluation and histological study. Results: In the macroscopic evaluation edema and hyperemia of the mucosa were observed in 2 (22%) animals in Group 1, in no (0%) animal in Group 2, in 10 (100%) animals in Group 3, and in 5 (50%) animals in Group 4. In the protamine + KCl group and in saline + GSNO, similar effects were observed in the bladder wall. The animals in Group 2 (saline + polymeric solution) showed significantly less vascular congestion compared to the other groups after 9 days of the instillation (p = 0.0035). Significant fibrosis was observed in Groups 3 and 4, 6 days (p = 0.3781) and 9 days (p = 0.0459) after instillations, when compared to controls (Group 2). All groups presented neutrophilic infiltrate of variable intensity, 6 days after instillations (p = 0.7277). After 9 days, there was a regression of the infiltrate, with no evidence of accentuated neutrophilic reaction in all the groups (p = 0.2301). Conclusions: The inflammatory response to bladder instillation with an aqueous solution of S-nitrousglutathione was very similar to that induced by bladder instillation of protamine and KCl. Instillation of an aqueous solution of S-nitrousglutathione can be considered a new model for experimental induction of interstitial cystitis.

Objetivo: O objetivo deste estudo foi o desenvolvimento de um modelo experimental para a indução de cistite intersticial, por meio da instilação vesical de uma solução polimérica de gel doador de óxido nítrico S-nitrosoglutationa (GSNO), e compará-lo ao modelo experimental para a indução da cistite intersticial por instilação vesical de protamina e cloreto de potássio. Métodos: Foram utilizadas 40 ratas Wistar, divididas em quatro grupos: 1 - dez ratas tratadas com solução salina + GSNO; 2 - dez ratas tratadas com solução salina + solução de polímeros (sem GNSO); 3 - dez ratas tratadas com sulfato de protamina + KCl; 4 - dez ratas tratadas com sulfato de protamina + GSNO. As ratas receberam uma aplicação (cinco animais em cada grupo) ou três aplicações (cinco animais em cada grupo) da substância correspondente através de instilação vesical, e após seis dias (cinco animais em cada grupo) ou nove dias (cinco animais em cada grupo) foram sacrificadas, e a bexiga foi removida para exame macroscópico e estudo histológico. Resultados: Na avaliação macroscópica observou-se edema e hiperemia da mucosa em 2 animais (22%) do Grupo 1, em nenhum animal (0%) do Grupo 2, em 10 animais (100%) do Grupo 3, e em 5 animais (50%) do Grupo 4. No grupo protamina + KCl e no grupo solução salina + GSNO, observamos efeitos semelhantes sobre a parede da bexiga. Os animais do Grupo 2 (salina + polímeros) apresentaram significantemente menos congestão vascular que os dos outros grupos após 9 dias de instilação (p = 0,0035). Observou-se fibrose significante nos Grupos 3 e 4, 6 dias (p = 0,3781) e 9 dias (p = 0,0459) após as instilações, quando comparados com o grupo controle (Grupo 2). Todos os grupos apresentaram infiltrados neutrofílicos de intensidade variável, 6 dias após as instilações (p = 0,7277). Após 9 dias, observou-se regressão do infiltrado, sem evidência de acentuada reação neutrofílica em todos os grupos (p = 0,2301). Conclusão: A resposta inflamatória à instilação da bexiga com uma solução aquosa de S-nitroglutationa foi muito semelhante àquela induzida pela instilação de protamina e KCl. A instilação de uma solução aquosa de S-nitroglutationa pode ser considerada um novo modelo experimental para a indução da cistite intersticial.

Sintomas urinários irritativos após parto vaginal ou cesárea / Irritative bladder symptoms after vaginal delivery or c-section

OBJETIVO: Avaliar a frequência de Sintomas Urinários Irritativos (SUI) três anos após o parto em mulheres previamente entrevistadas no terceiro trimestre da gestação e sua associação com a via de parto exclusiva, a paridade, a idade materna, o peso do RN, a realização da episiotomia e o uso de fórcipe. MÉTODOS: Das 340 mulheres, originalmente avaliadas no terceiro trimestre da gestação, 120 foram localizadas e entrevistadas por telefone, três anos após o parto, entre junho e outubro de 2006. Foi analisada a associação entre SUI e via exclusiva de parto (vaginalou cesáreo), paridade,idade materna, peso do recém-nascido, realização da episiotomia e uso de fórcipe. Os resultados foram avaliados por meio de estatística descritiva, teste Qui quadrado e cálculo da razão de prevalência (p< 0,05). RESULTADOS: O grupo de mulheres estudadas consistiu de primíparas (37,5 por cento) e multíparas (62,5 por cento). As 95 que tiveram via exclusiva de parto foram categorizadas em vaginal (53) e cesáreas (42). Não houve associação significativa entre a presença de SUI após o parto e a via de parto exclusiva e a paridade. Também não encontramos associação entre a presença de SUI e a idade materna (> 35) peso do recém-nascido (> 4000g), realização da episiotomia e uso de fórcipe. CONCLUSÃO: A via de parto e a paridade não foram fatores determinantes para a disfunção do trato urinário inferior após o parto, representada pelos sintomas urinários irritativos, tampouco, a idade materna, o peso do RN, a realização da episiotomia e o uso de fórcipe.

OBJECTIVE: This study intended to investigate the frequency of irritative bladder symptoms three years after delivery in women previously interviewed in the third trimester of pregnancy and its correlation to mode of delivery, parity, maternal age, birth weight, episiotomy and forceps. METHODS: From 340 women previously evaluated at the third trimester of pregnancy, 120 were interviewed three years after delivery, between June and October 2006. Correlation of postpartum irritative bladder symptoms and mode of delivery (exclusively vaginal or c-section), parity, maternal age, birth weight, episiotomy and forceps was analyzed. Associations between irritative bladder symptoms and obstetric parameters were assessed by the Fisher's exact test and Chi-square (p< 0.05). RESULTS: The study group consisted of 37.5 percent primiparous and 62.5 percent multiparous women. Mode of delivery was exclusively vaginal in 53 women and exclusively c-section in 42. No statistical difference was found between irritative bladder symptoms and mode of delivery and parity. No statistical difference was found between irritative symptoms and maternal age (> 35), birth weight (> 4000g), episiotomy and forceps. CONCLUSION: After childbirth, dysfunction of the lower urinary tract, characterized by irritative bladder symptoms, was not associated with mode of delivery, parity, maternal age, birth weight, episiotomy and forceps.

Tradução para português, adaptação cultural e validação do Female Sexual Function Index / Translation into Portuguese, cross-national adaptation and validation of the Female Sexual Function Index

OBJETIVO: traduzir para o português, adaptar culturalmente e validar o questionário Female Sexual Function Index (FSFI). MÉTODOS: dois tradutores brasileiros, cientes dos objetivos desta pesquisa, preparam duas versões do FSFI para o português, as quais foram retro-traduzidas por outros dois tradutores ingleses. As diferenças foram harmonizadas e pré-testadas em um estudo piloto. As versões finais do FSFI e de outro questionário, o Short-Form Health Survey, já vertido e publicado em português, foram simultaneamente administradas a cem pacientes. Foram testadas as propriedades psicométricas do FSFI, como confiabilidade (consistência interna e teste-reteste) e validades de construto. O reteste foi realizado após quatro semanas, a partir da primeira entrevista. RESULTADOS: o processo de adaptação cultural não alterou a versão em português do FSFI comparado ao original. O alfa de Cronbach padronizado do questionário foi 0,96; avaliado por domínios, variou de 0,31 a 0,97. Como medida de confiabilidade teste-reteste, foi aplicado o coeficiente de correlação intra-classes, que foi considerado forte e idêntico (1,0). O coeficiente de correlação de Pearson entre o FSFI e o Short-Form Health Survey foi positivo, mas fraco na maioria dos domínios afins, variando de 0,017 a 0,036. CONCLUSÕES: a versão do FSFI foi traduzida para o português e adaptada culturalmente e é válida para avaliação da resposta sexual das mulheres brasileiras.

PURPOSE: to translate from English into Portuguese, adapt culturally and validate the Female Sexual Function Index (FSFI). METHODS: knowing the objectives of this research, two Brazilian translators have prepared a version each from the FSFI into Portuguese. Both versions have then been retro-translated into English by two English translators. After harmonizing the differences, they have been pre-tested in a pilot study. The final versions from the FSFI and from another questionnaire, the Short-Form Health Survey, which had already been translated and published in Portuguese, have then been simultaneously administered to one hundred patients, to test the FSFI psychometric proprieties concerning reliability (internal consistency and testing-retesting) and construct validity. Retesting was done after four weeks from the first interview. RESULTS: the process of cultural adaptation has not altered the Portuguese version of the FSFI, as compared to the original. The FSFI standardized Cronbach alpha was 0.96, and the evaluation by domains has varied from 0.31 to 0.97. As a measure of test-retest confidentiality, it was applied the intra-class coefficient, which has been considered strong and identical (1.0). Pearson's correlation coefficient between the FSFI and the Short-Form Health Survey was positive, but weak in most of the interrelated domains, varying from 0.017 to 0.036. CONCLUSIONS: the FSFI English version has been translated into Portuguese and culturally adapted, being reliable to evaluate the sexual response of Brazilian women.

Tratamento cirúrgico do prolapso da parede vaginal anterior através da técnica de sling transobturatório / Surgical treatment of the anterior vaginal wall prolapse by the transobturator sling technique

A abordagem cirúrgica do prolapso genital, particularmente da parede vaginal anterior (cistocele), é realizada classicamente através de técnicas que envolvem tecidos pouco resistentes e suscetíveis à recidiva precoce, como a colporrafia anterior. Os princípios da biocirurgia introduzem o conceito de biomateriais para reforço tecidual, visando uma abordagem minimamente invasiva e resultados duradouros. Utilizando-se a via transobturatória, inicia-se por incisão da parede vaginal anterior seguida de dissecção lateral até o ramo ísquio-púbico. Após introdução das agulhas inferiores e superiores, coloca-se uma tela para correção do defeito vaginal central e quatro hastes auto-fixáveis para correção do defeito lateral, fazendo ajuste sem tensão. A correção transobturatória do prolapso da parede vaginal anterior é uma alternativa segura e de caracter minimamente invasivo para o tratamento do prolapso vaginal anterior, com significativa redução dos riscos de complicações intra e pós-operatória. Futuramente, havendo os bons resultados a longo prazo, poderá ser considerada opção de rotina nestes casos

Emprego da submucosa intestinal suína em uretroplastias complexas / The use of porcine intestinal submucosa for complex urethroplasty

We report the use of Porcine Intestinal Submucosa (PIS) in association with Johanson technique for urethroplasty, in the treatment of recurring urethral stenosis. The patient had obliterans xerotica balanitis and had previously undergone 15 internal uretotomies as well as various unsuccessful urethral dilations. As a result of stenotic extension, another surgery was planned using Johanson technique. During the first part of the surgery, intense local fibrosis was observed, which required greater care and protection to avoid fistulae formation. PIS was interposed to reduce the chances of the occurrence of this dreaded complication. During the second part of the surgery, a skin flap obtained from tissue parallel to the urethral plateau was used to prepare a neourethra according to the norms of this technique. PIS was fixed at its extremities, and interposed between the neourethral suture and the skin suture to prevent any contact between them. The procedure was completed with the use of meatoplasty and glandulaplasty. After 6-month follow up, clinical and urodynamic improvement could be seen. If these results can be confirmed by more extensive studies, PIS will provide new perspectives for complex urethroplasties.

Obturador uretral: uma alternativa para o tramento da incontinência urinária de esforço / Urethral obturator: an alternative in the treatment of urinary stress incontinence

Baseado nos modernos conceitos sobre o mecanismo de continência na mulher, foi desenvolvido um obturador uretral de formato muti-esférico a fim de promover uma coaptaçao ótima ao nível do terço médio da uretra. Com o objetivo de analisar os aspectos objetivos e subjetivos relacionados à utilizaçao do obturador uretral em portadoras de IUE, foram estudas 17 pacientes portadoras de IUE relacionada à insuficiência esfincteriana(7) e à hipermobilidade do colo vesical, onde foi proposta a utilizaçao deste dispositivo por um período temporário de quatro meses. Todas foram submetidas a exame de urina I e urocultura prévia e ao término dos quatro meses, ou mais precocemente na eventualidade de sintomas irritativos urinários. Cinco pacientes abandonaram o tratamento, devido aos seguintes motivos: duas apresentaram cistites agudas (ll,8 por cento), duas nao se adaptaram ao cateterismo (ll,8 por cento) e outra devido a desconforto perineal (5,9 por cento). As demais evoluíram com controle da IUE e sem complicaçoes. Concluímos que este tratamento representa uma alternativa atraente nos casos onde a intervençao cirúrgica for contra-indicada ou indesejada, embora uma seleçao rigorosa das pacientes seja necessária a fim de minimizar os riscos de complicaçoes.

Divertículo uretral no diagnóstico diferencial da incontinência urinária / Urethral diverticula in the differential diagnosis of urinary incontinence

É apresentado um caso de incontinência urinária de esforço com sintomas atípicos evoluindo com recidiva precoce após a correçåo cirúrgica, realizada através da técnica de Marshall-Marchetti-Krnatz. A propedêutica realizada no pós-operatório revelou um divertículo uretral. A aplicaçåo adequada dos métodos propedêuticos específicos nas portadoras de incontinência urinária de esforço de caráter atípico ou associada a sintomas irritativos do trato urinário inferior faz-se necessária a fim de aumentar a especificidade diagnósticada e o sucesso terapêutico

"Sling" vaginal simplificado no tratamento da incontinência urinária de esforço: experiência inicial / Modified vaginal wall sling in the treatment of stress urinary incontinence: preliminary report

Apresentamos a experiência inicial em nosso meio com a utlizaçåo do "sling" vaginal simplificado no tratamento da incontinência urinária de esforço (IUE) na mulher. Esta técnica tem por objetivo corrigir de forma integrada a hipermobilididade do colo vesical e a insuficiência esfincteriana intrínseca sem a utilizaçåo de aponeuroses ou materiais sintéticos, baseando-se nos modernos conceitos sobre a anatomia e fisiologia do assoalho pélvico e da uretra. Foram tratadas 19 pacientes no período entre setembro de 1994 e fevereiro de 1995, com idade mediana de 54 anos. Quatro pacientes (21,1 por cento) eram nulíparas (mediana de quatro partos vaginais anteriores), com 42, 1 por cento das pacientes tendo sido submetidas previamente a alguma tentativa de correçåo da incontinência por outra técnica. O período médio de seguimento é de 4,3 meses (1 até seis meses). Até o momento, 18 pacientes (94,7 por cento) encontram-se continentes, com uma paciente tendo desenvolvido urgeincontinência pós-operatória. Embora com pouco tempo de seguimento e experiência ainda restrita, este procedimento representa uma alternativa lógica, simples, eficaz e sobretudo aplicável às diversas formas de IUE

Lesöes ureterais em cirurgia ginecológica / Ureteral injuries in gynecologic surgery

Foram estudadas retrospectivamente 33 pacientes atendidas no Centro de Assistência Integral à Saúde da Mulher da Universidade Estadual de Campinas no período de 1982 a 1992 com a finalidade de apresentar a experiência no tratamento das lesöes uretais relacionadas a cirurgia ginecológica. Treze pacientes (39,4 por cento) eram portadoras de neoplasias e de 20 de doenças benignas (60,6 por cento). A histerectomia abdominal foi a cirurgia mais freqüentemente relacionada à lesåo ureteral (94 por cento). Os casos onde seu reconhecimento foi intra-operatório representaram a minoria (18,2 por cento) e foram submetidos a correçåo com bexiga psóica ou reimplante primário havendo uma paciente submetida a uteroileostomia cutânea. Dentre as pacientes diagnosticadas no pós-operatório (81,8 por cento), foram identificadas 20 fístulas uterovaginais, uma fístula ureteroileostomia cutânea. Todos os casos com fístulas foram submetidos inicialmente a tentativa de cateterismo com catéter duplo J, com sucesso em três casos (14,5 por cento). Os demais foram submetidos a reimplante ureteral (seis casos), bexiga psóica (11 casos), e uma paciente foi submetida a uretro-uretero anastomose. Das 6 pacientes com estenose ureteral três apresentavam exclusåo renal funcional por ocasiåo do diagnóstico e foram submetidas à nefrectomia. As outras foram submetidas a uretewro-uretero anastomose (um caso), reimplante com bexiga psóica (um caso) e ureterotomia endoscópica (um caso). Foram encontradas três complicaçöes, representadas por deiscência da sutura nos dois casos submetidos a uretero-uretero anastomose e estenose no submetido à ureterotomia endoscópica. As duas primeiras foram tratadas através de ressutura em um caso e transuretero-uretero anstomose em outra. A terceira foi submetida a reimplante ureteral com bexiga psóica. Nåo houve complicaçöes tardias no seguimento médio de 12 meses. A análise dos resultados sugere que o reimplante ureteral associado à bexiga psóica é uma boa conduta para a correçåo das lesöes ureterais diagnosticadas tanto no intra como no pós-operatório