Laparoscopic minimally invasive sacrocolpopexy or hysteropexy and transobturator tape combined with native tissue repair of the vaginal compartments in patients with advanced pelvic organ prolapse and incontinence.

INTRODUCTION AND HYPOTHESIS: The aim of the study was to evaluate hysterectomized and non-hysterectomized patients with prolapse and incontinence. Laparoscopic sacrohysteropexy (LSHP) and minimally invasive sacrocolpopexy (LMSCP) were done in combination with transobturator tape (TOT) and native tissue repair of the anterior and posterior vaginal compartments in patients with pelvic organ prolapse (POP) and occult, stress, or urinary incontinence (SUI). The hypothesis is that both methods are successful. METHODS: A total of 81 patients with POP were evaluated: 44 had vaginal vault prolapse (POPQ points Ba, C, and Bp were 1.2, 2.6, and 0.4, respectively) and 37 had uterine prolapse (POPQ points Ba, C, and Bp were 1.8, 1.7, and 1.3, respectively). LMSCP (which means less dissection of the vagina in its upper third and avoiding possible collision with the ureters anteriorly or the rectum posteriorly) was performed in patients with vault prolapse, whereas patients with uterine prolapse underwent LSHP. Transobturator tape (TOT) was placed in all patients to treat symptomatic and occult urinary incontinence. Systematic anterior and posterior colporrhaphy was performed in both groups. RESULTS: Both groups showed anatomic (p < 0.0001) and symptomatic improvement (p < 0.001-p < 0.05). Voiding was significantly improved after surgery without postoperative incontinence (p < 0.001). There was no significant difference between groups regarding duration of surgery (p = 0.06), hospital stay (p = 0.13), blood loss (0.83), Clavien-Dindo grade 3 (p = 0.87), and Clavien-Dindo grade 1-2 (p = 0.92) complications. CONCLUSION: Minimally invasive LSCP or LSHP combined with TOT and native tissue repair of the anterior and posterior vaginal compartment is a successful treatment for POP.

Protective effects of anthocyanins from bilberry extract in rats exposed to nephrotoxic effects of carbon tetrachloride.

This study examined the nephroprotective effects of 15 different anthocyanins from the bilberry extract on the acute kidney injury caused by CCl4. The acute nephrotoxicity in rats was induced 24 h after the treatment with a single dose of CCl4 (3 mL/kg, i.p.).The nephroprotective effects of the anthocyanins were examined in the animals that had been given the bilberry extract in a single dose of 200 mg of anthocyanins/kg daily, 7 days orally, while on the seventh day, 3 h after the last dose of anthocyanins, the animals received a single dose of CCl4 (3 mL/kg, i.p.) and were sacrificed 24 h later. When the nephrotoxicant alone was administered, it resulted in a substantial increase of the pro-oxidative (TBARS, CD, H2O2, XO, and GSSG) and pro-inflammatory markers (TNF-α, NO, and MPO), as well as a noticeable reduction of the antioxidant enzymes (CAT, SOD, POD, GPx, GST, GR) and GSH when compared to the results of the control group. Moreover, the application of CCl4 significantly influenced a reduction of the renal function, as well as an increase in the sensitive and specific injury indicators of the kidney epithelial cells (ß2-microglobulin, NGAL, KIM1/TIM1) in the serum and urine of rats. The pretreatment of the animals poisoned with CCl4 with the anthocyanins from the bilberry extract led to a noticeable reduction in the pro-oxidative and pro-inflammatory markers with reduced consumption of the antioxidant defence kidney capacity, compared to the animals exposed to CCl4 alone. Anthocyanins have been protective for the kidney parenchyma, with an apparent absence of the tubular and periglomerular necrosis, severe degenerative changes, inflammatory mononuclear infiltrates and dilatation of proximal and distal tubules, in contrast to the CCl4-intoxicated animals. The nephroprotective effects of anthocyanins can be explained by strong antioxidant and anti-inflammatory effects achieved through the stabilization and neutralization of highly reactive and unstable toxic CCl4 metabolites.

A martius flap in the treatment of iatrogenic distal urogenital fistula

ABSTRACT Introduction: Distal urogenital fistulas (DUF) are usually iatrogenic and are uncommon in Europe. They occur in the urethra or near the bladder neck, and can be caused by vaginal hysterectomy, para-urethral cyst surgery, or erosion of the bladder or urethra from tension-free slings or meshes. The psychological and physical health consequences of DUF are devastating because most patients consider themselves "healthy" before surgery. Incontinence can appear after successful DUF closure due to previously occult incontinence or urethral incompetence. Additional surgery for incontinence is sometimes necessary to achieve satisfactory outcome. Materials and Methods: A Martius flap was used in 23 patients between 2000 and 2015. Patient age range was 38-75 years (mean, 58.7). DUF was due to gynecologic surgery for benign disease (15 / 23; 65.2%), mesh / sling erosion (2 / 23; 8.7%), and malignancy (6 / 23; 26.1%). The follow-up period was one year. Results: DUF was closed in 22 patients (95.6%). Satisfaction and complete dryness was achieved in 16 patients (69.6%) after the first procedure. Postoperative complications were: postoperative hematoma in 1 (4.4%), primary failure in 1 (4.4%), overactive bladder (OAB) syndrome in 3 (13.2%) and postoperative incontinence in 6 (26.4%) patients. A fascial sling was placed in patients with incontinence. All patients were dry after the secondary surgery. Anticholinergics were used for the treatment of OAB syndrome. Discomfort at the flap harvesting site was of minor importance. Finally, 22 out of 23 patients (95.6%) were satisfied. Conclusion: A Martius flap and additional fascial sling could be successfully used to optimize DUF treatment.

A martius flap in the treatment of iatrogenic distal urogenital fistula.

INTRODUCTION: Distal urogenital fistulas (DUF) are usually iatrogenic and are uncommon in Europe. They occur in the urethra or near the bladder neck, and can be caused by vaginal hysterectomy, para-urethral cyst surgery, or erosion of the bladder or urethra from tension-free slings or meshes. The psychological and physical health consequences of DUF are devastating because most patients consider themselves "healthy" before surgery. Incontinence can appear after successful DUF closure due to previously occult incontinence or urethral incompetence. Additional surgery for incontinence is sometimes necessary to achieve satisfactory outcome. MATERIALS AND METHODS: A Martius flap was used in 23 patients between 2000 and 2015. Patient age range was 38-75 years (mean, 58.7). DUF was due to gynecologic surgery for benign disease (15 / 23; 65.2%), mesh / sling erosion (2 / 23; 8.7%), and malignancy (6 / 23; 26.1%). The follow-up period was one year. RESULTS: DUF was closed in 22 patients (95.6%). Satisfaction and complete dryness was achieved in 16 patients (69.6%) after the first procedure. Postoperative complications were: postoperative hematoma in 1 (4.4%), primary failure in 1 (4.4%), overactive bladder (OAB) syndrome in 3 (13.2%) and postoperative incontinence in 6 (26.4%) patients. A fascial sling was placed in patients with incontinence. All patients were dry after the secondary surgery. Anticholinergics were used for the treatment of OAB syndrome. Discomfort at the flap harvesting site was of minor importance. Finally, 22 out of 23 patients (95.6%) were satisfied. CONCLUSION: A Martius flap and additional fascial sling could be successfully used to optimize DUF treatment.

Enhanced Recovery After Surgery Protocols in Major Urologic Surgery.

THE PURPOSE OF THE REVIEW: The analysis of the components of enhanced recovery after surgery (ERAS) protocols in urologic surgery. RECENT FINDINGS: ERAS protocols has been studied for over 20 years in different surgical procedures, mostly in colorectal surgery. The concept of improving patient care and reducing postoperative complications was also applied to major urologic surgery and especially procedure of radical cystectomy. This procedure is technically challenging, due to a major surgical resection and high postoperative complication rate that may reach 65%. Several clinical pathways were introduced to improve perioperative course and reduce the length of hospital stay. These protocols differ from ERAS modalities in other surgeries. The reasons for this are longer operative time, increased risk of perioperative transfusion and infection, and urinary diversion achieved using transposed intestinal segments. Previous studies in this area analyzed the need for mechanical bowel preparation, postoperative nasogastric tube decompression, as well as the duration of urinary drainage. Furthermore, the attention has also been drawn to perioperative fluid optimization, pain management, and bowel function. SUMMARY: Notwithstanding partial resemblance between the pathways in major urologic surgery and other pelvic surgeries, there are still scarce guidelines for ERAS protocols in urology, which is why further studies should assess the importance of preoperative medical optimization, implementation of thoracic epidural anesthesia and analgesia, and perioperative nutritional management.

Simultaneous self-created transobturator tape and laparoscopic extraperitoneal vaginal support in patients with stress urinary incontinence and prolapse of the anterior and apical vaginal compartments.

OBJECTIVE: Stress urinary incontinence (SUI) is frequently associated with prolapse of the apical and anterior vaginal compartments. The standard treatment of SUI is transobturator tape (TOT). The usual treatment of prolapse (anterior colporrhaphy) has a high recurrence rate. The aim of this study is to evaluate the results of the treatment of SUI and concomitant anterior and apical prolapse with self-created transobturator tape and simultaneous laparoscopic anterior and apical support. STUDY DESIGN: A total of 36 patients with SUI and prolapse of the anterior and apical compartments were underwent operations. The mean follow-up was 18 months. Self-created transobturator tape and laparoscopical support of the anterior and apical compartment prolapse were performed in all patients. The most important symptoms of prolapse and incontinence, the anatomical outcome, and complications were evaluated before and after the surgery. RESULTS: Treatment of incontinence and anterior and apical prolapse was successful in 33/36 (91.7%), 30/36 (83.3%) and 31/36 (86.1%) patients, respectively (p<0.0001). There is a significant reduction of vaginal bulging and pelvic pressure (p<0.0001). Frequency and urgency were significantly reduced (p<0.0007 and p<0.03 respectively). There was no significant deterioration of the posterior compartment. The most important complications were bladder perforation in 2/36 (5.5%) patients and temporary urinary retention in 3/36 (8.3%) patients (Clavien-Dindo grade 3). CONCLUSION: Simultaneous laparoscopic anterior and lateral extraperitoneal support and transobturator tape are effective in the treatment of patients with both conditions.

Resection of the Urethral Plate and Augmented Ventral Buccal Graft in Patients with Long Obliterative Urethral Strictures.

Video available at: http://www.brazjurol.com.br/videos/november_december_2015/Ignjatovic_1234_1235video.htm

Self-created transobturator tape treatment of stress urinary incontinence without prior urodynamic investigation.

OBJECTIVES: The purpose of this study was to evaluate and compare the results of tension free self-created transobturator tape (SCTOT) with the standard industrially created transobturator tape (ICTOT) in the treatment of stress urinary incontinence (SUI). STUDY DESIGN: A prospective study of the treatment of SUI with SCTOT (67 patients) and ICTOT (47 patients) was performed. SCTOT was created from polypropylene mesh and monofilament sutures. The symptoms were evaluated before and after the surgery with the following: the Incontinence Impact questionnaire (IIC-7), the urogenital distress inventory (UDI-6), and the International Continence impact questionnaire short form (ICIQ5-SF). The overactive bladder symptom score (OABSS) was used to classify patients in the SUI or the mixed urinary incontinence (MUI) group. The follow up period was 18 months. Cure was defined as a negative stress test and no need for additional surgery. RESULTS: Objective cure was achieved in 56/67 (83.5%) participants in the SCTOT group and in 40/47 (85.1%) participants in the ICTOT group (p>0.05). There was a significant improvement in IIC-7, UDI-6, ICIQ5-SF and OABSS in both groups. Improvement was better in the group with pure SUI than in patients with MUI, but this difference was not significant. Postoperative infection occurred in 5/67 (7.4%) participants and in 5/47 (10.6%) patients in the SCTOT and the ICTOT group, respectively. De novo overactive bladder symptoms occurred in 4/67 (5.9%) of the participants in the SCTOT group and in 3/47 (6.3%) of the patients in the ICTOT group. Operating time was longer in patients with SCTOT compared to those with ICTOT. CONCLUSION: The results of the treatment with SCTOT are not inferior to the results of the treatment with ICTOT and other results reported in the literature.

Reconstruction of urethral strictures in patients with a long history of blind urethral dilatation.

PURPOSE: To compare urethral reconstructions in patients after several years with or without blind urethral dilatation. MATERIALS AND METHODS: A retrospective study of 107 patients with urethral reconstructions was performed. Sixty patients with a long history of blind urethral dilatation (group 1) were compared with 47 patients without prior dilatations (group 2). RESULTS: The type of surgery planned according to urethrography and endoscopy findings was appropriate in 37/60 (61.6%) patients in group 1 and in 39/47 (83%) patients in group 2(P < .03). Anastomotic repairs were more frequent among the patients in group 2 (P < .001).Eighty five out of 107 patients were available for the 24 months follow-up. The success rate was higher in group 2 (91.4%) than patients in group 1 (70%) (P < .04). The greatest improvement in symptoms and quality of life occurred three months after the surgery (P < .05).Postoperative infection was persistent in 20/107 (18.7%) patients. CONCLUSION: Urethral strictures with a long history of blind dilatation are separate entity.They are more difficult to image, require more augmentation and staged procedures and have a lower success rate.

Reconstruction of the long urethral strictures with the buccal mucosal free graft.

INTRODUCTION: Reconstruction of the long urethral strictures is a difficult task in urology. The most frequently usedmethod is augmentation with the free buccal mucosal graft. MATERIAL AND METHODS: Restrospective analysis of 57 patients with the long urethral stricture was performed. All patients were evaluated endosco- pically and radiologically before the surgery. Buccal mucosal graft harvested from the inner side of the cheek (unilateral or bilateral) was used for the urethral reconstruction in all patients. Follow-up was one year. RESULTS: Complete follow up is achieved in 44/57 (77.2%) patients. The most important etiology of the strictures was previous iatrogenic trauma (instrumentation). The strictures were the most frequently located in the bulbar urethra. Preoperative exact evaluation of the stricture length was possible in only 35/57 patients (61.4%). Overall success rate of the surgery was 38/44 (86.3%). Complications occurred in 6/44 (13.7%) of patients--primary graft failure and urinary fistula. Mean preoperative IPSS was 19.2 ± 5.2, and postoperative 10.3 ± 3.2 (p < 0.0001). IPSSQOL was 4.9 ± 3.7 before the surgery, 2.9 ± 1.1 after the surgery (p < 0.001). Persistent urinary infection was present in 12/44 (27.2%) patients. CONCLUSION: Buccal mucosal free graft could be successfully used in the reconstruction of long urethral strictures. However, complications are not uncommon, and residual symptoms still exist after the surgery, and could not be neglected.

[Superficial urinary bladder tumors treatment results--a 10-year experience].

BACKGROUND/AIM: The most common urinary bladder tumors are superficial tumors. Due to their tension to relapse and progress towards deeper layers after surgical therapy, an adequate therapy significantly contributed to the improvement of the results of urinary bladder tumors treatment. Staging and gradus of the tumor, presence of the cardnoma in situ (CIS) or relapses significantly influenced the choice of the therapy. The aim of this study was to ascertain the effectiveness of the intravesicelly applied BCG (Bacille Colmette-Guerin) vaccine or chemiotherapy in the prevention of the relapses and further progression of superficial urinary bladder tumors. METHODS: All of the diagnosed superficial tumors of bladder were removed by transurethral resection (TUR). After receiving the patohistological finding they were subjected to adjuvant therapy, immune BCG vaccine or chemiotherapy (epirubicin, doxorubicin, mitomycin-C). The third group did not accept adjuvant therapy, but had regularly scheduled cystoscopic controls. The appearance of relapses, progression of stage and gradus of the tumor, as well as possible unwanted effects of adjuvant therapy were registered. RESULTS: The applied immunotherapy (BCG) influenced decreased tumor relapses (7%) and statistically important difference between patients who had taken adjuvant chemotherapy (relapses 18.4%) and those without this therapy was acknowledged. Gradus of tumor did not show statistically significant difference on tumor relapse. A significantly longer period of time in the appearance of tumor relapse after BCG (29.33 months), had significant importance comparing to chemio (9.44 months) or non-taken adjuvant therapy (9.84 months). Very small number of unwanted effects suggested an obligatory undertaking adjuvant therapy after TUR of superficial tumors. CONCLUSION: A significant decrease of relapses as well as avoidance of further progression of urinary bladder tumors, has introduced adjuvant therapy in all of the protocols, while the dosing scheme is not unique yet due to trying to find the optimal dose, the length of application and possible dose maintenance.

Bilateral fused pelvic kidney ectopia with a single draining ureter solved by craniolateral displacement of the kidney and Boari-modified bladder-calyceal anastomosis with bladder augmentation.

A pelvic cake kidney with hydronephrosis and renal failure with the single draining ureter was reported. Frequent urination related to compression of the bladder was the most important symptom. The kidney was craniolaterally displaced, the malfunctioning ureter was replaced with the Boari-like tubularization of the bladder, and the neoureter was anastomosed with the calyx. The bladder was enlarged by intestinal augmentation.