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.

Two different melatonin treatment regimens prevent an increase in kidney injury marker-1 induced by carbon tetrachloride in rat kidneys.

Acute kidney injury is a frequent disorder that can be mimicked by the application of different nephrotoxic agents, including carbon tetrachloride (CCl4), where kidney injury marker-1 (KIM-1) has been recognized as a highly specific marker. Melatonin is one of the most powerful natural antioxidants and has numerous beneficial properties. We evaluated the nephroprotective potential of 2 melatonin treatment regimens (pre- and post-intoxication) in a CCl4-induced acute kidney injury model based on the standard serum parameters, kidney tissue antioxidative capacity, KIM-1 levels, and kidney tissue morphological changes. The two treatment regimens were found to preserve kidney function, as judged from the evaluated standard serum parameters. Only when administered after the intoxication, melatonin preserved total kidney antioxidant capacity; pre-treatment melatonin only preserved reduced glutathione levels. An increase in tissue KIM-1 level was found to be prevented by both treatment regimens, which correlated with the morphological changes seen in the kidney tissues of animals treated with melatonin and CCl4. The findings of our study are in agreement with the known actions of melatonin in relieving kidney tissue oxidative burden, but also contribute to the understanding of its action by preventing an increase in KIM-1.

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.

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.

Iatrogenic ureteral trauma: a 16-year single tertiary centre experience.

INTRODUCTION: lItrogenic ureteral injuries can occur during various abdominopelvic and retroperitoneal surgical procedures including gynecological, urological, colorectal and vascular. OBJECTIVE: The aim of our study was to examine the incidence and types of iatrogenic ureteral injuries occurred over the period of 16 years, as well as to evaluate the values of applied diagnostic and therapeutic procedures. METHODS: A retrospective analysis of clinical data (medical records and operative reports) of 55 patients (11 male and 44 female; mean age 54.5 years) with verified iatrogenic ureteral injury from 1998 to 2014, was performed. RESULTS: latrogenic ureteral injuries occurred during gynecological procedures in 55%, urological in 25%, colorectal in 15% and vascular in 5% of cases. Mechanisms of injury were incomplete transection (n=23), complete transection (n=1), ligation (n=7), partial perforation (mucosal abrasion) (n=1 3) and total perforation (n=1). The most frequent diagnostic procedures for postoperative identification of ureteral injuries were abdominal ultrasonography, excretory urography, antegrade pyeloureterography and retrograde ureteropyelography. Early therapeutic procedures were applied in 35 (64%), while delayed in 20 cases (36%). Early (<30 days) or late (>30 days) postoperative complications were verified in 14 cases (25%). CONCLUSION: Among different surgeries that may lead to the development of iatrogenic ureteral injury, gynecological procedures represent the most common cause. Rapid diagnosis enables immediate ureteral repair and is associated with low morbidity rates, representing a major factor contributing to the treatment success and ultimately preserving the renal function.

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.

Tension free vaginal tape (TVT) vs Transobturator tape (TOT) complications and outcomes.

BACKGROUND: Stress urinary incontinence (SUI) is managed with both TVT and TOT. The TVT route of placement could result in a higher com-plication rate. The aim of this study is to analyze and compare outcomes and complications of TVT and TOT in SUI treatment. METHODS: Prospective study in 64 women with isolated SUI was validated through Urogenital Distress Inventory (UDI-6), Incontinence Impact questionnaire (IIQ-7) and International Continence Impact Questionnaire (ICIQ5-SF). Intraoperative and postoperative complications were noted. Patients were considered cured when negative on stress test and with no need for additional surgery during follow up, after one and three months. RESULTS: The cure rates for both TVT 26/30 (86,6%) and TOT 30/34 (88,2) were comparable. Higher rates of bleeding, bladder perforations, pain and dyspareunia are recorded in TVT group. Quality of life graded on the questionnaire basis proved significant improvement in both procedures. CONCLUSION: Both TVT and TOT have comparable cure results in the treatment of SUI. The TOT is equally effective in the SUI treatment with significantly lower complication incidence.

Complications of Camey-Le Duck ureteral reimplantation technique in modified ureterosigmoidostomy (Mainz pouch II) urinary diversion.

OBJECTIVE: to analyze complications and clinical outcome of Camey-Le Duck ureteral reimplantation technique in modified Mainz pouch II urinary diversion. PATIENTS AND METHODS: this retrospective study included a total of 110 patients (101 male and 9 female, mean age 59.2 years, SD = 10.2), who had underwent a modified Mainz pouch II urinary diversion with Camey-Le Duck ureteral reimplantation technique, following total cystectomy, during the period 1995-2014. The mean follow-up, available for 90 (82%) patients period was 19 (1-74) months. Early and late postoperative complications were analyzed. RESULTS: early complications developed in 22 (20%) patients as follow: unilateral ureterohydronephrosis in 8 (7%) patients, bilateral ureterohydronephrosis in one (1%)-two RU (renoureteral units), urinary leakage in 8 (7%), and pyelonephritis in 5 (5%) patients. Late complications developed in 28 (25%) patients: pyelonephritis in 17 (15%), and ureteral reimplantation site stenosis in 11 (10%) patients with 12 RU. Balloon dilatation procedure was applied in all 12 RU, with additional metallic Strecker stent insertion in 5 RU. At 24-month follow-up, all patients with metallic Strecker stent had normal results of serum biochemistry, blood gas analysis and renal ultrasound. In the rest of six patients with 7RU, balloon dilatation has failed and restenosis of ureteral reimplantation site with consequent ipsilateral hydronephrosis was verified. In these patients, permanent percutaneous nephrostomy catheter was applied. CONCLUSION: Camey-Le Duck ureteral reimplantation technique following Mainz pouch II urinary diversion is simple, reliable and durable. It enables well upper urinary tract protection and is associated with relatively low major complication rates.

Holmium laser enucleation versus transurethral resection of the prostate: a comparison of clinical results.

Holmium laser enucleation of the prostate (HoLEP) represents a great potential alternative technique to standard transurethral resection of the prostate (TURP). We present 12-month follow up results of a randomized clinical trial, comparing HoLEP with TURP. A total of 40 patients with BPH and prostate volume < 50 g, have been randomized for HoLEP (n = 20) or TURP (n = 20). Urinary tract ultrasound with postvoid residual urine (PVR), International Prostate Symptom Score (IPSS) and Single Question Quality of Life (QoL) Score were evaluated preoperatively and during the follow-up period at 1, 3, 6, and 12 mo postoperatively. Intra- and perioperative data as well as early and late complications were assessed. Operative time was longer in the HoLEP group (p < 0.001); catheterisation time (p < 0.05) and hospital stay (p < 0.05) shorter. Hemoglobin levels drop (p < 0.001) was higher in the TURp group. Early and late postoperative complications were more frequent in the TURp group (p < 0.001). Follow-up data favored the HoLEP group, both regarding IPSS at 6-month (p < 0.05) and 12-month (p < 0.01), and single question QoL score, at 6-month (p < 0.01) and 12-month (p < 0.05). PVR was lower in the HoLEP group at 6-month (p < 0.01). HoLEP demonstrates superiority to TURp in regards to perioperative parameters and follow-up data and has a great potential to become the new gold standard in the surgical treatment of BPH.

Simultaneous correction of anterior and apical vaginal prolapse with the modified placement of the transobturator-guided mesh (Anterior Prolift™) set.

AIM: Modified placement of the Anterior Prolift™ (MODAP) in patients with prolapse of the anterior and middle vaginal compartment is described. It was performed in order to achieve simultaneous tension-free correction of the anterior and middle vaginal compartment without excessive use of the mesh. MATERIAL AND METHODS: MODAP was performed in 32 patients. The anterior part of the mesh was placed transobturatorily. Surplus of the central part of the mesh was longitudinally divided and fixed around the cervix. Posterior mesh arms were passed through the sacrospinous ligament. All patients were analyzed regarding anatomy and symptoms 1 year after surgery. RESULTS: Cure of pelvic organ prolapse was achieved in 28 of 32 (87.5%) patients. The position of Ba and C points was significantly corrected (p = 0.00). Deterioration of the posterior compartment occurred in 1 case. Symptoms of pelvic organ prolapse were significantly corrected (p = 0.05 up to p = 0.00) except for rectal emptying. CONCLUSION: MODAP makes an improvement of both anatomy support and symptoms in cases with mixed insufficiency of the anterior vaginal wall and apical vaginal support.

Reconstruction of the penile skin loss due to "radical" circumcision with a full thickness skin graft.

BACKGROUND: Excessive resection of penile skin is a rare but important complication of circumcision. Penis "trapping" under the skin and consequent sexual dysfunction occur as a result. CASE REPORT: Excessive circumcision with complete resection of the penile skin is shown. Penis, trapped under the skin, was deliberated and skin defect was substituted with the full thickness skin graft. One year after the surgery penis has a good cosmetic appearance, adequate size and sexual function. CONCLUSION: Full thickness skin graft is a good option for augmentation of the penile skin loss in cases with intact hypodermal tissue and extensive skin loss, for the reconstruction in a single act.

Optimal primary minimally invasive treatment for patients with stress urinary incontinence and symptomatic pelvic organ prolapse: tension free slings with colporrhaphy, or Prolift with the tension free midurethral sling?

OBJECTIVE: Comparison of procedures in patients with concomitant stress urinary incontinence (SUI) and pelvic organ prolapse (POP) was performed. Tension free vaginal tape (TVT) or transobturator tape (TOT) with colporrhaphy was compared with fixed mesh (Prolift) applied with a tension free suburethral sling. STUDY DESIGN: A total of 76 women with both SUI and POP were evaluated. TVT or TOT with colporrhaphy was performed in 39 patients and Prolift with the midurethral sling in 37 patients. Anatomy, symptoms and quality of life (QOL) were evaluated prior to, and at 1, 6 and 12 months after surgery. RESULTS: Continence was achieved in both groups equally (p=0.57). The better anatomic outcome regarding the correction of POP was in the Prolift group but with a higher rate of additional procedures and complications. QOL was better in patients with grade III-IV POP corrected with Prolift (p=0.05) and equal in both groups with grade I-II POP during the follow-up. Impairment of sexual life was present in both groups before surgery. After surgery, there was no improvement in sexual life regardless of correction of both anatomy and incontinence. CONCLUSION: Both procedures are effective and safe. TVT or TOT performed with colporrhaphy looks a better primary choice for grade II POP and SUI. Results for grade III-IV POP and SUI are better with the Prolift with the sling. Sexual life could not be improved effectively with these types of surgery.

Characteristics of upper urothelial carcinoma in an area of Balkan endemic nephropathy in south Serbia. A fifty-year retrospective study.

AIMS AND BACKGROUND: Upper urinary tract transitional cell carcinoma, a relatively rare tumor, is up to 100 times more frequent in regions with Balkan endemic nephropathy. Characteristics of transitional cell carcinoma in the endemic South Morava Region in Serbia in the previous 50 years were evaluated. PATIENTS: We analyzed 477 cases with pathologically confirmed transitional cell carcinoma who underwent surgery from 1957 to 2006: 91 from endemic, 106 from adjacent and 280 from control settlements. Cases in the study came from 10 endemic villages, 46 adjacent villages, 51 control villages and the city of Nis. RESULTS: The increase in number of transitional cell carcinoma from 1957 was followed by a peak between 1967 and 1978 (yearly incidence 21.9 per 100,000) and a slow decrease thereafter to 7.4 (1997-2006). In the control settlements, the increase was steady. Reduced kidney function at surgery was found in 58% of patients from endemic and in 20% from control settlements. Age at surgery has significantly increased from 52.3 and 51.5 (1957-1966) to 70.9 and 66.1 (1997-2006) for endemic and control settlements, respectively. The female sex was predominant in endemic and adjacent settlements and the male sex in control settlements. Transitional cell carcinoma from endemic settlements was of a lower grade in the period from 1957-1986, but in the period from 1987-2006 they were predominantly high grade. Low tumor stage (pTa-pT1) predominated in transitional cell carcinoma from the endemic and adjacent but not the control settlements in the period from 1957 to 1986. However, in the last 20 years, upper urinary tract transitional cell carcinoma stage increased, the highest in the period from 1997 to 2006 in all settlements studied. Conservative surgery was advocated for transitional cell carcinoma in Balkan endemic nephropathy areas up to 1996. Transitional cell carcinoma are now more malignant and more advanced than before, and a less aggressive approach is used only for absolute indications. CONCLUSIONS: An increased number of transitional cell carcinoma in endemic settlements was observed, markedly decreasing in the last decade. An increasing age and a shorter survival were recorded in patients both from Balkan endemic nephropathy and control settlements. Sporadic cases upper urinary tract transitional cell carcinoma in settlements adjacent to endemic settlements were demonstrated.