In vivo ureteroscopic intrarenal pressures and clinical outcomes: a multi-institutional analysis of 120 consecutive patients.

OBJECTIVES: To evaluate the pressure range generated in the human renal collecting system during ureteroscopy (URS), in a large patient sample, and to investigate a relationship between intrarenal pressure (IRP) and outcome. PATIENTS AND METHODS: A prospective multi-institutional study was conducted, with ethics board approval; February 2022-March 2023. Recruitment was of 120 consecutive consenting adult patients undergoing semi-rigid URS and/or flexible ureterorenoscopy (FURS) for urolithiasis or diagnostic purposes. Retrograde, fluoroscopy-guided insertion of a 0.036-cm (0.014″) pressure guidewire (COMET™ II, Boston Scientific, Marlborough, MA, USA) to the renal pelvis was performed. Baseline and continuous ureteroscopic IRP was recorded, alongside relevant operative variables. A 30-day follow-up was completed. Descriptive statistics were applied to IRP traces, with mean (sd) and maximum values and variance reported. Relationships between IRP and technical variables, and IRP and clinical outcome were interrogated using the chi-square test and independent samples t-test. RESULTS: A total of 430 pressure traces were analysed from 120 patient episodes. The mean (sd) baseline IRP was 16.45 (5.99) mmHg and the intraoperative IRP varied by technique. The mean (sd) IRP during semi-rigid URS with gravity irrigation was 34.93 (11.66) mmHg. FURS resulted in variable IRP values: from a mean (sd) of 26.78 (5.84) mmHg (gravity irrigation; 12/14-F ureteric access sheath [UAS]) to 87.27 (66.85) mmHg (200 mmHg pressurised-bag irrigation; 11/13-F UAS). The highest single pressure peak was 334.2 mmHg, during retrograde pyelography. Six patients (5%) developed postoperative urosepsis; these patients had significantly higher IRPs during FURS (mean [sd] 81.7 [49.52] mmHg) than controls (38.53 [22.6] mmHg; P < 0.001). CONCLUSIONS: A dynamic IRP profile is observed during human in vivo URS, with IRP frequently exceeding expected thresholds. A relationship appears to exist between elevated IRP and postoperative urosepsis.

Upper urinary tract pressures in endourology: a systematic review of range, variables and implications.

OBJECTIVES: To systematically review the literature to ascertain the upper tract pressures generated during endourology, the relevant influencing variables and clinical implications. MATERIALS AND METHODS: A systematic review of the MEDLINE, Scopus and Cochrane databases was performed by two authors independently (S.C., N.D.). Studies reporting ureteric or intrarenal pressures (IRP) during semi-rigid ureteroscopy (URS)/flexible ureterorenoscopy (fURS)/percutaneous nephrolithotomy (PCNL)/miniaturized PCNL (mPCNL) in the period 1950-2021 were identified. Both in vitro and in vivo studies were considered for inclusion. Findings were independently screened for eligibility based on content, with disagreements resolved by author consensus. Data were assessed for bias and compiled based on predefined variables. RESULTS: Fifty-two studies met the inclusion criteria. Mean IRP appeared to frequently exceed a previously proposed threshold of 40 cmH2 O. Semi-rigid URS with low-pressure irrigation (gravity <1 m) resulted in a wide mean IRP range (lowest reported 6.9 cmH2 O, highest mean 149.5 ± 6.2 cmH2 O; animal models). The lowest mean observed with fURS without a ureteric access sheath (UAS) was 47.6 ± 4.1 cmH2 O, with the maximum peak IRP being 557.4 cmH2 O (in vivo human data). UAS placement significantly reduced IRP during fURS, but did not guarantee pressure control with hand-operated pump/syringe irrigation. Miniaturization of PCNL sheaths was associated with increased IRP; however, a wide mean human IRP range has been recorded with both mPCNL (lowest -6.8 ± 2.2 cmH2 O [suction sheath]; highest 41.2 ± 5.3 cmH2 O) and standard PCNL (lowest 6.5 cmH2 O; highest 41.2 cmH2 O). Use of continuous suction in mPCNL results in greater control of mean IRP, although short pressure peaks >40 cmH2 O are not entirely prevented. Definitive conclusions are limited by heterogeneity in study design and results. Postoperative pain and pyrexia may be correlated with increased IRP, however, few in vivo studies correlate clinical outcome with measured IRP. CONCLUSIONS: Intrarenal pressure generated during upper tract endoscopy often exceeds 40 cmH2 O. IRP is multifactorial in origin, with contributory variables discussed. Larger prospective human in vivo studies are required to further our understanding of IRP thresholds and clinical sequelae.

Gleason grade accuracy of transperineal and transrectal prostate biopsies in MRI-naïve patients.

PURPOSE: Accurate assessment of Gleason grade is essential to guiding prostate cancer management. Not all healthcare systems have universal access to prostate MRI. We investigated whether transperineal (TP) prostate biopsies provide more accurate Gleason grading than transrectal (TR) biopsies in MRI-naïve patients. METHODS: Consecutive patients undergoing TP and TR systematic prostate needle biopsies from 2011 to 2018 were analysed. Patients who underwent radical prostatectomy (RP) within 180 days of biopsies were included. Patients undergoing MRI prior to biopsies were excluded. Pathological concordance, incidence of Gleason upgrading, and correlation coefficients among biopsies and RP Gleason grade were compared. A sub-analysis for concordance in anterior prostate tumours was conducted. RESULTS: 262 patients were included (112 TP; 150 TR), the median age was 63 years, and median time from biopsy to RP was 68 days. Concordance with RP histology for TP was 65% compared to 49% for TR (p = 0.011). Biopsy technique predicted RP concordance independent of the number of cores. Gleason upgrading occurred following 24% of TP versus 33% of TR biopsies. In anterior and apical tumours, upgrading occurred in 19% of TP biopsies and 38% of TR biopsies (p = 0.027). CONCLUSION: This study suggests TP approach to prostate biopsies result in improved histological grade accuracy in men whom MRI is not available, even after controlling for number of cores. TP approach also resulted in less upgrading for lesions in the anterior and apical prostate compared to TR.

What is the best way to manage ureteric calculi in the time of COVID-19? A comparison of extracorporeal shockwave lithotripsy (SWL) and ureteroscopy (URS) in an Australian health-care setting.

Objectives: To determine the best way to intervene for ureteric stones which still require treatment during the COVID-19 pandemic, with respect to infection control. In this setting, in which resources are constrained, extracorporeal shockwave lithotripsy (SWL) has prima facie advantages over ureteroscopy (URS). It is also necessary to also consider posttreatment resource consumption in regards to complications and repeat procedures. Subjects and methods: The ideal ureteric stone treatment during a pandemic such as COVID-19 would involve minimum resource consumption and a minimum number of patient attendances. We compared all patients initially treated with SWL to those initially treated with URS for acute ureteral colic within the state of Victoria, Australia in 2017. Results: A total of 2724 ureteric stones were analyzed, a cumulative "3-month exposure and burden on the healthcare system" was calculated for each patient by their initial procedure type. The readmission rate for URS was significantly higher than for SWL, 0.92 readmissions/patient for URS versus 0.54 readmissions/patient for SWL (P < .001). The cumulative hospital stay per patient for these two procedures was 2.35 days for SWL versus 3.21 days for URS (P < .001). The number of procedures per patient was 1.52 for SWL versus 1.89 for URS (P = .0213). Conclusions: Patients with ureteric stones treated initially by SWL have shorter length of stay with fewer overall attendances and procedures at 3 months than those treated with URS. During a pandemic such as COVID-19, SWL may have benefits in preserving hospital resources and limiting opportunity for virus transmission, compared to URS.

Which has more complications?-Shockwave lithotripsy versus endoscopic treatment of renal calculi with 1-year follow-up in an Australian population.

Introduction and objectives: Renal calculi are a common medical problem with incidence rates calculated to be approximately 6%-9% in men & 3%-4% in women worldwide. Incidence appears to be increasing. This study compares emergency presentations and unplanned readmissions between extracorporeal shock wave lithotripsy (SWL) and pyeloscopic stone treatment in the population of Victoria, Australia after 1-year follow-up. Methods: This is a population study comparing all patients with renal calculi electively treated with SWL to those initially treated with flexible ureteroscopy (URS) in Victoria, Australia. We used data linkage across the state of Victoria to follow patients treated with either modality in a 12 months period (with no urological surgery in the prior 12 months). Each patient's emergency presentations and subsequent re-admissions were followed up for 1 year after their index treatment to assess for stone complications. We assessed for selection bias between the two patient groups by comparing age, gender, insurance status, geographical location, and comorbidity scores. Results: We report stone-related complications for 739 flexible URS and 1317 SWL procedures undertaken across public and private hospitals in Victoria over 12 months. Unplanned emergency presentations within 60-days of surgery were (22/739) 2.98% for flexible URS patients and (83/1317) 6.30% for SWL patients (P = .001); however, at 12 months, this became 16.23% (120/739) for flexible URS patients and 12.83% (169/1317) for SWL patients (P = .034). Flexible URS patients were more likely than SWL patients to be admitted with 71.76% of flexible URS versus 53.97% of SWL patients requiring an admission at any given emergency presentation (P ≤ .001) within 12 months. On multivariate analysis, both flexible URS ([OR] 1.67, CI 1.23-2.26, P = .001) and being a public patient ([OR] 3.06, CI 2.24-4.18, P < .001) significantly increased the likelihood that patients required an unplanned re-admission within 12 months. Conclusions: There is work needed to reduce emergency presentations and unplanned re-admissions after both SWL and flexible URS. At 12-months follow-up, unplanned emergency visits and re-admission rates were significantly more after flexible URS. Symptoms at emergency presentation indicate that better education regarding stent management is needed, especially in the public health care system.

Stone clearance times with mini-percutaneous nephrolithotomy: Comparison of a 1.5 mm ballistic/ultrasonic mini-probe vs. laser.

INTRODUCTION: A limitation of mini-percutaneous nephrolithotomy (mPCNL) is the narrow working channel of mini-nephroscopes, typically restricting instrumentation to 5 French (F) or smaller. We evaluated the efficacy of the 1.5 mm Swiss LithoClast ® Trilogy (Trilogy) rigid probe and compared the results to consecutive cases performed with a 30 W Holmium:YAG (Ho:YAG) laser. METHODS: A retrospective review of 30 consecutive mPCNL cases using the Trilogy and 30 W Holmium laser was performed. A 12 F MIPS nephroscope with a 16.5 F access sheath and 6.7 F working channel was used for all mPCNL cases. The Trilogy was used with a disposable 1.5 mm × 440 mm probe with dual ultrasonic and ballistic energy. The Ho:YAG laser was used with a 550 micron fibre and a maximum of 30 W. Stone clearance time (SCT) was defined by the total time interval between activation of the lithotripter until insertion of the nephrostomy tube and measured in mm2/minutes. SCT included time for fragment retrieval, equipment adjustments, and rigid and flexible nephroscopy during and after lithotripsy. RESULTS: Eleven cases using a 1.5 mm Trilogy probe and 16 cases using a Ho:YAG laser met final inclusion criteria. Three cases using the Trilogy were excluded from final analysis due to conversion to alternative energy sources - two of those were upsized to standard PCNL and one was converted to laser. Mean stone diameter and density in the final Trilogy cohort was 26.7 mm and 1193 Hounsfield units (HU). Mean diameter and density in the laser cohort was 25.2 mm and 1049 HU. The mean stone area clearance time for Trilogy was 4.7±1.8 mm2/minute vs. 3.4±0.7 mm2/minute with Ho:YAG laser (p=0.21). For hard stones, defined as density >1000 HU, the Trilogy averaged 3.7±1.6 mm2/minutes, while the laser averaged 3.1±1.3 mm2/minutes (p=0.786). For soft stones, defined as <1000 HU, the Trilogy averaged 8.9±1.0 mm2/minutes compared to the Ho:YAG, which averaged 3.6±1.8mm2/minutes (p=0.019). No device-related complications occurred in either cohort. CONCLUSIONS: The 1.5 mm mPCNL Trilogy probe was comparable to 30 W Ho:YAG laser for clearing hard stones. The Trilogy performed better than laser on soft stones with a HU density <1000 HU.

Pressurized-Bag Irrigation Versus Hand-Operated Irrigation Pumps During Ureteroscopic Laser Lithotripsy: Comparison of Infectious Complications.

Introduction and Objectives: A variety of irrigation systems are available during ureteroscopy. We sought to compare gravity-driven pressure bags with hand-operated irrigation pumps in terms of postoperative complications after ureteroscopy with lithotripsy. Methods: A retrospective analysis of 234 patients undergoing flexible ureteropyeloscopy with laser lithotripsy by 24 supervised trainees over 4 years at a single teaching institution. Patients were divided into those who had procedures performed by using gravity-driven pressure bags fixed at 60 to 204 cm H2O, vs those who had procedures performed by using a hand-operated irrigation pump capable of delivering 1 to 10 mL per flush. Variables including surgical duration, hypotension, fever, sepsis, and hematuria were extracted from the charts, along with the surgical techniques utilized. Statistical analyses included chi-squared tests and Student's t-tests. Results: There were no differences in gender, age, indication, or stone size in the two groups. Postoperative systemic inflammatory response syndrome was significantly greater in the hand-assisted n = 11/144 (7.6%) compared with the fixed irrigation group n = 1/90 (1.1%); p = 0.032. Emergency room presentations were greater in the hand irrigation group, n = 46/144 (32%) vs n = 12/90 (13%) in the pressure-bag irrigation, p = 0.002. Postoperative fever was also greater in the hand pump irrigation cohort compared with the continuous pressure cohort (13/144 [9%] vs 1/90 [1%], p = 0.011). No statistical difference was found between the two groups with respect to stone clearance and subsequent procedures required (p = 0.123). Conclusions: This analysis suggests that using continuous flow irrigation at a fixed maximum pressure of 150 mmHg (204 cm H2O) or less may result in decreased pain, infection, and sepsis compared with handheld pressure irrigation.

Digital and Mechanical Characterization of Ureteral Stent Luminal Reduction in Response to Extrinsic Compression Forces.

PURPOSE: To investigate the principles that govern ureteral stent failure by digitally and mechanically characterizing their luminal reduction in response to various extrinsic compression forces. To explore the relationship between ureteral stent "material area," "luminal area," and "cross-sectional area (CSA)" for resisting extrinsic compression forces. MATERIALS AND METHODS: We mechanically investigated 4.8F (n = 9), 6F (n = 9), and 7F (n = 9) ureteral stents to determine parameters that contribute to resisting radial compression forces. Digitalized images of luminal reduction values under incrementally increased reductions of stent outer diameters were obtained (0%, 25%, 50%, and 60% of original outer diameter). Forces (Newton [N]) and percentage luminal reduction that resulted in complete ureteral stent obstruction were determined. RESULTS: Uniaxial incremental compression in the radial direction demonstrated complete luminal reduction (95%-100%) when 58% to 62% of the outer stent diameter was compressed. The 6F ureteral stents demonstrated the greatest resistance to extrinsic compression and the greatest "material area" relative to "CSA" (mm2). The force (N) required for 50% compression of outer stent diameter was 10.44, 28.13, and 25.39 N for 4.8F, 6F, and 7F ureteral stents, respectively. The "material area"/"CSA" at 50% compression of the outer stent diameter was 76%, 86%, and 78% for 4.8F, 6F, and 7F ureteral stents, respectively. CONCLUSIONS: Maintenance of intraluminal stent diameter in the presence of extrinsic compressive forces is primarily dependent on the stent's ratio of "material area" to "CSA." Urologists should be aware of these findings to decrease the risk of ureteral stent failure when treating extrinsic ureteral obstruction.

The Role of Stem Cells for Reconstructing the Lower Urinary Tracts.

BACKGROUND: The urinary bladder and urethra comprise the lower urinary tracts. Pathological conditions that affect both structures necessitate reconstructive urological intervention with autologous tissue sources that cause neuromechanical and metabolic complications. Stem-cell therapies may offer an attractive alternative as they can replicate important host derived cellular functions such as mitosis, proliferation, differentiation and apoptosis. OBJECTIVE: To provide an overview on the application of stem cell therapies for regenerating the lower urinary tracts and to discuss factors that need to be addressed before stem-cells can be reliably introduced into clinical urological practice. RESULTS: Advantages of stem cells in reconstructive urology are their ability to self-renew and their durability. Mesenchymal stem cells (MSCs), embryonic stem cells (ESCs) and adult stem cells (ASCs) demonstrate excellent urological regenerative properties. Repairing defective lower urinary tract structures with various stem-cell derived therapies has been widely reported with encouraging results in vitro and in pre-clinical in vivo trials. Ethical considerations, cost, regulation, manufacturing and reimbursement need to be fully transparent before stem-cells are routinely applied to urological patients. International collaboration with consensus guidelines should be considered to facilitate standards that allow safe use of stem-cell therapies in urology. CONCLUSION: Stem cells therapies in urology are developing rapidly with many important achievements to date. Despite promising in vitro and pre-clinical data; implementation of stem cells into daily urological practice is not imminent. Further investigation is required to determine whether stem-cells will provide better clinical outcomes than current urological tissue replacement strategies.

Fragmentation of transrectal ultrasound-guided biopsy cores is influenced by the method of specimen retrieval.

OBJECTIVE: To determine whether the method of specimen preparation after transrectal ultrasound-guided biopsy of the prostate affected core fragmentation, and secondly to determine whether such fragmentation was influenced by the presence of malignancy in the biopsy specimen. METHODS: A prospective randomized study comparing 2 different mechanisms of specimen preparation, wash vs swipe of biopsy cores, with blinded assessment by a specific uropathologist was undertaken. RESULTS: For those cores in which prostate cancer was present, the wash method of specimen preparation resulted in fewer and longer core fragments (P = .005). Those patients in whom cancer was present on biopsy also had a greater degree of biopsy core fragmentation in those cores in which only benign tissue was identified (P = .017). Gleason score did not appear to influence the extent of fragmentation. CONCLUSION: The method of specimen preparation at prostate biopsy influences the degree of fragmentation seen at histologic evaluation. This has the potential to affect the interpretation of biopsy results, including suitability of patients for inclusion in active surveillance protocols. Core fragmentation might be minimized by modification of technique.

Integration of laparoscopic partial nephrectomy into an Australian public hospital: three-year follow-up of our initial 50 cases.

OBJECTIVE: To examine the early outcomes and complications of integrating laparoscopic partial nephrectomy (LPN) into a public teaching hospital in Australia. PATIENTS AND METHODS: An outcomes review from prospectively collected data on our initial 50 cases of LPN. The median follow-up was 36 months with a minimum follow-up of 2 years and a maximum of 5 years. RESULTS: The mean patient age was 60 years, mean tumour size was 2.9 cm, and mean baseline creatinine concentration was 79 µmol/L. One patient had a solitary kidney, and one patient had bilateral tumours. The mean operative duration was 168 min, with a mean warm ischaemia time of 25 min. The median blood loss was 100 mL and the median (range) hospital stay was 4 (2-12) days. The complication rate was 6%, including two instances of secondary haemorrhage, and one port-site hernia. No patient required conversion to radical nephrectomy or experienced clinically significant deterioration in their renal function. There have been no local or systemic recurrences to date, with a maximum follow-up of 5 years. CONCLUSIONS: LPN can be successfully integrated into the Australian public health care sector as standard of care for stage 1 renal masses requiring treatment. Due to the inherent risk of bleeding early in the learning curve, cases should be performed in the setting of adequate surgical and interventional radiographic support.

Nuclear fusion-independent smooth muscle differentiation of human adipose-derived stem cells induced by a smooth muscle environment.

Human adipose-derived stem cells hASC have been isolated and were shown to have multilineage differentiation capacity. Although both plasticity and cell fusion have been suggested as mechanisms for cell differentiation in vivo, the effect of the local in vivo environment on the differentiation of adipose-derived stem cells has not been evaluated. We previously reported the in vitro capacity of smooth muscle differentiation of these cells. In this study, we evaluate the effect of an in vivo smooth muscle environment in the differentiation of hASC. We studied this by two experimental designs: (a) in vivo evaluation of smooth muscle differentiation of hASC injected into a smooth muscle environment and (b) in vitro evaluation of smooth muscle differentiation capacity of hASC exposed to bladder smooth muscle cells. Our results indicate a time-dependent differentiation of hASC into mature smooth muscle cells when these cells are injected into the smooth musculature of the urinary bladder. Similar findings were seen when the cells were cocultured in vitro with primary bladder smooth muscle cells. Chromosomal analysis demonstrated that microenvironment cues rather than nuclear fusion are responsible for this differentiation. We conclude that cell plasticity is present in hASCs, and their differentiation is accomplished in the absence of nuclear fusion.

Prevention and management of TURP-related hemorrhage.

Transurethral resection of the prostate (TURP) is the most common surgical treatment for benign prostatic hyperplasia (BPH) worldwide, but despite its minimally invasive nature, perioperative bleeding remains a common morbidity. Anticoagulant and antiplatelet medications are increasingly common in this patient population and further contribute to the risk of bleeding and extended hospital stay. Preoperative cessation of anticoagulant and antiplatelet drugs is recommended but requires risk assessment of thrombotic complications. Pharmacologic maneuvers to reduce hemorrhage include perioperative administration of 5α-reductase inhibitors. Technical considerations include the use of hemostatic energy sources such as laser and bipolar technologies. Ultimately, no surgical technique is devoid of bleeding risks, and urologists should be aware of how best to prevent and treat TURP-related hemorrhage.

Placenta percreta with urinary tract involvement: the case for a multidisciplinary approach.

OBJECTIVES: To reduce the complications associated with placenta percreta (PP) by adequate preoperative planning with a multidisciplinary team. PP is a rare and potentially morbid condition of pregnancy, particularly if the urinary tract is involved. Cesarean delivery and hysterectomy are typically required to reduce the pelvic hemorrhage, placing the urinary tract at risk. METHODS: We reviewed our urologic consultations and experience with PP in the past year. Maternal factors, surgical timing, blood loss, surgical complications, and outcomes were recorded. The timing of the urologic assessment was divided into preoperative and perioperative. RESULTS: Five cases of PP were available. Of the 5 cases, 4 had been successfully diagnosed by prenatal ultrasonography, with 2 also requiring magnetic resonance imaging. All patients underwent cesarean delivery and hysterectomy, with significant blood loss (median 12 U transfused). A preoperative urologic assessment was done in 2 of the 5 patients, with no urinary complications found in this group. Both patients had undergone cystoscopy with placement of temporary ureteral catheters, even though the cases were emergent. In contrast, 3 patients underwent urologic consultation during or immediately after surgery. All 3 had bladder injuries, with 1 ureteral injury and delayed convalescence in this group of patients. CONCLUSIONS: PP remains a technically challenging and high-risk obstetric condition. In the setting of urinary tract involvement, adequate imaging, surgical planning, and preoperative urologic assessment with placement of temporary ureteral catheters were associated with a lower incidence of urologic complications in our series. Adequate preoperative planning with a multidisciplinary team is recommended to reduce the complications associated with PP.

Urinary bladder smooth muscle engineered from adipose stem cells and a three dimensional synthetic composite.

Human adipose stem cells were cultured in smooth muscle inductive media and seeded into synthetic bladder composites to tissue engineer bladder smooth muscle. 85:15 Poly-lactic-glycolic acid bladder dome composites were cast using an electropulled microfiber luminal surface combined with an outer porous sponge. Cell-seeded bladders expressed smooth muscle actin, myosin heavy chain, calponinin, and caldesmon via RT-PCR and immunoflourescence. Nude rats (n=45) underwent removal of half their bladder and repair using: (i) augmentation with the adipose stem cell-seeded composites, (ii) augmentation with a matched acellular composite, or (iii) suture closure. Animals were followed for 12 weeks post-implantation and bladders were explanted serially. Results showed that bladder capacity and compliance were maintained in the cell-seeded group throughout the 12 weeks, but deteriorated in the acellular scaffold group sequentially with time. Control animals repaired with sutures regained their baseline bladder capacities by week 12, demonstrating a long-term limitation of this model. Histological analysis of explanted materials demonstrated viable adipose stem cells and increasing smooth muscle mass in the cell-seeded scaffolds with time. Tissue bath stimulation demonstrated smooth muscle contraction of the seeded implants but not the acellular implants after 12 weeks in vivo. Our study demonstrates the feasibility and short term physical properties of bladder tissue engineered from adipose stem cells.

Familial transmission of genitovaginal prolapse.

Some females with little to no risk factors develop prolapse, while other females with multiple risk factors do not. It appears that some women may have a predisposition for prolapse in the setting of equivalent risk factors. We identified 10 patients younger than 55 years old with a family history of prolapse. Their average age was 37 years (range 27-51), the mean number of deliveries was 1.8, and their mean birth weight was 8 lbs. Genetic analysis of the inheritance pattern within these families demonstrated that pelvic organ prolapse segregated in a dominant fashion with incomplete penetrance in these families. Both maternal and paternal transmissions were observed. The relative risk to siblings of affected patients was five times that of the risk for the general population. Further investigation of these families may identify a genetic defect responsible for prolapse.

Processed lipoaspirate cells for tissue engineering of the lower urinary tract: implications for the treatment of stress urinary incontinence and bladder reconstruction.

PURPOSE: We performed a pilot study to investigate the ability of human adipose derived, multipotent stem cells to be delivered to and survive within bladder and urethral smooth muscle. MATERIALS AND METHODS: Lipoaspirate was acquired from female patients undergoing liposuction. The lipoaspirate was processed to yield a pluripotent population of processed lipoaspirate (PLA) cells. For tissue delivery PLA cells were fluorescent labeled and suspended in Hanks' balanced salt solution (Sigma Chemical Co., St. Louis, Missouri). To assess PLA viability in multiple animal models 8 Rnu athymic rats (Charles River, Wilmington, Massachusetts) and 6 SCID mice (Taconic Farms, Oxnard, California) underwent laparotomy and injection of PLA cells into the bladder and urethra. An additional 8 rats underwent sham injection of Hanks' balanced salt solution alone. Experimental and control animals were sacrificed 2, 4, 8 and 12 weeks after injection, and the bladders and urethras were analyzed. RESULTS: Self-regenerating, pluripotent PLA cells were easily isolated from human adipose tissue. Evaluation 2, 4, 8 and 12 weeks after injection demonstrated PLA cell viability and incorporation into the recipient smooth muscle. Eight weeks following injection PLA cells demonstrated in vivo expression of alpha-smooth muscle actin, an early marker of smooth muscle differentiation. CONCLUSIONS: PLA cells are an easily accessible source of pluripotent cells, making them ideal for tissue regeneration. PLA cells remain viable up to 12 weeks in the lower urinary tract. Human PLA cells injected into the urinary tract show morphological and phenotypic evidence of smooth muscle incorporation and differentiation with time. PLA cells may provide a feasible and cost-effective cell source for urinary tract reconstruction.

Conservative management options for Peyronie's disease.

Peyronie's disease is an acquired condition that presents clinically with a palpable induration, a distinct plaque, or a curvature of the erect penis. At times, the erections are painful. Erectile dysfunction (ED) often is associated with Peyronie's disease. The current era of phosphodiesterase therapy for the treatment of ED seems to have increased the number of patients presenting for treatment of Peyronie's disease. During the past decade, significant advances have been made in understanding the pathophysiology of the disease, resulting in numerous nonsurgical therapies proposed for the treatment of Peyronie's disease. These medical treatments can be administered systemically, locally, or intralesionally. Unfortunately, there are few randomized, placebo-controlled trials to evaluate most of these proposed therapies. In evaluating therapies for Peyronie's disease, it must be remembered that the natural disease history includes spontaneous resolution of pain and even a small improvement in penile curvature in some men. This article reviews the natural history, scientific understanding, and nonsurgical treatment options for the mild to moderate Peyronie's deformities. Surgical therapy remains the mainstay of treatment for severe and refractory cases of Peyronie's disease that result in a physical or psychologic dysfunction.

New objective measures to quantify stress urinary incontinence in a novel durable animal model of intrinsic sphincter deficiency.

Existing animal models of stress urinary incontinence (SUI) are limited because of the low rate of incontinence seen in the animals and to their relatively low durability. In addition, most methods described to measure incontinence are operator-dependent. The aim of this study was to develop a new durable animal model of SUI and establish objective measures to quantify SUI. We subjected female rats to transabdominal urethrolysis. At baseline and at 1, 4, 8, 12, and 24 wk after intervention, animals underwent cystometry and evaluation with abdominal leak point pressure (ALPP). Urethral resistance was evaluated by retrograde urethral perfusion pressure (RUPP). Tissues were obtained for histology and immunohistochemistry. Normal female rats had an average ALPP of 19.4 cmH2O and RUPP of 22.6 cmH2O at baseline. More than 93% of the animals had significantly decreased ALPP and RUPP after the procedure. The mean ALPP and RUPP decreased to 9.8 cmH2O and 11.2 cmH2O, respectively, by 1 wk after urethrolysis. These changes were maintained for up to 24 wk. Changes seen in urethral resistance and ALPP appear to be mediated by apoptosis, decreased neuronal mass, and smooth muscle atrophy. These results indicate that transabdominal urethrolysis is a reliable method of achieving durable decreased urethral resistance in a SUI model. RUPP and ALPP are objective and reproducible methods of assessing urethral resistance. Changes in continence and urethral resistance appear to be mediated by denervation and smooth muscle atrophy, which are seen in both elderly incontinent patients and in patients with intrinsic sphincter dysfunction.

Current treatment options for penile fractures.

The diagnosis of "penile fracture" describes the traumatic rupture of the tunica albuginea of an erect penis. Penile fractures typically occur when the engorged penile corpora are forced to buckle and literally "pop" under the pressure of a blunt sexual trauma. Patients typically describe immediate detumescence, severe pain, and swelling as a result of the injury. Prompt surgical exploration and corporal repair is the most efficacious therapy. Although a majority of cases can be diagnosed from the history and physical examination alone, radiographic studies, including retrograde urethrography and corporal cavernosography can aid in the diagnosis of unusual cases.