Six-Month Results of Selective Bladder Denervation in Women with Refractory Overactive Bladder.

PURPOSE: We report 6-month efficacy and safety outcomes of selective bladder denervation in women with refractory overactive bladder. MATERIALS AND METHODS: Women with refractory overactive bladder and urgency urinary incontinence were enrolled in 2 prospective feasibility studies with the same entry criteria. They underwent selective bladder denervation of the subtrigonal region containing afferent sensory nerves. Patients were followed for 6 months and assessed for adverse events, overactive bladder symptoms and health related quality of life measures. RESULTS: In the 35 women with a mean age of 66 years who were enrolled in the study all selective bladder denervation procedures were completed successfully. During 6 months of followup the symptom improvement based on 3-day bladder diaries was 59% for urgency urinary incontinence (p <0.001), 59% for urinary incontinence (p <0.001), 39% for urgency (p <0.001), 9% for urinary frequency (p = 0.01) and 27% for the total urgency and frequency score (p <0.001). Most of this treatment benefit was realized in the first month. The rate of clinical success, defined as a 50% or greater reduction in urgency urinary incontinence, was 70%, treatment benefit was reported in 75% of patients and the dry/cure rate was 27%. Statistically significant improvements during 6 months were identified on the symptom bother and health related quality of life scales on the OAB-q (Overactive Bladder Questionnaire) and on all KHQ (King's Health Questionnaire) domains except general health perception. Device or procedure related adverse events were reported in 6 patients (17%). CONCLUSIONS: Pooled results of 2 prospective feasibility studies suggest that selective bladder denervation is a promising minimally invasive treatment option in women with refractory overactive bladder.

Excessive vomiting abolished by carotid denervation.

The carotid sinus syndrome (CSS) is characterized by repetitive syncope due to prolonged heart rate slowing or a profound drop in systolic blood pressure. CSS is due to an inappropriate response of a hypersensitive carotid sinus following pressure on or stretching of the neck. We report on a patient with excessive gagging and vomiting elicited by pressure on the right side of the neck as an aberrant presentation of the carotid sinus syndrome. Her incapacitating symptoms were abolished by a surgical carotid denervation.

Spinal cord stimulation is an effective treatment for the chronic intractable visceral pelvic pain.

OBJECTIVE: Recent studies have demonstrated significant involvement of dorsal column pathways in transmission of visceral pelvic pain. Spinal cord stimulation (SCS) suppresses visceral response to colon distension in an animal model and therefore may be an effective therapy for chronic pelvic pain of visceral origin. We are reporting on the value of neurostimulation for chronic visceral pelvic pain in six female patients with the diagnosis of long-standing pelvic pain (history of endometriosis, multiple surgical explorations, and dyspareunia). DESIGN AND SETTINGS: Case-series report. All patients received repeated hypogastric blocks (in an average of 5.3 blocks) with a significant pain relief for a period ranging from 1 to 6 weeks. Three received neurolytic hypogastric block with the pain relief of 3, 8, and 12 months, respectively. Following psychological evaluation and clearance by our Multidisciplinary Committee on Implantable Devices, they all underwent SCS trial for 7-14 days. All patients received SCS systems with dual leads (Compact or Quad leads, Medtronic Inc., Minneapolis, MN, USA). RESULTS: The average follow-up was 30.6 months. Median visual analog scale pain score decreased from 8 to 3. All patients had more than 50% of the pain relief. Pain Disability Index changed from an average of 57.7 +/- 12 to 19.5 +/- 7. Opiate use decreased from an average 22.5 mg to 6.6 mg of morphine sulfate milligram equivalents per day. CONCLUSION: It appears that SCS may have a significant therapeutic potential for treatment of visceral pelvic pain.

Does the cardinal ligament of the uterus contain a nerve that should be preserved in radical hysterectomy?

The cardinal ligament (CL) of the uterus is present as a specific part of the parametrium when the pararectal and paravesical spaces are developed surgically. According to usual nerve-sparing radical hysterectomy (the Tokyo method), the CL is divided into two parts, the vascular part for dissection and the nerve part that contains the pelvic splanchnic nerve (PSN) as a major target for nerve sparing. In contrast, we hypothesized that the CL and another structure outside of the usual area for surgical dissection, that is, the lateral rectal ligament, are mutually continuous and that the PSN runs through the lateral ligament rather than the CL. In the present study, a combination of routine dissection, fresh cadaver dissection and in situ sectional anatomy revealed that: (i) the CL did not contain the PSN; (ii) a well-defined fascial structure existed in the bottom or dorsal margin of the CL area; and (iii) the pelvic plexus was separated from vascular components of the CL. The present results provide a new perspective for nerve-sparing radical hysterectomy with extensive lateral parametrial dissection of the CL.

Effects of selective sinoaortic denervations on phenylephrine-induced activational responses in the nucleus of the solitary tract.

Intravenous administration of phenylephrine provokes a pattern of cellular activation in the nucleus of the solitary tract that resembles the central distributions of primary baroreceptor afferents supplied by the carotid sinus and aortic depressor nerves. Transganglionic transport and denervation methods were used in an experimental setting to test the dependence of phenylephrine-induced Fos immunoreactivity on the integrity of buffer nerve afferents, and to identify the subregions of the nucleus of the solitary tract supplied by each. Cholera toxin B-horseradish peroxidase injections into either or both nerves revealed terminal labeling concentrated in, but not restricted to, the dorsal commissural part of the nucleus of the solitary tract at the level of the apex of calamus scriptorius, and extending into the dorsal subnucleus at the level of the area postrema. Preferential ramifications of carotid sinus and aortic depressor nerve afferents at the levels of the commissural part of the nucleus and the area postrema, respectively, were reflected in the extent to which labeled fibers comingled with neurons exhibiting phenylephrine-induced Fos in dual labeling experiments. Complete sinoaortic denervation reduced by 90% the number of neurons exhibiting drug-induced Fos expression. Selective carotid and aortic sinus denervations effected partial reductions manifest preferentially in the caudal and rostral foci of the distribution, respectively. Reduced activational responses at the level of the area postrema of aortic sinus-denervated rats were accompanied by a reduction in cellular nicotinamide adenine dinucleotide phosphate-diaphorase activity in this region. Animals killed 30 days after complete sinoaortic denervation displayed no evidence of recovery of phenylephrine-induced Fos, while the strength and distribution of the response in rats that received selective carotid sinus denervation were indistinguishable from those seen in controls. These findings (i) support the dependence of phenylephrine-induced Fos expression on the integrity of carotid sinus and aortic depressor nerve afferents, (ii) provide anatomical and functional evidence that the two buffer nerves distribute differentially within the nucleus of the solitary tract, and (iii) implicate central reorganization as a likely basis for functional recovery of baroreflex mechanisms following partial sinoaortic denervation.