What are the supportive structures of the female urethra?

Association Between Urinary Stress Incontinence and Levator Avulsion Detected by 3D Transperineal Ultrasound

PURPOSE

 To determine the association between levator avulsion and urinary stress incontinence (USI) by 3/4D transperineal ultrasound.

MATERIALS AND METHODS

 842 patients who were admitted to our hospital from 2016 to 2019 were recruited for our study. 3D/4D transperineal ultrasound was performed. After standard interview and clinical evaluation, general conditions and levator hiatus data were collected and measured to compare with each group. The odds ratio (OR) of USI symptoms or ultrasound features with levator avulsion were calculated.

RESULTS

 A total of 593 women were studied: 204 suffered from levator avulsion (96 cases of left-side avulsion, 80 cases of right-side avulsion and 28 cases of bilateral avulsion) and 389 women had no avulsion. The gravidity and episiotomy conditions of the avulsion groups were significantly different from the no-avulsion group. Significant differences were found in the transverse diameters and anteroposterior diameters between the levator avulsion group and the no-avulsion group, but there was no difference among the avulsion groups, regardless of whether the patient was at rest or performing the Valsalva maneuver. Interestingly, a significant difference was found in the presence of USI symptoms between the uni-avulsion group and the no-avulsion group. The odds ratio (OR) of USI symptoms in the uni-avulsion group is 2.786 (95 %CI, 1.663-4.669), but 0.939 (95 %CI, 0.276-3.199) for the bilateral avulsion and no-avulsion groups.

CONCLUSION

 Unilateral levator avulsion may be a risk factor for urinary stress incontinence.

Vaginal delivery effects on 3D morphology of the bladder, urethra, and vagina: a pilot study comparing women with different numbers of deliveries

PURPOSE

To explore 3D morphological changes of the bladder, urethra, and vagina following different numbers of vaginal deliveries.

METHODS

Sampled patients had undergone magnetic resonance imaging for gynecological diseases in Nanfang Hospital. A total of 167 patients who met the study inclusion and exclusion criteria were enrolled and divided into four groups. Mimics and UG software packages were used for reconstructions and measurements, and data were compared with one-way analyses of variance.

RESULTS

A total of 167 3D models were constructed, and eight parameters related to the bladder and urethra were measured (5 angles, 2 lengths, and 1 thickness). No statistically significant differences were found between subgroups, although mean plot figures of urethra pubic and α angles showed trends to increase with more deliveries, and the opposite trend was seen for the urethra tilt angle. There were no obvious trends between other parameters and delivery number. There were seven vaginal parameters (6 lengths and 1 shape). Mid-urethral and vaginal gap measurements tended to become wider as delivery number increased, and the opposite was seen for the distal gap. Mid-vaginal 2D cross-sectional shape and the proportion of shallow concave types also tended to significantly increase with more deliveries, especially after the third birth.

CONCLUSION

As the number of deliveries through the vagina increases, the lateral support function of this organ and the urethra become relatively weaker. These fine anatomical changes are related to delivery numbers and become most obvious after the third birth.

The Female Pelvic Floor Fascia Anatomy: A Systematic Search and Review

The female pelvis is a complex anatomical region comprising the pelvic organs, muscles, neurovascular supplies, and fasciae. The anatomy of the pelvic floor and its fascial components are currently poorly described and misunderstood. This systematic search and review aimed to explore and summarize the current state of knowledge on the fascial anatomy of the pelvic floor in women. Methods: A systematic search was performed using Medline and Scopus databases. A synthesis of the findings with a critical appraisal was subsequently carried out. The risk of bias was assessed with the Anatomical Quality Assurance Tool. Results: A total of 39 articles, involving 1192 women, were included in the review. Although the perineal membrane, tendinous arch of pelvic fascia, pubourethral ligaments, rectovaginal fascia, and perineal body were the most frequently described structures, uncertainties were identified in micro- and macro-anatomy. The risk of bias was scored as low in 16 studies (41%), unclear in 3 studies (8%), and high in 20 studies (51%). Conclusions: This review provides the best available evidence on the female anatomy of the pelvic floor fasciae. Future studies should be conducted to clarify the discrepancies highlighted and accurately describe the pelvic floor fasciae.

Urethral and bladder development during the 2nd gestational trimester applied to the urinary continence mechanism: translational study in human female fetuses with neural tube defects

INTRODUCTION AND HYPOTHESIS

We hypothesized that anencephaly impacts female lower urinary tract development during the human fetal period. The aim of the present study is to compare the biometric parameters of the bladder and urethra in female human fetuses with and without neural tube defects.

METHODS

We studied 34 female fetuses (22 normal and 12 anencephalic), aged 12 to 22 weeks post-conception (WPC). After pelvic dissection and individualization of the urinary tract structures, we evaluated the bladder and urethra length and width using Image J software. Means were statistically compared using the Wilcoxon-Mann-Whitney test, and linear regression was performed.

RESULTS

We identified statistical significance between the groups regarding bladder length [normal: 6.58-19.98 mm (mean = 12.13 ± 3.21 SD) vs. anencephalic: 4.59-15.27 mm (mean = 8.79 ± 3.31 SD, p = 0.0048] and urethral length [normal: 2.22-7.04 mm (mean = 4.24 ± 1.45 SD) vs. anencephalic: 0.81-6.36 mm (mean = 3.25 ± 1.71 SD, p = 0.05]. We did not observe significant differences in bladder and urethra width between the two groups. The linear regression analysis indicated that the bladder length in anencephalic fetuses increased faster than in normal fetuses.

CONCLUSIONS

We observed significant differences in the development of the bladder and urethra in fetuses with anencephaly during the fetal period studied, proving that anencephaly can affect the development of the female fetal lower urinary tract.

Development of an ultrathin sheet plastination technique in rat humeral joints with osteoarthritis induced by monosodium iodoacetate for neovascularization study

Injection with monosodium iodoacetate (MIA) is widely used to produce osteoarthritis (OA). Ultrathin sheet plastination has been used to study the morphology of structures, with strong application in anatomical education and research. Our aim was to carry out, for the first time, ultrathin sheet plastination of rat humeral joints to observe the neovascularization provoked by OA. We injected 0.1 mL of MIA into the left humeral joints of ten Sprague-Dawley rats. The right shoulders of the same rats were used as control. Sixteen weeks after the injection, the animals were euthanized and were given an immediate red epoxy resin injection through the thoracic aorta. The samples were fixed in 10% formalin, prior to the plastination process, without decalcification. Samples were dehydrated with acetone (100%) at - 25 °C, for 10 days. Later, for degreasing, samples were immersed in methylene chloride at room temperature during 1 week. Forced impregnation was performed inside a stove within a vacuum chamber. The plastinated blocks obtained were cut with a slow velocity diamond blade saw. Slices were placed in curing chambers to achieve curing and final tissue transparentation. 230 μm thickness slices were obtained. The slices were analyzed under magnifying glass and microscope, achieving visualization of OA neovascularization. The cartilage affected by OA loses its ability to remain avascular, and blood vessels invade it from the subchondral bone to the calcified and uncalcified cartilage. Ultra-thin sheet plastination is useful to observe articular cartilage neovascularization, caused by OA induced with MIA in humeral rat joint.

Detailed muscular structure and neural control anatomy of the levator ani muscle: a study based on female human fetuses

BACKGROUND

Injury to the levator ani muscle or pelvic nerves during pregnancy and vaginal delivery is responsible for pelvic floor dysfunction.

OBJECTIVE

We sought to demonstrate the presence of smooth muscular cell areas within the levator ani muscle and describe their localization and innervation.

STUDY DESIGN

Five female human fetuses were studied after approval from the French Biomedicine Agency. Specimens were serially sectioned and stained by Masson trichrome and immunostained for striated and smooth muscle, as well as for somatic, adrenergic, cholinergic, and nitriergic nerve fibers. Slides were digitized for 3-dimensional reconstruction. One fetus was reserved for electron microscopy. We explored the structure and innervation of the levator ani muscle.

RESULTS

Smooth muscular cell beams were connected externally to the anococcygeal raphe and the levator ani muscle and with the longitudinal anal muscle sphincter. The caudalmost part of the pubovaginal muscle was found to bulge between the rectum and the vagina. This bulging was a smooth muscular interface between the levator ani muscle and the longitudinal anal muscle sphincter. The medial (visceral) part of the levator ani muscle contained smooth muscle cells, in relation to the autonomic nerve fibers of the inferior hypogastric plexus. The lateral (parietal) part of the levator ani muscle contained striated muscle cells only and was innervated by the somatic nerve fibers of levator ani and pudendal nerves. The presence of smooth muscle cells within the medial part of the levator ani muscle was confirmed under electron microscopy in 1 fetus.

CONCLUSION

We characterized the muscular structure and neural control of the levator ani muscle. The muscle consists of a medial part containing smooth muscle cells under autonomic nerve influence and a lateral part containing striated muscle cells under somatic nerve control. These findings could result in new postpartum rehabilitation techniques.

Architectural differences in the anterior and middle compartments of the pelvic floor of young-adult and postmenopausal females

The pelvic floor guards the passage of the pelvic organs to the exterior. The near-epidemic prevalence of incontinence in women continues to generate interest in the functional anatomy of the pelvic floor. However, due to its complex architecture and poor accessibility, the classical 'dissectional' approach has been unable to come up with a satisfactory description, so that many aspects of its anatomy continue to raise debate. For this reason, we opted for a 'sectional' approach, using the Chinese Visible Human project (four females, 21-35 years) and the Visible Human Project (USA; one female, 59 years) datasets to investigate age-related changes in the architecture of the anterior and middle compartments of the pelvic floor. The puborectal component of the levator ani muscle defined the levator hiatus boundary. The urethral sphincter complex consisted of a circular proximal portion (urethral sphincter proper), a sling that passed on the vaginal wall laterally to attach to the puborectal muscle (urethral compressor), and a circular portion that surrounded the distal urethra and vagina (urethrovaginal sphincter). The exclusive attachment of the urethral sphincter to soft tissues implies dependence on pelvic-floor integrity for optimal function. The vagina was circular at the introitus and gradually flattened between bladder and rectum. Well-developed fibrous tissue connected the inferior vaginal wall with urethra, rectum and pelvic floor. With eight-muscle insertions, the perineal body was a strong, irregular fibrous node that guarded the levator hiatus. Only loose areolar tissue comprising a remarkably well developed venous plexus connecting the middle and superior parts of the vagina with the lateral pelvic wall. The posterolateral boundary of the putative cardinal and sacrouterine ligaments coincided with the adventitia surrounding the mesorectum. The major difference between the young-adult and postmenopausal pelvic floor was the expansion of fat in between the components of the pelvic floor. We hypothesize that accumulation of pelvic fat compromises pelvic-floor cohesion, because the pre-pubertal pelvis contains very little fibrous and adipose tissue, and fat is an excellent lubricant.

Successful induction of stress urinary incontinence in mice by vaginal distension does not depend on the estrous cycle

OBJECTIVE

To determine if the performance of vaginal distension (VD) in different estrous cycle phases affects the successful induction of stress urinary incontinence in mice.

METHODS

Female virgin C57BL/6 mice were distributed into 4 groups according to their estrous cycle phase: proestrus, estrus, metestrus, or diestrus. The estrous cycle was staged by examining vaginal smears, and the method was corroborated by histologic examination of the vagina in a subset of each group. Each group was divided into 4 subgroups for measurement of 24-hour micturition behavior and the leak point pressure (LPP) 4 or 20 days after VD or sham VD.

RESULTS

Voiding events increased and mean void volume decreased 4 days, but not 20 days after VD, and the LPP was decreased 4 days, but not 20 days after VD compared with the corresponding sham group, regardless of the estrous cycle phase when VD was performed. There were no differences in 24-hour micturition behavior or LPP among the 4 different estrous cycle phases either in sham or VD group.

CONCLUSION

Successful induction of reversible stress urinary incontinence in mice is not dependent on the estrous cycle.

Oblique sectional planes of block plastinates eased by Sac Plastination

To find an oblique cutting plane of a plastinate, e.g. to cut gamma-nails in the femur, the Block Plastination technique was modified. After CT and MRI examination, the specimens were plastinated with the standard resin mixture E6/E12/E600. Instead of using a box to form a block during the casting and curing stage, we embedded the specimen in a sac made of polyester foil. A polymerized wooden block was attached to the specimen. The sac was wrapped with tape to the embedded specimen with the block. This approach limited the amount of required resin to the inner volume of the plastinate. Then, the plastination sac was put in the incubator for further polymerization and curing. When the foil was removed from the plastinated specimen, the wooden block served as a socket for the grip when sawing. The outer shape of the specimen remained visible. Doing so, the adequate cutting plane could be determined easily.

Identification of protein marker in vaginal wall tissues of women with stress urinary incontinence by protein chip array

AIM

We sought to investigate protein biomarkers for stress urinary incontinence (SUI) in vaginal tissues using surface-enhanced laser desorption/ionization time-of-flight mass spectrometry (SELDI-TOF MS) and examine if this is a reliable methodology to examine proteins in small tissue specimens.

MATERIAL AND METHODS

  We compared protein expression profile of vaginal tissue from women with SUI and continent controls. A 22.6kDa peak was identified by subsequent weak cation-exchange, reverse-phase fractionation, gel electrophoresis, and trypsin digestion, then analyzed by matrix assisted laser desorption/ionization mass spectrometry (MALDI MS) and MALDI MS-MS. Biomarker identity and expression level were confirmed by Western-blotting and immunohistochemistry.

RESULTS

Expression of the 22.6kDa protein, identified as SM-22α, was significantly higher in women with SUI versus controls. A 3×3-mm tissue sample was sufficient for identification. Western-blot/immunohistochemistry confirmed the SELDI-TOS MS findings.

CONCLUSION

SM-22α, a marker for myofibroblasts, was identified as a biomarker of SUI. Differential protein profiling by SELDI-TOF MS is a powerful and reliable tool for urogynecological research as it allows us to study an array of proteins simultaneously using small tissue samples.

Accuracy of concepts in female pelvic floor anatomy: facts and myths!

The pelvic floor is characterized by a complex morphology because different functional systems join here. Since a clear understanding of the pelvic floor region is crucial for female pelvic surgery and fundamental mechanisms of urogenital dysfunction and treatment, we here describe the accurate and functional anatomy of important pelvic structures and landmarks, clarify their terminology and point out possible errors or misunderstandings as to their existence.

Expression of apoptotic factors in vaginal tissues from women with urogenital prolapse

AIMS

Increased apoptotic activity in pelvic tissues may contribute to development of pelvic floor disorders. We evaluated expression of apoptotic factors (Bcl-2 family) in vaginal tissues from women with pelvic organ prolapse (POP) and how these factors correlate with severity of prolapse.

METHODS

mRNA and protein expression of anti-apoptotic and pro-apoptotic factors in vaginal tissues from subjects and controls were determined by real-time PCR and Western blot. Severity of prolapse was staged using POP-Q criteria.

RESULTS

Differential expression of Bcl-2 family factors was observed in protein rather than in gene expression. During the secretory phase, the anti-apoptotic (Bcl-2, Bcl-xl) and pro-apoptotic protein (Bax) were upregulated in controls compared to cases (P < 0.05). The ratios of Bcl-2/Bax and Bcl-2/Bad, which determine cellular sensitivity to induction of apoptosis, were higher in controls versus cases. Higher ratios indicate reduced cellular sensitivity to apoptosis. Protein expression of Bax and Bad was higher in women with severe compared to mild prolapse (P < 0.05).

CONCLUSION

Increased expression of Bad, Bax, and decreased ratios of Bcl-2/Bax, Bcl-2/Bad suggest increased apoptotic activity or sensitivity to induction of apoptosis in vaginal tissues of women with POP.

Anatomy and histology of the lower urinary tract

The function of the lower urinary tract is basically storage of urine in the bladder and the at-will periodic evacuation of the stored urine. Urinary incontinence is one of the most common lower urinary tract disorders in adults, but especially in the elderly female. The urethra, its sphincters, and the pelvic floor are key structures in the achievement of continence, but their basic anatomy is little known and, to some extent, still incompletely understood. Because questions with respect to continence arise from human morbidity, but are often investigated in rodent animal models, we present findings in human and rodent anatomy and histology. Differences between males and females in the role that the pelvic floor plays in the maintenance of continence are described. Furthermore, we briefly describe the embryologic origin of ureters, bladder, and urethra, because the developmental origin of structures such as the vesicoureteral junction, the bladder trigone, and the penile urethra are often invoked to explain (clinical) observations. As the human pelvic floor has acquired features in evolution that are typical for a species with bipedal movement, we also compare the pelvic floor of humans with that of rodents to better understand the rodent (or any other quadruped, for that matter) as an experimental model species. The general conclusion is that the "Bauplan" is well conserved, even though its common features are sometimes difficult to discern.

A questionnaire on pelvic floor dysfunction postpartum

Introduction and hypothesis

The incidence of obstetric anal sphincter injuries is used in Sweden as a measurement of quality of care and this might influence the reporting. However, the correlation between reported diagnosis of pelvic floor injury at delivery and pelvic floor symptoms a year later is unknown. A questionnaire could identify such symptoms and provide beneficial feedback to obstetrical practices.

Methods

We made a cross-sectional study by sending out a questionnaire about pelvic floor dysfunction to 599 women depending on reported injury at delivery. The answers provided by the groups were then compared.

Results

The questionnaire identified women with pelvic floor dysfunction. Anal incontinence was most common among women with obstetric anal sphincter injuries but also occurred among women delivered vaginally without known tears.

Conclusion

We suggest that a questionnaire is used 12–18 months after delivery to establish the short-time outcome in terms of pelvic floor dysfunction.

Pelvic fracture with complete urethrovaginal complex avulsion

BACKGROUND

The anatomic support of the urethra is controversial. We present a case of an intact urethra and vagina avulsing from the symphysis pubis after pelvic fracture.

CASE

An 18-year-old female pedestrian was struck by a motor vehicle. Operative reevaluation revealed an intact vagina and urethra; however, they were avulsed from the symphysis pubis. The avulsed urethra and vagina were reapproximated to the periosteum and surrounding soft tissue circumferentially with no urogenital sequelae.

CONCLUSION

Complete anterior vaginal wall avulsion may occur with sparing of the lower urinary tract in the setting of pelvic fracture. This case supports the current anatomic understanding of a strong and dense attachment between the urethra and the anterior vaginal wall.

The relationship between urethral mobility and parity

OBJECTIVE

Urethral mobility is associated with stress urinary incontinence (SUI) and urodynamic stress incontinence, and this is particularly true for mid-urethral mobility. The purpose of this study was to determine whether there is a significant relationship between segmental urethral mobility and vaginal parity in women undergoing urodynamic testing for prolapse or lower urinary tract symptoms.

DESIGN

Retrospective study. SETTING Tertiary referral service for multichannel urodynamic testing.

POPULATION

Women undergoing urodynamic testing for lower urinary tract symptoms or pelvic organ prolapse.

METHODS

The stored 3D translabial ultrasound volume data sets of 648 women were assessed. Measurements were performed using post-processing software in volumes obtained at rest and on maximal Valsalva manoeuvre. Analysis was based on a co-ordinate system using the dorsocaudal margin of the pubic symphysis. The urethral length was traced and divided into five equal segments. Mobility vectors are determined by the formula radical[(y(V) - y(R))(2) + (x(V) - x(R))(2)], where V indicates Valsalva and R indicates rest, with 'x' as the vertical distance and 'y' as the horizontal distance from the dorsocaudal margin of the pubic symphysis.

MAIN OUTCOME MEASURES

Mobility vector lengths.

RESULTS

The distal urethra is consistently the least mobile part of the organ, regardless of parity. Vaginal childbirth seems to increase urethral mobility by about 20% for all urethral segments (all P < or = 0.009). The first vaginal delivery showed the greatest effect, particularly on mid-urethral mobility.

CONCLUSIONS

There is a significant association between urethral mobility and vaginal delivery in women seen for symptoms of pelvic floor dysfunction, affecting all segments of the urethra equally. Most of this effect seems to result from the first vaginal birth.

In search of clinical truths: equine and comparative studies of anatomy

The importance of correlating anatomical studies with diagnostic and therapeutic approaches in practice has long been recognised. Such studies in the horse have, until recently, lagged behind this discipline in human medicine and surgery. Clinical techniques by which this correlation is achieved include radiography, ultrasound, computed tomography and magnetic resonance imaging. This review presents published literature on the subject and, in addition, describes the part played by plastination, a recently developed technique for the preservation of biological specimens. In this, tissue fluids and part of the lipids are replaced by certain polymers yielding specimens that can be handled without gloves, do not smell or decay, and even retain microscopic properties of the original sample. The technique has proved to be a useful tool to correct previously presented anatomical descriptions and is one now favoured by human surgeons. Studies of the horse employing this technique include those of the temporomandibular joint and tarsus. The aim of the review is to stimulate further correlations of anatomical structure and equine medical and surgical procedures, thereby advancing knowledge and understanding in practice and teaching.

The anatomical components of urinary continence

BACKGROUND

The levator ani muscle (LAM) plays an important role in urinary continence, but the anatomical relationship between this pelvic floor muscle and the external urethral sphincter (EUS) remains incompletely understood.

OBJECTIVE

To investigate the topographical relationship between the EUS and the LAM.

DESIGN, SETTING, AND PARTICIPANTS

Serially sectioned and histochemically stained foetal pelves from eleven females and nine males (10-27 wk of gestation) were studied. Three foetal pelves (two female, 12 and 18 wk of gestation; one male, 12 wk of gestation) and three adult pelves (two females, 54 and 85 yr; one male, 75 yr) were stained immunohistochemically for the presence of striated and smooth muscle tissue. Three-dimensional reconstructions were prepared.

MEASUREMENTS

Anatomy of the LAM and urethral sphincter components was evaluated qualitatively.

RESULTS AND LIMITATIONS

The EUS has no direct bony attachment. In female foetuses, the inferior part of the EUS is firmly attached to the LAM by a tendinous connection. Contraction of this part of the EUS produces a force on the urethra in a posteroinferior direction. Contraction of the LAM compresses the rectum and moves the rectovaginal complex anteriorly and superiorly towards the urethra in a plane that lies parallel to, but superior of, that of the EUS. Simultaneous contraction of the LAM and EUS causes an anteriorly convex bend in the midurethra, which closes the midurethral lumen. A similar attachment of the EUS to the LAM is absent in the male. Our study is limited due to the absence of young adult study specimens.

CONCLUSIONS

The EUS in females is anchored to the levator ani muscle via a tendinous connection. Because of this attachment to the LAM, proper function of the EUS is dependent on the integrity of the LAM and its attachment to the pelvic wall.

Urinary incontinence after obstetric anal sphincter injuries (OASIS)—is there a relationship?

This study aimed to compare urinary symptoms and its impact on women's quality of life after obstetric anal sphincter injuries (OASIS) with a matched control group in the short term. The study group consisted of 100 primiparous women with OASIS and 104 controls who sustained a second-degree tear or had a mediolateral episiotomy performed. All women completed a validated International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) questionnaire 10 weeks after delivery. Compared to controls, significantly more women with OASIS reported overall urinary incontinence (21.2 vs 38%, p = 0.005) and had significantly worse quality of life score (incontinence score: 2.42 vs 1.2; p = 0.008). Significantly more women with OASIS suffered from stress urinary incontinence (33 vs 14%; p = 0.002; OR 3.06; CI = 1.54-6.07) than controls. Logistic regression analysis revealed that OASIS and a prolonged (>50 min) second stage of labour were independent risk factors for the development of stress urinary incontinence. This study highlights the importance of inquiring about urinary incontinence in women with OASIS.

Adult stem cell therapy of female stress urinary incontinence

OBJECTIVES

To investigate the efficacy of transurethral ultrasound (TUUS)-guided injections of autologous myoblasts and fibroblasts in women with incontinence.

METHODS

Between January and June 2005, 20 female patients suffering from stress urinary incontinence (SUI) were included. Skeletal muscle biopsies were taken from the left arm to obtain cultures from autologous fibroblasts and myoblasts. By TUUS guidance the fibroblasts were injected into the urethral submucosa and the myoblasts were injected into the rhabdosphincter. A defined incontinence score, quality-of-life score and urodynamic, electromyographic, and laboratory parameters, as well as morphology and function of urethra and rhabdosphincter were evaluated before and up to 2 yr after therapy.

RESULTS

Eighteen of 20 patients were cured 1 yr after injection of autologous stem cells and in 2 patients SUI was improved. Two years after therapy 16 of the 18 patients presented as cured, 2 others were improved, and 2 were lost to follow-up. Incontinence and quality-of-life scores were significantly improved postoperatively. The thickness of urethra and rhabdosphincter as well as activity and contractility of the rhabdosphincter were also statistically significantly increased after therapy.

CONCLUSIONS

Clinical results demonstrate that SUI can be treated effectively with autologous stem cells. The present data support the conclusion that this therapeutic concept represents an elegant and minimally invasive treatment modality to treat SUI.

Autologous myoblasts and fibroblasts versus collagen for treatment of stress urinary incontinence in women: a randomised controlled trial

BACKGROUND

Preclinical studies have suggested that transurethral injections of autologous myoblasts can aid in regeneration of the rhabdosphincter, and fibroblasts in reconstruction of the urethral submucosa. We aimed to compare the effectiveness and tolerability of ultrasonography-guided injections of autologous cells with those of endoscopic injections of collagen for stress incontinence.

METHODS

Between 2002 and 2004, we recruited 63 eligible women with urinary stress incontinence. 42 of these women were randomly assigned to receive transurethral ultrasonography-guided injections of autologous myoblasts and fibroblasts, and 21 to receive conventional endoscopic injections of collagen. The first primary outcome measure was an incontinence score (range 0-6) based on a 24-hour voiding diary, a 24-hour pad test, and a patient questionnaire. The other primary outcome measures were contractility of the rhabdosphincter and thickness of both the urethra and rhabdosphincter. Analysis was by intention to treat. This trial is registered with Controlled-Trials.com, number CCT-NAPN-16630.

FINDINGS

At 12-months' follow-up, 38 of the 42 women injected with autologous cells were completely continent, compared with two of the 21 patients given conventional treatment with collagen. The median incontinence score decreased from a baseline of 6.0 (IQR 6.0-6.0; where 6 represents complete incontinence), to 0 (0-0) for patients treated with autologous cells, and 6.0 (3.5-6.0) for patients treated with collagen (p<0.0001). Ultrasonographic measurements showed that the mean thickness of the rhabdosphincter increased from a baseline of 2.13 mm (SD 0.39) for all patients to 3.38 mm (0.26) for patients treated with autologous cells and 2.32 mm (0.44) for patients treated with collagen (p<0.0001). Contractility of the rhabdosphincter increased from a baseline of 0.58 mm (SD 0.32) to 1.56 mm (0.28) for patients treated with autologous cells and 0.67 mm (0.51) for controls (p<0.0001). The change in the thickness of the urethra after treatment was not significantly different between treatment groups. No adverse effects were recorded in any of the 63 patients.

INTERPRETATION

Long-term postoperative results and data from multicentre trials with larger numbers of patients are needed to assess whether injection of autologous cells into the rhabdosphincter and the urethra could become a standard treatment for urinary incontinence.