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Fleischmann N, Chughtai B, Plair A, Hurtado E, Jacobson N, Segal S, Panza J, Cichowski SB. Urethral Bulking. UROGYNECOLOGY (PHILADELPHIA, PA.) 2024; 30:667-682. [PMID: 39051928 DOI: 10.1097/spv.0000000000001548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/27/2024]
Abstract
OBJECTIVE This Clinical Practice Statement aims to provide clinicians with evidence-based guidance for the use of urethral bulking agents (UBAs) in the treatment of stress urinary incontinence (SUI). METHODS We conducted a structured search of the English literature published from January 1960 to November 2022. Search terms identified studies of both current and historic UBAs. Data extracted at the time of full-text review included type of study, research setting, number of participants, age group, bulking agent, primary outcome, secondary outcome, efficacy, and complications. RESULTS One thousand five hundred ninety-four nonduplicate articles were identified using the search criteria. After limiting the article types to randomized control led trials, prospective studies, guideline documents, reviews, meta-analyses, and case reports of complications, 395 studies were screened. CONCLUSIONS Based on our findings, we propose the following recommendations for clinicians when considering UBA: First, UBA is indicated in cases of demonstrable SUI. Intrinsic sphincter deficiency is not predictive of patient outcomes. Second, patients should be counseled on the risks, lack of long-term efficacy data, potential need for repeat injections, possible need for surgery for recurrent SUI, implications for future procedures, and pelvic imaging findings that may be observed after UBA. Third, UBA may be considered for initial management of SUI. Fourth, UBA is an option for patients with persistent or recurrent SUI after a sling procedure. Fifth, clinicians may prioritize UBA over surgery in specific patient populations. Sixth, polyacrylamide hydrogel demonstrates marginally improved safety and durability data over other available agents.
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Affiliation(s)
| | | | - Andre Plair
- Stony Brook Medicine University Hospital, Stony Brook, NY
| | | | - Nina Jacobson
- Hackensack Meridian School of Medicine/Jersey Shore University Medical Center, Neptune, NJ
| | - Saya Segal
- Weill Cornell Medical College, New York, NY
| | - Joseph Panza
- University of Rochester Medical Center, Rochester, NY
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Peters B, Powers SA, Burleson LK, Odom MR, Pak ES, Turner AC, Sivanesan N, Koontz BF, Hannan JL. Preclinical Female Model of Urogenital Dysfunction and Pathophysiological Changes After Pelvic Radiation Therapy. Cureus 2024; 16:e66374. [PMID: 39246936 PMCID: PMC11379420 DOI: 10.7759/cureus.66374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/07/2024] [Indexed: 09/10/2024] Open
Abstract
Introduction Radiation therapy (RT) is the gold standard for many pelvic cancers and improves overall patient survival. However, pelvic RT is associated with increased sexual dysfunction and urinary incontinence. Although the side effects of pelvic RT are well-documented, the pathological mechanisms leading to pelvic organ dysfunction are unknown, and a preclinical model has not been established. This study characterized the impact of pelvic RT at early and late timepoints on female rat bladder, vaginal, and urethral physiology and morphology. Methods Adult female Sprague-Dawley rats were divided into three groups (n = 8/group): (I) Sham, (II) four weeks RT (4wk RT), and (III) nine weeks RT (9wk RT). The RT groups received a single dose of 20 Gy external beam radiation, and experiments were conducted at 4wk and 9wk post-RT. Nerve-mediated vaginal blood flow was measured via laser Doppler. Tissue bath studies assessed vaginal contractility to electric field stimulation (EFS), adrenergic and cholinergic agonists, and relaxation to a nitric oxide donor. Bladder and urethral sphincters were evaluated for cholinergic, caffeine, and EFS-mediated contractility. Quantitative polymerase chain reaction (qPCR) measured gene expression of markers of oxidative stress. Vaginal, bladder, and urethral fibrosis were assessed with Masson's trichrome staining. Results At 4wk post-RT, total vaginal blood flow decreased, and at 9wk post-RT, returned to baseline levels. At 9wk post-RT, vaginal neurogenic and adrenergic-mediated contractile responses increased significantly. Vaginal epithelial thickness decreased post-RT and correlated with an acute rise in vaginal inflammatory gene expression. At 4wk post-RT, bladder neurogenic contractions decreased and remained lowered. Internal urethral contractions increased at 4wk post-RT and returned to Sham levels after 9wk post-RT. Pelvic RT increased external urethral neurogenic contractions, which remained elevated. Conclusion This novel preclinical model provides valuable insights into the temporal pathophysiology of pelvic RT-induced sexual and urinary dysfunction. The establishment of this model is crucial for understanding the underlying mechanisms involved in RT-induced pelvic injury. A reliable, clinically relevant model will allow for the testing of therapeutic strategies to prevent adverse effects with RT in pelvic cancer survivors.
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Affiliation(s)
- Bethlehem Peters
- Department of Physiology, Brody School of Medicine, East Carolina University, Greenville, USA
| | - Shelby A Powers
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, USA
- Department of Physiology, Brody School of Medicine, East Carolina University, Greenville, USA
| | - Lindsey K Burleson
- Department of Obstetrics and Gynecology, Indiana University School of Medicine, Indianapolis, USA
- Department of Physiology, Brody School of Medicine, East Carolina University, Greenville, USA
| | - Michael R Odom
- Department of Urology, Duke University School of Medicine, Durham, USA
- Department of Physiology, Brody School of Medicine, East Carolina University, Greenville, USA
| | - Elena S Pak
- Department of Biomedical Sciences, Louisiana State University (LSU) School of Veterinary Medicine, Baton Rouge, USA
- Department of Physiology, Brody School of Medicine, East Carolina University, Greenville, USA
| | - Alexander C Turner
- Department of Medicine, University of Texas (UT) Southwestern Medical Center, Dallas, USA
- Department of Physiology, Brody School of Medicine, East Carolina University, Greenville, USA
| | - Nethusan Sivanesan
- Department of Physiology, Brody School of Medicine, East Carolina University, Greenville, USA
| | - Bridget F Koontz
- Department of Radiation Oncology, Brody School of Medicine, East Carolina University, Greenville, USA
| | - Johanna L Hannan
- Department of Physiology, Brody School of Medicine, East Carolina University, Greenville, USA
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Kalra S, Pal AK, Dorairajan LN. Understanding female urinary continence-lessons from complications of female urethral surgery. Asian J Urol 2024; 11:504-506. [PMID: 39139536 PMCID: PMC11318384 DOI: 10.1016/j.ajur.2024.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Indexed: 08/15/2024] Open
Affiliation(s)
- Sidhartha Kalra
- Department of Urology and Renal Transplantation, Jawaharlal Institute of Post Graduate Medical Education and Research, Puducherry, India
| | - Atanu Kumar Pal
- Department of Urology and Renal Transplantation, Jawaharlal Institute of Post Graduate Medical Education and Research, Puducherry, India
| | - Lalgudi Narayanan Dorairajan
- Department of Urology and Renal Transplantation, Jawaharlal Institute of Post Graduate Medical Education and Research, Puducherry, India
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Alves Firmeza M, de Vasconcelos Oliveira NM, Mendes Alves F, Teixeira Moreira Vasconcelos C, Ananias Vasconcelos Neto J. Urinary symptoms and sexual function after hysterectomy secondary to cervical cancer: A prospective, cohort study. Eur J Obstet Gynecol Reprod Biol 2024; 296:208-214. [PMID: 38461785 DOI: 10.1016/j.ejogrb.2024.02.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 11/19/2023] [Accepted: 02/22/2024] [Indexed: 03/12/2024]
Abstract
INTRODUCTION AND HYPOTHESIS The estimated worldwide incidence of cervical cancer (CC) is half a million cases per year. Surgical treatment is the mainstay approach for this condition. OBJECTIVES To assess the effects of hysterectomy due to cervical cancer in urinary symptoms and sexual function and the disorder related impact on the quality of patients life. STUDY DESIGN A cohort study was performed in Fortaleza/CE (Brazil) with 71 patients; of these, 31 were diagnosed with cervical cancer (G-CCU) and 40 with gynecological benign disease (G-PB). Sexual function (FSFI questionnaire), quality of life (SF-36 questionnaire) and urinary symptoms (KHQ instrument) were investigated in both groups at baseline (T0), one month (T1) and four months after surgery (T2). RESULTS Both groups presented at baseline, similar urinary symptoms (p > 0.05), but this frequency doubled for the G-CCU group at T1 and remained unchanged at T2 (p = 0.012). G-PB's frequency of symptoms remained the same for 4 months after surgery. At baseline G-PB had higher risk for sexual dysfunction than G-CCU (82.5 % versus 54.8 %, p = 0.011). However for G-CCU, an increase of this percentage was perceived at T2.Women from the G-CCU group presented worse general and specific quality of life results. CONCLUSION Women underwent to hysterectomy due to cervical cancer presented higher percentages of urinary symptoms, higher risk for sexual dysfunction and worse general and specific quality of life scores.
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Affiliation(s)
- Mariana Alves Firmeza
- Nursing Department, Federal University of Ceará, St Alexandre Baraúna, n.1115 - 1° floor, room 3 - Rodolfo Teófilo district, city of Fortaleza, state of Ceará, 60430-160, Brazil
| | - Natália Maria de Vasconcelos Oliveira
- Woman's Health Department, Federal University of Ceará, 1608 Prof. Costa Mendes St - 2° floor - Rodolfo Teófilo district, city of Fortaleza, state of Ceará 60416-200, Brazil.
| | - Flávio Mendes Alves
- Woman's Health Department, Federal University of Ceará, 1608 Prof. Costa Mendes St - 2° floor - Rodolfo Teófilo district, city of Fortaleza, state of Ceará 60416-200, Brazil.
| | - Camila Teixeira Moreira Vasconcelos
- Nursing Department, Federal University of Ceará, St Alexandre Baraúna, n.1115 - 1° floor, room 3 - Rodolfo Teófilo district, city of Fortaleza, state of Ceará, 60430-160, Brazil.
| | - José Ananias Vasconcelos Neto
- Woman's Health Department, Federal University of Ceará, 1608 Prof. Costa Mendes St - 2° floor - Rodolfo Teófilo district, city of Fortaleza, state of Ceará 60416-200, Brazil.
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Hines K, Nieto K, Dezarn W, Greven K, Krol B, Matthews C, Parker-Autry C. An assessment of urethral radiation exposure in the treatment of endometrial and rectal cancers. Int Urogynecol J 2023; 34:929-935. [PMID: 36181547 DOI: 10.1007/s00192-022-05363-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 09/03/2022] [Indexed: 10/06/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Female survivors of endometrial and rectal cancers have increased risk of urinary incontinence. Survivors with prior radiation therapy are counseled against mesh incontinence surgery. We hypothesize that urethral radiation dose varies based on modality which may influence surgical risks. We aimed to demonstrate urethral radiation dose differences between vaginal brachytherapy (VBT) and external beam radiation therapy (EBRT). METHODS This is a retrospective cohort study of women exposed to VBT for endometrial cancer and EBRT for rectal cancer. The urethra was contoured on CT imaging to calculate radiation doses in centigray (cGy). The primary outcome was the percent of treatment radiation dose estimated to be received by the urethra based on the volume dose to 0.2 cc of urethra. Secondary outcomes were point doses to the bladder neck, mid-urethra, and total mean urethral dose. Descriptive statistics described demographic characteristics. Bivariate analyses compared urethral radiation dose based on radiation modality. RESULTS Between 2014-2017, 32 women treated were included: 18 with VBT and 14 with EBRT. Mean ± SD urethral volume doses were lower in VBT (1266 cGy ± 533, 42.2% of prescribed treatment dose) compared to EBRT (5051 cGy ± 192, 100.2% of prescribed treatment dose), p < 0.0001. VBT also had significantly lower mean total urethral dose and point doses to bladder neck and mid- urethra compared to EBRT (p < 0.0001). CONCLUSIONS The female urethra is exposed to significantly less radiation in VBT compared to EBRT. These data highlight that modality of pelvic radiation should be considered in treatment counseling on urinary incontinence in women.
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Affiliation(s)
- Katherine Hines
- Wake Forest Department of Urology, Division of Female Pelvic Health, Winston-Salem, NC, USA
| | - Karina Nieto
- Wake Forest Department of Radiation Oncology, Winston-Salem, NC, USA
| | - William Dezarn
- Wake Forest Department of Radiation Oncology, Winston-Salem, NC, USA
| | - Kathryn Greven
- Wake Forest Department of Radiation Oncology, Winston-Salem, NC, USA
| | - Bridget Krol
- Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Catherine Matthews
- Wake Forest Department of Urology, Division of Female Pelvic Health, Winston-Salem, NC, USA
| | - Candace Parker-Autry
- Wake Forest Department of Urology, Division of Female Pelvic Health, Winston-Salem, NC, USA.
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Bernard S, Frenette AG, McLean L, Noël P, Froment MA, Hébert LJ, Moffet H. Reliability of ultrasound imaging of pelvic floor morphology and function among females who have undergone pelvic radiotherapy. Neurourol Urodyn 2021; 40:1001-1010. [PMID: 33739537 DOI: 10.1002/nau.24656] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 02/03/2021] [Accepted: 03/02/2021] [Indexed: 12/27/2022]
Abstract
AIMS To investigate the intra- and inter-rater reliability of two-dimensional (2D) transperineal ultrasound imaging (USI) measures of bladder wall thickness (BWT), urethral length (UL), and parameters related to levator plate length (LP) and transient changes in LP during pelvic floor muscle (PFM) contraction, and on Valsalva in women who received radiation therapy (RT) for treatment of pelvic cancer. METHODS Twenty women with a history of RT for the treatment of pelvic cancer were assessed independently by two raters on the same day. Five outcomes were assessed for reliability: BWT, UL, and LP at rest (LP-R), during a maximal voluntary contraction of the PFMs (LP-MVC), and during a maximal-effort Valsalva maneuver (LP-MVM). Reliability was determined using intra-class correlation coefficients (ICC) and Bland-Altman analyses. Measurement error was determined using standard error of the measurement (SEM) and minimal detectable difference. RESULTS Intra-rater reliability was very good for LP-R, LP-MVC, LP-MVM, and UL (ICC: 0.97 [0.93-0.99], 0.95 [0.88-0.98], 0.84 [0.59-0.94], and 0.96 [0.89-0.98], respectively). Inter-rater reliability was very good for LP-R (ICC: 0.82 [0.55-0.93]), and good for LP-MVC, LP-MVM, and UL (ICC: 0.79 [0.46-0.92], 0.79 [0.49-0.92], and 0.75 [0.36-0.90], respectively). BWT had poor intra- and inter-rater reliability. The variability between measurements was the smallest for LP-R, LP-MVC, and UL for intra-rater assessments, and for LP-R and UL for inter-rater assessments. SEM values for intra-rater assessments were LP-R: 1.5 mm, LP-MVC: 1.84 mm, LP-MVM: 4.33 mm, and UL: 1.16 mm. CONCLUSIONS Although these results support the reliability of 2D-transperineal USI for the evaluation of UL and PFM parameters, they do not support its use for the assessment of BWT.
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Affiliation(s)
- Stéphanie Bernard
- Department of Rehabilitation, Faculté de Médecine, Université Laval, Québec, Québec, Canada
| | - Anne-Gabrielle Frenette
- Departments of Radiology and Radiation Oncology, Centre Hospitalier Université de Québec, Hôtel-Dieu de Québec, Université Laval, Québec, Québec, Canada
| | - Linda McLean
- Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada
| | - Patricia Noël
- Departments of Radiology and Radiation Oncology, Centre Hospitalier Université de Québec, Hôtel-Dieu de Québec, Université Laval, Québec, Québec, Canada
| | - Marie-Anne Froment
- Departments of Radiology and Radiation Oncology, Centre Hospitalier Université de Québec, Hôtel-Dieu de Québec, Université Laval, Québec, Québec, Canada
| | - Luc J Hébert
- Department of Rehabilitation, Faculté de Médecine, Université Laval, Québec, Québec, Canada
| | - Hélène Moffet
- Department of Rehabilitation, Faculté de Médecine, Université Laval, Québec, Québec, Canada
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