Nuclear Charge Radius of ^{26m}Al and Its Implication for V_{ud} in the Quark Mixing Matrix

Collinear laser spectroscopy was performed on the isomer of the aluminium isotope ^{26m}Al. The measured isotope shift to ^{27}Al in the 3s^{2}3p ^{2}P_{3/2}^{○}→3s^{2}4s ^{2}S_{1/2} atomic transition enabled the first experimental determination of the nuclear charge radius of ^{26m}Al, resulting in R_{c}=3.130(15)  fm. This differs by 4.5 standard deviations from the extrapolated value used to calculate the isospin-symmetry breaking corrections in the superallowed β decay of ^{26m}Al. Its corrected Ft value, important for the estimation of V_{ud} in the Cabibbo-Kobayashi-Maskawa matrix, is thus shifted by 1 standard deviation to 3071.4(1.0) s.

The Effect of Chronic Psychological Stress on Lower Urinary Tract Function: An Animal Model Perspective

Chronic psychological stress can affect urinary function and exacerbate lower urinary tract (LUT) dysfunction (LUTD), particularly in patients with overactive bladder (OAB) or interstitial cystitis–bladder pain syndrome (IC/BPS). An increasing amount of evidence has highlighted the close relationship between chronic stress and LUTD, while the exact mechanisms underlying it remain unknown. The application of stress-related animal models has provided powerful tools to explore the effect of chronic stress on LUT function. We systematically reviewed recent findings and identified stress-related animal models. Among them, the most widely used was water avoidance stress (WAS), followed by social stress, early life stress (ELS), repeated variable stress (RVS), chronic variable stress (CVS), intermittent restraint stress (IRS), and others. Different types of chronic stress condition the induction of relatively distinguished changes at multiple levels of the micturition pathway. The voiding phenotypes, underlying mechanisms, and possible treatments of stress-induced LUTD were discussed together. The advantages and disadvantages of each stress-related animal model were also summarized to determine the better choice. Through the present review, we hope to expand the current knowledge of the pathophysiological basis of stress-induced LUTD and inspire robust therapies with better outcomes.

Nuclear Charge Radii of the Nickel Isotopes ^{58-68,70}Ni

Collinear laser spectroscopy is performed on the nickel isotopes ^{58-68,70}Ni, using a time-resolved photon counting system. From the measured isotope shifts, nuclear charge radii R_{c} are extracted and compared to theoretical results. Three ab initio approaches all employ, among others, the chiral interaction NNLO_{sat}, which allows an assessment of their accuracy. We find agreement with experiment in differential radii δ⟨r_{c}^{2}⟩ for all employed ab initio methods and interactions, while the absolute radii are consistent with data only for NNLO_{sat}. Within nuclear density functional theory, the Skyrme functional SV-min matches experiment more closely than the Fayans functional Fy(Δr,HFB).

Charge Radius of the Short-Lived ^{68}Ni and Correlation with the Dipole Polarizability

We present the first laser spectroscopic measurement of the neutron-rich nucleus ^{68}Ni at the N=40 subshell closure and extract its nuclear charge radius. Since this is the only short-lived isotope for which the dipole polarizability α_{D} has been measured, the combination of these observables provides a benchmark for nuclear structure theory. We compare them to novel coupled-cluster calculations based on different chiral two- and three-nucleon interactions, for which a strong correlation between the charge radius and dipole polarizability is observed, similar to the stable nucleus ^{48}Ca. Three-particle-three-hole correlations in coupled-cluster theory substantially improve the description of the experimental data, which allows to constrain the neutron radius and neutron skin of ^{68}Ni.

Laser Spectroscopy of Neutron-Rich Tin Isotopes: A Discontinuity in Charge Radii across the N=82 Shell Closure

The change in mean-square nuclear charge radii δ⟨r^{2}⟩ along the even-A tin isotopic chain ^{108-134}Sn has been investigated by means of collinear laser spectroscopy at ISOLDE/CERN using the atomic transitions 5p^{2} ^{1}S_{0}→5p6 s^{1}P_{1} and 5p^{2} ^{3}P_{0}→5p6s ^{3}P_{1}. With the determination of the charge radius of ^{134}Sn and corrected values for some of the neutron-rich isotopes, the evolution of the charge radii across the N=82 shell closure is established. A clear kink at the doubly magic ^{132}Sn is revealed, similar to what has been observed at N=82 in other isotopic chains with larger proton numbers, and at the N=126 shell closure in doubly magic ^{208}Pb. While most standard nuclear density functional calculations struggle with a consistent explanation of these discontinuities, we demonstrate that a recently developed Fayans energy density functional provides a coherent description of the kinks at both doubly magic nuclei, ^{132}Sn and ^{208}Pb, without sacrificing the overall performance. A multiple correlation analysis leads to the conclusion that both kinks are related to pairing and surface effects.

Symptom Duration in Patients With Urologic Chronic Pelvic Pain Syndrome is not Associated With Pain Severity, Nonurologic Syndromes and Mental Health Symptoms: A Multidisciplinary Approach to the Study of Chronic Pelvic Pain Network Study

OBJECTIVE

To evaluate if patients with urologic chronic pelvic pain syndromes (UCPPS) with longer duration of symptoms experience more severe pain and urologic symptoms, higher rates of chronic overlapping pain conditions (COPC) and psychosocial comorbidities than those with a more recent onset of the condition. We evaluated cross-sectional associations between UCPPS symptom duration and (1) symptom severity, (2) presence of COPC, and (3) mental health comorbidities.

METHODS

We analyzed baseline data from the Multidisciplinary Approach to the Study of Chronic Pelvic Pain. Symptom severity, COPC, and mental health comorbidities were compared between patients with symptom duration of < 2 vs ≥ 2 years. Symptom severity was assessed by the Genitourinary Pain Index, the Interstitial Cystitis Symptom and Problem Index, and Likert scales for pelvic pain, urgency, and frequency. Depression and anxiety were evaluated with the Hospital Anxiety and Depression Scale and stress with the Perceived Stress Scale.

RESULTS

Males (but not females) with UCPPS symptom duration ≥2 years had more severe symptoms than those with <2 years. Participants with short (<2 years) and longer (≥2 years) symptom duration were as likely to experience COPC.

CONCLUSION

Longer UCPPS symptom duration was associated with more severe symptoms only in limited patient subpopulations. Symptom duration was not associated with risk for COPC or mental health comorbidities. Females with longer UCPPS duration had decreased distress, but the association was largely attributable to age.

The role of C-fibers in the development of chronic psychological stress induced enhanced bladder sensations and nociceptive responses: A multidisciplinary approach to the study of urologic chronic pelvic pain syndrome (MAPP) research network study

AIMS

To evaluate C fiber-mediated changes in bladder sensation and nociception in an animal model of stress induced bladder hyperalgesia and urinary frequency.

METHODS

Female Wistar-Kyoto (WKY) rats were exposed to a chronic (10 days) water avoidance stress (WAS) and compared to controls. Rats were evaluated by cystometrogram (CMG) and visceromotor reflex (VMR) to bladder infusion with room temperature (RT) or cold saline. Cold saline activates afferent C-fibers via cold bladder receptors. To further evaluate bladder hyperalgesia, CMG and VMR were also obtained during RT isometric bladder distention (RT-iBD) at variable pressures.

RESULTS

During RT infusion, WAS rats had significant decreases in pressure threshold (PT) and in the ratio of VMR threshold/maximum intravesical pressure (IVPmax), and a significant increase in VMR duration. Cold infusion also induced significant decreases in PT and in the ratio of VMR threshold/IVPmax in WAS rats. During RT-iBD, rats exposed to WAS showed a significant decrease in VMR latency and a significant increase in VMR area under the curve (AUC) compared to controls.

CONCLUSION

Chronic WAS induced bladder hypersensitivity manifested by earlier voiding with earlier VMR appearance. Chronic stress also enhanced bladder nociceptive responses. WAS leads to increase responses to ice cold water infusion, implying a role of sensitized C-fibers and mechanoreceptors in WAS-induced bladder dysfunction and hypersensitivity.

The Glt1 glutamate receptor mediates the establishment and perpetuation of chronic visceral pain in an animal model of stress-induced bladder hyperalgesia

Psychological stress exacerbates interstitial cystitis/bladder pain syndrome (IC/BPS), a lower urinary tract pain disorder characterized by increased urinary frequency and bladder pain. Glutamate (Glu) is the primary excitatory neurotransmitter modulating nociceptive networks. Glt1, an astrocytic transporter responsible for Glu clearance, is critical in pain signaling termination. We sought to examine the role of Glt1 in stress-induced bladder hyperalgesia and urinary frequency. In a model of stress-induced bladder hyperalgesia with high construct validity to human IC/BPS, female Wistar-Kyoto (WKY) rats were subjected to 10-day water avoidance stress (WAS). Referred hyperalgesia and tactile allodynia were assessed after WAS with von Frey filaments. After behavioral testing, we assessed Glt1 expression in the spinal cord by immunoblotting. We also examined the influence of dihydrokainate (DHK) and ceftriaxone (CTX), which downregulate and upregulate Glt1, respectively, on pain development. Rats exposed to WAS demonstrated increased voiding frequency, increased colonic motility, anxiety-like behaviors, and enhanced visceral hyperalgesia and tactile allodynia. This behavioral phenotype correlated with decreases in spinal Glt1 expression. Exogenous Glt1 downregulation by DHK resulted in hyperalgesia similar to that following WAS. Exogenous Glt1 upregulation via intraperitoneal CTX injection inhibited the development of and reversed preexisting pain and voiding dysfunction induced by WAS. Repeated psychological stress results in voiding dysfunction and hyperalgesia that correlate with altered central nervous system glutamate processing. Manipulation of Glu handling altered the allodynia developing after psychological stress, implicating Glu neurotransmission in the pathophysiology of bladder hyperalgesia in the WAS model of IC/BPS.

Chronic psychological stress in high-anxiety rats induces sustained bladder hyperalgesia

OBJECTIVE

To evaluate whether anxiety-prone rats exposed to chronic water avoidance stress (WAS) develop visceral bladder hyperalgesia in addition to increased voiding frequency and anxiety-related behaviors.

MATERIALS AND METHODS

Female Wistar-Kyoto (WKY) rats were exposed to chronic (10-day) WAS or sham paradigms. Referred hyperalgesia and tactile allodynia were tested using von Frey filaments applied to the suprapubic region and plantar region of the hindpaw, respectively. To confirm that suprapubic nociception represented referred visceral bladder hyperalgesia, we recorded abdominal visceromotor responses (VMR) to slow (100 μl/min) and fast (1 cc/sec) bladder filling with room temperature or ice-cold saline. We assessed the development of hyperalgesia over the 10-day WAS protocol and the durability of increased pain sensations over time.

RESULTS

Animals exposed to chronic WAS had significantly lower hindpaw withdrawal thresholds post-stress and significant differences in referred hyperalgesia. Rats exposed to chronic WAS demonstrated an increased pain response to suprapubic stimulation and decreased response threshold to mechanical hindpaw stimulation by day 8 of the stress protocol, which persisted for more than one month. Animals exposed to chronic WAS showed increased VMR to fast filling and ice water testing in comparison to sham animals. Cystometry under anesthesia did not show increases in the frequency of non-voiding contractions.

CONCLUSION

Chronic WAS induces sustained bladder hyperalgesia, lasting over a month after exposure to stress. The urinary frequency demonstrated previously in anxiety-prone rats exposed to chronic WAS seems to be associated with bladder hyperalgesia, suggesting that this is a potential model for future studies of bladder hypersensitivity syndromes such as interstitial cystitis/painful bladder syndrome (IC/PBS).

The MAPP research network: a novel study of urologic chronic pelvic pain syndromes

Urologic chronic pelvic pain syndrome (UCPPS) may be defined to include interstitial cystitis/bladder pain syndrome (IC/BPS) and chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). The hallmark symptom of UCPPS is chronic pain in the pelvis, urogenital floor, or external genitalia often accompanied by lower urinary tract symptoms. Despite numerous past basic and clinical research studies there is no broadly identifiable organ-specific pathology or understanding of etiology or risk factors for UCPPS, and diagnosis relies primarily on patient reported symptoms. In addition, there are no generally effective therapies. Recent findings have, however, revealed associations between UCPPS and “centralized” chronic pain disorders, suggesting UCPPS may represent a local manifestation of more widespread pathology in some patients. Here, we describe a new and novel effort initiated by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) of the U.S. National Institutes of Health (NIH) to address the many long standing questions regarding UCPPS, the Multidisciplinary Approach to the Study of Chronic Pelvic Pain (MAPP) Research Network. The MAPP Network approaches UCPPS in a systemic manner, in which the interplay between the genitourinary system and other physiological systems is emphasized. The network’s study design expands beyond previous research, which has primarily focused on urologic organs and tissues, to utilize integrated approaches to define patient phenotypes, identify clinically-relevant subgroups, and better understand treated natural history and pathophysiology. Thus, the MAPP Network provides an unprecedented, multi-layered characterization of UCPPS. Knowledge gained is expected to provide important insights into underlying pathophysiology, a foundation for better segmenting patients for future clinical trials, and ultimately translation into improved clinical management. In addition, the MAPP Network’s integrated multi-disciplinary research approach may serve as a model for studies of urologic and non-urologic disorders that have proven refractory to past basic and clinical study.

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.

The effects of acute and chronic psychological stress on bladder function in a rodent model

OBJECTIVE

Psychological stress plays a role in the exacerbation of functional lower urinary tract disorders, such as painful bladder syndrome and overactive bladder. To better understand the mechanism underlying this relationship, we characterized changes in micturition, anxiety-related behavior, and bladder pathology in rats exposed to repeated water avoidance (WA) stress.

METHODS

Twenty-four Wistar rats were subjected to WA stress or sham. Immediately after acute (day 1) and chronic (day 10) stress or sham, rats were placed in a metabolic cage for a 2-hour voiding behavior assessment. Voiding parameters were compared with baseline values obtained before stress. Four animals from each group were sacrificed on day 10 and bladders harvested for histologic and gene expression studies. The remaining 8 animals per group underwent repeated voiding assessment every 3 days for 1 month followed by 10 days of repeat WA stress or sham. Bladder histology and gene expression were studied.

RESULTS

Rats exposed to WA stress developed a significant increase in micturition frequency and decrease in latency to void, voiding interval, and volume of first void compared with sham and baseline. Alterations in micturition persisted for approximately 1 month. Stressed rats showed increased fecal pellet excretion and anxiety-like behavior. In addition, bladder specimens from stressed animals revealed increased angiogenesis, and increased total and activated mast cells.

CONCLUSION

In rats, repeated psychological stress results in lasting alterations in micturition frequency, interval, and volume. This rodent model may represent a valid tool for studying syndromes characterized by increased urinary frequency.

Stem cells for the treatment of urinary incontinence

Stress urinary incontinence (SUI) is highly prevalent. As of now, there is no minimally invasive long-term treatment available. Adult stem cells are nonimmunogenic and have the ability to self-renew and to differentiate into multiple cell types. Over the past decade, in vivo studies have described periurethral injections of adult-derived stem cells for the treatment of SUI. The ultimate goal has been to achieve a permanent cure for SUI by restoration of the intrinsic and extrinsic urethral sphincter and the surrounding connective tissue, including peripheral nerves and blood vessels. For this purpose, future studies need to focus on delivery systems, cell survival, and functional improvement of the urethral closure mechanism, including improvement of innervation and vascularization.

Misconceptions and miscommunication among aging women with overactive bladder symptoms

OBJECTIVES

To better understand aging women's experience with overactive bladder (OAB) symptoms and the care they receive, with the ultimate goal of improving the quality of care provided to aging women with overactive bladder.

METHODS

Women seen in outpatient female urology clinics were identified by ICD-9 codes for OAB and recruited. Patients with painful bladder syndrome, mixed stress and urge incontinence, prolapse, or recent pelvic surgery were excluded. Patient focus groups were conducted by trained nonclinician moderators incorporating topics related to patients' perceptions of OAB physiology, symptoms, diagnostic evaluation, treatments, and outcomes. Qualitative data analysis was performed using grounded theory methodology.

RESULTS

Five focus groups totaling 33 women with OAB were conducted. Average patient age was 67 years (range, 39-91). Older women with OAB lacked knowledge about the physiology of their disease and had poor understanding regarding the rationale for many diagnostic tests, including urodynamics and cystoscopy. The results of diagnostic studies often were not understood by older patients. Many women were dissatisfied with the care they had received. This lack of knowledge and understanding was more apparent among the elderly women in the group.

CONCLUSIONS

Findings demonstrated a poor understanding of the physiology of overactive bladder and the rationale for various diagnostic modalities and treatments. This was associated with dissatisfaction with care. There is a need for better communication with older women experiencing OAB symptoms about the physiology of the condition.

Gating of sensory information differs in patients with interstitial cystitis/painful bladder syndrome

PURPOSE

Altered sensory processing in interstitial cystitis/painful bladder syndrome cases may result from a deficiency of the central nervous system to adequately filter incoming visceral afferent information. We used prepulse inhibition as an operational measure of sensorimotor gating to examine early pre-attentive stages of information processing in females with interstitial cystitis/painful bladder syndrome and healthy controls.

MATERIALS AND METHODS

We assessed prepulse inhibition in 14 female patients with interstitial cystitis/painful bladder syndrome and 17 healthy controls at 60 and 120-millisecond prepulse-to-startle stimulus intervals. We evaluated group differences in prepulse inhibition, and relationships between prepulse inhibition, neuroticism and acute stress ratings.

RESULTS

Patients showed significantly decreased prepulse inhibition at 60 and 120-millisecond prepulse intervals. The prepulse inhibition deficit was related to acute stress ratings in the patients. However, increased neuroticism appeared to mitigate the prepulse inhibition deficit in those with interstitial cystitis/painful bladder syndrome, possibly reflecting greater vigilance.

CONCLUSIONS

Compared to healthy controls, female patients with interstitial cystitis/painful bladder syndrome had decreased ability to adequately filter incoming information and perform appropriate sensorimotor gating. These results suggest that a possible mechanism for altered interoceptive information processing in interstitial cystitis/painful bladder syndrome cases may be a general deficit in filtering mechanisms due to altered pre-attentive processing.

Correlates of urinary incontinence in community-dwelling older Latinos

The prevalence of urinary incontinence (UI) has varied in the literature and is reflective of the definition and sampling methodologies used, as well as the age, ethnicity, and sex being studied. The aim of the current study was to measure the prevalence and correlates of UI in a sample of 572 older Latinos participating in Caminemos, a trial of a behavioral intervention to increase walking. Participants completed an in-person survey and physical performance measures. UI was measured using the International Consultation on Incontinence item: "How often do you leak urine?" Potential correlates of UI included sociodemographic variables, body mass index, smoking, physical activity, medical comorbidity, physical performance, activity of daily living (ADL) impairment, use of assistive ambulatory devices, health-related quality of life (HRQoL), and depressive symptoms. The prevalence of UI in this sample was 26.9%. Women were more likely to report UI, as were those who were less physically active; used assistive ambulatory devices; and had depressive symptoms, greater medical comorbidity, worse physical performance, greater ADL impairment, worse cognitive function, and lower HRQoL. Multivariate logistic regression revealed that medical comorbidity was independently associated with higher rates of UI (odds ratio (OR)=1.66, 95% confidence interval (CI)=1.30-2.12), whereas better cognitive function (OR=0.73, 95% CI=0.57-0.93) and higher weighted physical activity scores (OR=0.77, 95% CI=0.60-0.98) were independently associated with lower rates of UI. UI is highly prevalent but not ubiquitous among community-residing older Latinos, suggesting that UI is not an inevitable consequence of aging. Future studies should examine whether interventions that decrease comorbidity and cognitive decline and increase physical activity improve continence status.

Thromboembolic complications of sling surgery for stress urinary incontinence among female Medicare beneficiaries

OBJECTIVES

To determine the rate of thromboembolic complications after sling surgery for stress urinary incontinence among female Medicare beneficiaries aged 65 and older.

METHODS

We analyzed the 1999-2001 Medicare public use files provided by the Centers for Medicare and Medicaid Services on a 5% national random sample of beneficiaries. Women undergoing sling procedures from January 1, 1999 to July 31, 2000 were identified by the Physicians Current Procedural Terminology Coding System (4th edition) codes and tracked for 12 months. Diagnoses of postoperative thromboembolism were identified with International Classification of Diseases (9th revision) codes. Multivariate analysis was used to determine independent risk factors for developing a thromboembolic event.

RESULTS

A total of 1356 slings were performed on patients in the 5% sample of female Medicare beneficiaries during the 18-month index period. Concomitant prolapse surgery was performed in 467 (34.4%) cases. At 3 months after surgery, thromboembolic complications had occurred in 0.9% women undergoing a sling alone and in 2.2% women undergoing concomitant prolapse surgery (P = .05). Multivariate analysis revealed that concomitant prolapse surgery was associated with nearly 3 times the odds of thromboembolic complications (odds ratio 2.86, 95% confidence interval 1.10-7.45).

CONCLUSIONS

Our results show a low rate of thromboembolism after an isolated sling procedure. However, we found an increased rate of deep venous thrombosis and pulmonary embolism among women undergoing sling surgery with prolapse repair, which emphasizes the need for appropriate deep venous thrombosis prophylaxis in this patient group.

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.

Increased startle responses in interstitial cystitis: evidence for central hyperresponsiveness to visceral related threat

PURPOSE

Hypersensitivity to visceral stimuli in interstitial cystitis/painful bladder syndrome may result from enhanced responsiveness of affective circuits (including the amygdala complex) and associated central pain amplification. Potentiation of the eyeblink startle reflex under threat is mediated by output from the amygdala complex and, therefore, represents a noninvasive marker to study group differences in responsiveness in this brain circuit.

MATERIALS AND METHODS

Acoustic startle responses were examined in female patients with interstitial cystitis/painful bladder syndrome (13) and healthy controls (16) during context threat (application of muscle stimulation electrodes to the lower abdomen overlying the bladder), and cued conditions for safety (no stimulation possible), anticipation and imminent threat of aversive abdominal stimulation over the bladder.

RESULTS

Patients showed significantly greater startle responses during nonimminent threat conditions (baseline, safe and anticipation periods) while both groups showed similar robust startle potentiation during the imminent threat condition. Higher rates of anxiety and depression symptoms in the patient group did not account for the group differences in startle reflex magnitude.

CONCLUSIONS

Compared to controls, female patients with interstitial cystitis/painful bladder syndrome showed increased activation of a defensive emotional circuit in the context of a threat of abdominal pain. This pattern is similar to that previously reported in patients with anxiety disorders as well as those with irritable bowel syndrome. Since these circuits have an important role in central pain amplification related to affective and cognitive processes, these results support the hypothesis that the observed abnormality may be involved in the enhanced perception of bladder signals associated with interstitial cystitis/painful bladder syndrome.

The effect of concomitant prolapse repair on sling outcomes

PURPOSE

We analyzed the effect of concomitant prolapse surgery performed at the time of sling surgery on short-term postoperative outcomes in women with urinary incontinence.

MATERIALS AND METHODS

We analyzed 1999 to 2001 Medicare claims data on a 5% national random sample of female beneficiaries who underwent sling procedures. Subjects were tracked for 12 months after surgery to assess short-term complications. Concomitant prolapse repairs and prolapse repairs performed in the first 12 months after sling surgery were identified by CPT-4 procedure codes. Postoperative complications and treatments were identified by ICD-9 diagnosis codes and CPT-4 procedure codes, respectively. Bivariate and multivariate analyses were performed to measure the effect of concomitant prolapse surgery on sling outcomes.

RESULTS

Concomitant prolapse repairs were performed in 34.4% of sling cases. Women who underwent prolapse repair at the time of the sling surgery were significantly more likely to be diagnosed with postoperative outlet obstruction (9.4% vs 5.5%, p <0.007) than those who did not. Women who underwent concomitant prolapse repair were less likely to undergo a repeat procedure for stress incontinence in postoperative year 1 (4.7% vs 10.2%, p = 0.0005). Multivariate analysis revealed that women who underwent prolapse repair at the time of the sling surgery were significantly less likely to undergo a reoperation for prolapse within 1 year after the sling surgery (OR 0.31, 95% CI 0.22-0.44).

CONCLUSIONS

Our findings suggest that addressing prolapse at the time of stress incontinence surgery may avoid an early repeat operation for either prolapse or stress incontinence. However, rates of postoperative outlet obstruction are higher.

The effect of age on outcomes of sling surgery for urinary incontinence

OBJECTIVES

To measure the effect of patient age on outcomes of sling surgery for stress urinary incontinence.

DESIGN

Analysis of Medicare claims data.

SETTING

Analysis of the 1999 to 2001 Medicare Public Use Files provided by the Centers for Medicare and Medicaid Services on a 5% national random sample of beneficiaries.

PARTICIPANTS

Women who underwent sling procedures between July 1, 1999, and December 31, 2000, were identified according to Common Procedural Terminology, Fourth Edition, code 57288 (sling operation for stress incontinence). Subjects were tracked for 6 months before surgery to identify preoperative comorbidities and for 12 months after surgery to assess short-term complications. Subjects were stratified for analysis at age 75.

MEASUREMENTS

Bivariate analyses were conducted with patients stratified at age 75, and multivariate analyses were also conducted to identify the independent effects of patient age and comorbidities on outcomes.

RESULTS

A total of 1,356 procedures were performed during the 18-month index period. This extrapolates to 27,120 procedures in all Medicare beneficiaries. At 1 year after surgery, overall outcomes in younger women (aged 65-74) were significantly better than in older women with respect to postoperative urge incontinence (20.0% vs 12.6%), treatment failure (10.5% vs 7.2%), and outlet obstruction (10.5% vs 6.6%). Older age and greater comorbidity were associated with greater risk of nonurological events (e.g., pulmonary embolism and cardiac events).

CONCLUSION

Women aged 75 and older are more likely to experience postoperative urge incontinence, treatment failure, and outlet obstruction after sling surgery. Older age and comorbidities were associated with higher rates of nonurological complications.

Familial transmission of urogenital prolapse and incontinence

PURPOSE OF REVIEW

To summarize recent evidence suggesting a genetic basis for the development of urogenital prolapse and stress urinary incontinence.

RECENT FINDINGS

Epidemiological evidence suggests that some women have a genetic predisposition to the development of urogenital prolapse and stress incontinence. Abnormal expression of various structural proteins is thought to be the molecular genetic mechanism for the development of these conditions. A group of families with an autosomal dominant pattern of transmission of urogenital prolapse with high penetrance has been identified. No similar cohort of families with familial stress incontinence currently exists, although candidate genes have been identified that appear to predispose women to urogenital prolapse and stress incontinence. Additionally, animal models of urogenital prolapse have been developed that closely parallel the development of prolapse in humans.

SUMMARY

A growing body of evidence suggests a genetic basis for the development of urogenital prolapse and stress incontinence. Candidate genes have been identified that may result in alteration of the normal metabolism of various structural proteins which may ultimately predispose some women to both urogenital prolapse and stress incontinence. Further research into the genetic basis of these conditions may provide a comprehensive understanding of the biological basis of these disorders.

The effects of bilateral caudal epidural S2-4 neuromodulation on female sexual function

This is a pilot study to evaluate the effects of caudal epidural S2-4 neuromodulation on female sexual function in a population of women with voiding dysfunction. We prospectively studied 36 consecutive female patients who underwent caudal epidural sacral neuromodulation. Patients received the Female Sexual Function Index (FSFI) questionnaire preoperatively and 6 months postoperatively. Six months after permanent implantation, the overall score on the FSFI improved by 52% (p = 0.05). Results were better in patients who underwent the treatment for voiding dysfunction compared to those who had pain as their primary complaint. In this group, the overall score improved by 157% (p = 0.004). Stimulation of S2-4 by bilateral caudal epidural neuromodulation in this small group of women with voiding dysfunction, retention, and/or pelvic pain resulted in self-reported improvements in sexual function. Further studies are needed to evaluate the potential role of S2-4 sacral stimulation in the treatment of female sexual dysfunction.

Short-term results of bilateral S2-S4 sacral neuromodulation for the treatment of refractory interstitial cystitis, painful bladder syndrome, and chronic pelvic pain

We evaluated the efficacy of bilateral caudal epidural sacral neuromodulation for the treatment of refractory chronic pelvic pain (CPP), painful bladder syndrome, and interstitial cystitis (IC). Thirty consecutive patients (21 female, 9 male) with severe refractory symptoms underwent bilateral S2-S4 sacral neuromodulation for CPP/IC. Patients were evaluated with the O'Leary IC symptom and problem index (ICSI, ICPI), the short form of the Urogenital Distress Inventory (UDI-6), and the RAND 36-item health survey (SF-36) preoperatively and 6 months postoperatively. The mean and minimum follow-up were 15 and 6 months, respectively. Of the 30 patients, 23 (77%) had a successful trial stimulation and were permanently implanted. Among these patients, the ICSI and ICPI scores improved by 35 (p = 0.005) and 38% (p = 0.007), respectively. The pain score improved by 40% (p = 0.04) and the UDI-6 score by 26% (p = 0.05). On average, patients reported a 42% improvement in their symptoms. SF-36 scores did not improve significantly. In refractory patients, bilateral caudal epidural sacral neuromodulation is another possible mode of treatment, which appears to improve both pelvic pain and voiding symptoms.

The Role of Preoperative Testing on Outcomes After Sling Surgery for Stress Urinary Incontinence

PURPOSE

In this study we analyzed Medicare claims data to measure the effect of preoperative urodynamics and cystoscopy on outcomes after sling surgery.

MATERIALS AND METHODS

We analyzed 1999 to 2001 Medicare claims data on a 5% national random sample of beneficiaries. Women who underwent sling procedures between July 1, 1999 and December 31, 2000 were identified on the basis of the presence of CPT-4 code 57288 (sling operation for stress incontinence). Subjects were tracked for 6 months before surgery to identify type of preoperative studies performed (urodynamics and cystoscopy) and for 12 months after surgery to assess short-term complications.

RESULTS

Of 1,356 subjects 24.8% underwent preoperative cystoscopy and 27.4% underwent preoperative urodynamic testing. In postoperative year 1, 32.4% of subjects underwent cystoscopy and 30.5% underwent urodynamics. Patients who underwent preoperative urodynamics were more likely to be newly diagnosed with urge incontinence after surgery (21.9% vs 12.7%, p <0.0001). Those who underwent preoperative cystoscopy were significantly more likely to be diagnosed with (9.4% vs 6.1%, p <0.043) or treated for (10.6% vs 7.2%, p <0.047) outlet obstruction postoperatively than those who did not. Multivariate analysis revealed that subjects who underwent preoperative urodynamics were significantly less likely to undergo postoperative urodynamics than those who did not (OR 0.34, 95% CI 0.24-0.48).

CONCLUSIONS

Our findings of worse outcomes among women who underwent preoperative testing may be due in part to case selection. Our finding that women who underwent preoperative urodynamics were only a third as likely to undergo postoperative urodynamics as those who did not supports the use of urodynamics in the preoperative setting. However, the true effect of urodynamics on sling outcomes remains controversial.

Severe cystocele: Optimizing results

Despite multiple variations in cystocele repair techniques, success rates have been historically low. In this review we summarize strategies to optimize long-term results of vaginally approached cystocele repair for the high-grade defect. Our proposed strategies include addressing prolapse of the vaginal apex (the uterus or the vaginal cuff), using the obturator fascia as an anchor for lateral cystocele defect repair, augmenting the repair with loosely woven polypropylene mesh, and placing a midurethral sling.

Variations in stress incontinence and prolapse management by surgeon specialty

PURPOSE

Numerous studies have documented a relationship between provider specialty and outcomes for surgical procedures. In this study we sought to determine the effect of surgeon specialty on outcomes of sling surgery for women with stress urinary incontinence.

MATERIALS AND METHODS

We analyzed the 1999 to 2001 Medicare claims data from a 5% national random sample of Medicare beneficiaries. Women 65 years or older who underwent a sling procedure between July 1, 1999 and December 31, 2000 were identified on the basis of CPT-4 codes and tracked for 12 months. Key complications were identified using CPT-4 and ICD-9 revision codes for relevant procedures and diagnoses. Outcomes were compared between urologists and gynecologists.

RESULTS

A total of 1,356 sling procedures were performed. Of them 1,063 (78.4%) were performed by urologists, while 246 (18.1%) were performed by gynecologists. Urologists performed concomitant prolapse repairs in 29.1% of cases, and gynecologists performed prolapse repairs in 55.7% (p <0.0001). In the 12 months following sling surgery, urologists were more likely than gynecologists to perform a repeat incontinence procedure (9.3% vs 4.9%, p = 0.024) and prolapse repair (26.0% vs 12.2%, p <0.0001). The 2 surgical specialties did not differ in postoperative outlet obstruction, urological complications, or nonurological complications.

CONCLUSIONS

Early prolapse management by gynecologists corresponded to fewer prolapse repairs in the year following the sling. Our findings suggest that gynecologists are more likely to identify and manage prolapse at the time of the evaluation of urinary incontinence, a strategy that appears to avoid the morbidity and cost of repeat surgery.

Bilateral Caudal Epidural Neuromodulation for Refractory Urinary Retention: A Salvage Procedure

PURPOSE

Sacral neuromodulation with InterStim is approved for idiopathic urinary retention with a success rate of approximately 69%. To our knowledge currently no alternatives exist for patients in whom S3 neuromodulation fails. We report a new technique and our experience with bilateral caudal epidural neuromodulation in patients in urinary retention in whom unilateral or bilateral S3 InterStim failed.

MATERIALS AND METHODS

Eight patients with multifactorial urinary retention in whom S3 InterStim previously failed underwent retrograde placement of bilateral tined leads into the caudal epidural space for sacral nerve stimulation. Patients with a 50% or greater clinical response underwent stage 2 Synergy-Versitrel implantable pulse generator placement. Patients were evaluated with voiding diaries, the Urinary Distress Inventory Questionnaire short form, quality of life assessment, need for catheterization and post-void residual urine preoperatively, and 6 months after implantation.

RESULTS

Five of the 8 patients experienced return of micturition and underwent placement of a permanent implantable pulse generator. At 6-month followup 4 of the 5 patients voided to completion. One patient improved more than 50% and now catheterizes once daily with a post-void residual urine of 200 cc. There was a significant decrease in obstructive symptoms on the Urinary Distress Inventory Questionnaire short form and improved overall quality of life.

CONCLUSIONS

To our knowledge this is the first report of the use of bilateral caudal epidural neuromodulation for refractory urinary retention. This therapy can be successful in patients in whom prior InterStim therapy failed.

Racial Disparities in the Surgical Management of Stress Incontinence Among Female Medicare Beneficiaries

PURPOSE

The relationship between urinary incontinence and race/ethnicity is poorly understood. We analyzed Medicare claims data to identify racial differences in the diagnosis, treatment and outcomes of women with stress urinary incontinence.

MATERIALS AND METHODS

We analyzed the 1999 to 2001 Medicare Public Use Files provided by the Centers for Medicare and Medicaid Services on a 5% national random sample of beneficiaries. Women 65 years or older with a diagnosis of stress urinary incontinence were identified on the basis of International Classification of Diseases, 9th revision codes. Those who underwent an autologous or synthetic sling procedure during the index period were identified on the basis of Physicians Current Procedural Terminology Coding System, 4th edition codes. Racial differences in diagnosis, treatment and outcomes were compared.

RESULTS

Of all female Medicare beneficiaries older than 65 years overall only 1.1% had a claim that listed a diagnosis of stress urinary incontinence. White women were more likely than nonwhite women to have a claim listing a diagnosis of stress urinary incontinence. Approximately 27,120 slings were performed on the Medicare population during the study period. Among women with a diagnosis of stress urinary incontinence white and Hispanic women were disproportionately more likely to undergo a sling than were black or Asian women (p<0.01). After controlling for age and comorbidities, nonwhite women undergoing sling surgery were twice as likely to develop nonurological complications, pelvic organ prolapse and urinary obstruction within 1 year postoperatively.

CONCLUSIONS

We identified racial differences in the frequency of diagnosis of stress urinary incontinence, frequency of sling procedures and rate of postoperative complications after sling surgery. Further research is necessary to determine whether such differences are due to racial differences in incontinence incidence and severity or disparities in care for minorities.

The Role of Provider Volume on Outcomes After Sling Surgery for Stress Urinary Incontinence

PURPOSE

Studies of various surgical procedures have documented a relationship between provider volume and outcomes, suggesting that providers who perform a high volume of procedures provide better quality of care. We ascertained whether this relationship held in sling surgery for urinary incontinence.

MATERIALS AND METHODS

We analyzed the 1999 to 2001 Medicare Public Use Files provided by the Centers for Medicare and Medicaid Services for a 5% national random sample of beneficiaries. Women undergoing pubovaginal sling procedures between July 1, 1999 and December 31, 2000 (the index period) were identified and followed for 12 months. The number of slings performed was stratified empirically by cumulative surgeon volume. Main outcomes measures included postoperative complications, concomitant or delayed prolapse repair, outlet obstruction and repeat incontinence surgery.

RESULTS

Among the 5% of Medicare beneficiaries analyzed during the index period 1,356 sling procedures were performed. This extrapolates to 27,120 slings in the entire Medicare population. High volume providers (upper 24th percentile) performed significantly more prolapse repairs at the time of sling surgery than did low volume providers (40.8% vs 32.4%, p <0.006). Subsequently low volume providers performed almost twice the number of prolapse repairs during the first postoperative year following the index sling procedure (p <0.0001). There was no significant difference in complication rates or repeat anti-incontinence procedures between high and low volume providers.

CONCLUSIONS

High volume surgeons were more likely to perform concomitant prolapse surgery at the time of sling surgery, whereas low volume providers had higher reoperation rates to correct prolapse during the first postoperative year. This suggests that high volume providers are more likely to diagnose and manage prolapse at the time of the sling, obviating the need for a second operation.

Complications of sling surgery among female Medicare beneficiaries

OBJECTIVE

To analyze Medicare claims data to determine short-term complications after sling surgery among female beneficiaries aged 65 years and over.

METHODS

We analyzed the 1999-2001 Medicare Public Use Files provided by the Centers for Medicare and Medicaid Services on a 5% national random sample of beneficiaries. Women undergoing sling procedures between January 1, 1999, and July 31, 2000, (the index period) were identified by Physicians Current Procedural Terminology Coding System (4th edition) and tracked for 12 months. Main outcome measures were complications as identified by International Classification of Diseases (9th revision) (ICD-9) diagnosis codes and Current Procedural Terminology procedure codes in the first postoperative year.

RESULTS

A total of 1,356 sling procedures were performed during the index period. In the 3 months after the procedure, 12.5% of women developed surgical or urologic complications, and 33.6% were diagnosed with urinary tract infections. Within 1 year of the procedure, 6.9% of subjects had a new diagnosis of outlet obstruction, and 8.0% underwent treatments to manage outlet obstruction. There was a high incidence of new diagnoses of urge incontinence (15.2%) and treatment of pelvic prolapse (23.2%). Both cystoscopy and urodynamic testing, which may serve as indicators of possible complications, were performed frequently during the first year after surgery (32.4% and 30.5%, respectively). Patient race, age, and comorbidity each had a significant influence on outcomes.

CONCLUSION

Complication rates within 1 year after sling surgery among Medicare beneficiaries were found to be higher than those reported in the clinical literature. The high rates of postoperative urinary tract infections, prolapse, and outlet obstruction suggest the need for quality improvement measures in the management of women with incontinence and pelvic prolapse.

LEVEL OF EVIDENCE

III.

Bladder necrosis following hydrodistention in patients with interstitial cystitis

PURPOSE

Bladder hydrodistention is used to diagnose and treat patients with interstitial cystitis. This procedure has been shown to have minimal morbidity and provide symptomatic relief in a subset of patients with interstitial cystitis. We report our experience with almost total bladder necrosis after hydrodistention at 2 institutions. To our knowledge this rare complication has not been previously reported in the literature. We also reviewed the literature regarding complications of hydrodistention and discuss their possible etiology.

MATERIALS AND METHODS

We report 3 cases of bladder necrosis after therapeutic hydrodistention for interstitial cystitis at 2 institutions. All records were reviewed, and the clinical presentation, findings and treatments are discussed. A literature review was performed to evaluate the effectiveness and complications of hydrodistention for interstitial cystitis.

RESULTS

There were 2 female and 1 male patient between ages 29 and 46. All patients had a previous diagnosis of interstitial cystitis and had been previously treated with hydrodistention. All patients presented with severe abdominal pain and had necrosis of the entire bladder wall with sparing of the trigone. Two patients were treated with supratrigonal cystectomy. A review of the literature revealed little data on the effectiveness of hydrodistention for interstitial cystitis.

CONCLUSIONS

Vesical necrosis is a rare but devastating complication of hydrodistention. It can occur in young patients in the absence of a contracted bladder and it usually presents as severe postoperative abdominal pain. At exploration bladder necrosis with sparing of the trigone was observed. All patients required enterocystoplasty.

The prevalence of urinary incontinence among community dwelling men: results from the National Health and Nutrition Examination survey

PURPOSE

To measure the prevalence of urinary incontinence in community dwelling men in the United States, we analyzed data from respondents to the National Health and Nutrition Examination Survey.

MATERIALS AND METHODS

From 1999 to 2000 the National Health and Nutrition Examination Survey asked a national sample of community dwelling men, "In the past 12 months, have you had difficulty controlling your bladder, including leaking small amounts of urine when you cough or sneeze?" Questionnaire results were recorded and analyzed with respect to demographic data, and compared to the National Health and Nutrition Examination Survey data in women.

RESULTS

The overall prevalence of urinary incontinence in men was 17%. Prevalence increased with age from 11% in men 60 to 64 years old to 31% in men 85 years old or older. Of the men reporting any incontinence 42% reported daily incontinence and 24% reported it weekly. Black men had the highest prevalence of male incontinence (21%) and black women had the lowest prevalence of female incontinence (20%). While the prevalence of incontinence in black women was virtually the same as that in black men, the prevalence of incontinence in white and Mexican-American women was at least 2.5 times that of men of the same ethnicity.

CONCLUSIONS

The National Health and Nutrition Examination Survey draws a nationally representative sample of subjects from the community and, thus, provides prevalence data for urinary incontinence for all men in the United States. Ethnicity appears to be a contributing risk factor for incontinence, although racial patterns clearly differ between men and women.

Sequence variant in the laminin gamma1 (LAMC1) gene associated with familial pelvic organ prolapse

Pelvic organ prolapse is a common condition, affecting up to a third of women throughout their lifetime. Genetic factors are believed to account for about 30% of the incidence, and are the least understood component of the disorder. Familial cases, particularly those in which prolapse manifests in young women, are especially valuable in the effort to find the genes involved. We recently reported autosomal dominant transmission as the most likely mode of inheritance, based on a collection of families with high incidence of prolapse. Of greatest interest was a family in which three generations of female relatives suffered from prolapse at a very young age. A genome-wide linkage scan performed using the Affymetrix GeneChip Human mapping 10K array identified ten regions with a LOD score of 1.5, the maximum possible for this family. Candidate genes within those regions were analyzed for expression in vaginal tissue by RT-PCR. Of the genes confirmed to be expressed, LAMC1 was further evaluated by sequencing and select single nucleotide polymorphism (SNP) genotyping for causative sequence variants in affected family members. We identified one such SNP, rs10911193. The rare T variant segregating with the condition is present at a frequency of 4.9% in the general population and 22% among probands from our cohort of families. It affects the binding site for NFIL3, a transcription factor that we verified to be co-expressed in vaginal tissue. Altogether these data suggest that a polymorphism in the promoter of LAMC1 may increase the susceptibility to early-onset pelvic organ prolapse.

Clonogenic multipotent stem cells in human adipose tissue differentiate into functional smooth muscle cells

Smooth muscle is a major component of human tissues and is essential for the normal function of a multitude of organs including the intestine, urinary tract and the vascular system. The use of stem cells for cell-based tissue engineering and regeneration strategies represents a promising alternative for smooth muscle repair. For such strategies to succeed, a reliable source of smooth muscle precursor cells must be identified. Adipose tissue provides an abundant source of multipotent cells. In this study, the capacity of processed lipoaspirate (PLA) and adipose-derived stem cells to differentiate into phenotypic and functional smooth muscle cells was evaluated. To induce differentiation, PLA cells were cultured in smooth muscle differentiation medium. Smooth muscle differentiation of PLA cells induced genetic expression of all smooth muscle markers and further confirmed by increased protein expression of smooth muscle cell-specific alpha actin (ASMA), calponin, caldesmon, SM22, myosin heavy chain (MHC), and smoothelin. Clonal studies of adipose derived multipotent cells demonstrated differentiation of these cells into smooth muscle cells in addition to trilineage differentiation capacity. Importantly, smooth muscle-differentiated cells, but not their precursors, exhibit the functional ability to contract and relax in direct response to pharmacologic agents. In conclusion, adipose-derived cells have the potential to differentiate into functional smooth muscle cells and, thus, adipose tissue can be a useful source of cells for treatment of injured tissues where smooth muscle plays an important role.

Failure of Sacral Nerve Stimulation Due to Migration of Tined Lead

PURPOSE

Stimulation of the sacral nerves is a commonly used treatment for frequency, urgency, urge incontinence, retention and other types of voiding dysfunction. Minimally invasive placement of a percutaneous permanent quadripolar tined lead into the sacral foramen has been described. No lead migration has been reported. We report on our experience with lead migration and the subsequent failure of InterStim in a large cohort of patients with a focus on possible diagnostic and salvage techniques.

MATERIALS AND METHODS

Between February 2002 and April 2005 tined lead electrodes were implanted in the S3 foramen in 235 patients using the InterStim system. Patients with a good response during the testing phase (greater than 50% improvement) underwent placement of an implantable pulse generator. Position was confirmed by radiographic evaluation intraoperatively. Sacral radiographs were obtained at the first postoperative visit, after IPG placement and whenever there was a change in symptomatic response.

RESULTS

There were 5 patients (2.1%) in whom treatment failed after a successful trial of stimulation due to lead migration. This was seen as early as 3 weeks and as late as 8 months. Migration of the lead occurred between first and second stage implantation in 1 of the 5 cases, and occurred after the second stage in 4 of 5. Anterior migration was noted in 4 patients and posterior migration was noted in 1.

CONCLUSIONS

Lead migration after placement of the tined lead can occur and thus sacral radiographs should be routinely used. This complication can be easily resolved without significant morbidity to the patient.

Spiral Sling Salvage Anti-Incontinence Surgery in Female Patients With a Nonfunctional Urethra: Technique and Initial Results

PURPOSE

Female patients with severe urethral incompetence are a unique surgical challenge. Urethral closure and continent diversion are often the next step in the treatment of these patients. We present a technique that provides circumferential coaptation of the urethra as a salvage procedure in this severe subset of patients.

MATERIALS AND METHODS

We prospectively evaluated 47 patients who had a spiral sling. A 1 x 15 cm piece of soft polypropylene mesh was prepared with a zero polyglactin suture applied at each end. A clamp was used to pass the mesh between the urethra and pubis. The ends of the mesh were crossed at the ventral aspect of the urethra, creating a complete circle around the urethra. The sutures were transferred to the suprapubic area and tied without tension. The surgical outcome was determined by patient self-assessment, including symptom, bother and quality of life questionnaires.

RESULTS

Mean patient age was 59 years. At presentation patients had undergone a mean of 2.6 incontinence procedures and wore a mean of 6 pads daily. Mean daily pad use decreased to 0.9 (p <0.005). Preoperatively mean SUI symptom severity and bother scores were 2.8 and 2.9, respectively, on a scale of 0--none to 3--severe. Postoperatively these values decreased to 0.6 and 0.4, respectively (each p <0.005). There was a mean 87% overall improvement in symptoms.

CONCLUSIONS

The spiral sling is an effective salvage transvaginal procedure that may be considered in a small subset of female patients with a nonfunctional urethra as a last resort before urethral closure procedures.

True prevalence of urinary incontinence among female nursing home residents

OBJECTIVES

Urinary incontinence is a significant problem in nursing home residents in the United States. Estimates of its prevalence have often been based on data from medical records obtained at nursing home admission. To measure the sensitivity of this method of defining the prevalence of urinary incontinence among female nursing home residents, we examined data from a clinical survey.

METHODS

We analyzed data from the National Nursing Home Survey, which collected information from nursing homes for each resident concerning admission diagnoses, presence of an indwelling Foley catheter or ostomy, need for assistance from equipment or personnel in using the toilet, and difficulty controlling urination.

RESULTS

Residents' medical records revealed a very low rate of admission diagnoses of incontinence. However, clinical queries revealed a high prevalence of bladder dysfunction. More than one half of all female nursing home residents were reported to have "difficulty controlling urination," and more than one half needed assistance in using the toilet.

CONCLUSIONS

Although only 1% to 2% of nursing home residents have a diagnosis of urinary incontinence, the true prevalence of bladder dysfunction in this group is much greater. The sharp divergence of National Nursing Home Survey data from published studies on the prevalence of incontinence in nursing homes highlights the limitations of using administrative data to study the epidemiology of bladder dysfunction.

Long-Term Durability of the Distal Urethral Polypropylene Sling Procedure for Stress Urinary Incontinence: Minimum 5-Year Followup of Surgical Outcome and Satisfaction Determined by Patient Reported Questionnaires

PURPOSE

We report on the long-term outcomes of the distal urethral polypropylene sling.

MATERIALS AND METHODS

We performed a prospective study of all consecutive patients who underwent a distal urethral polypropylene sling procedure between November of 1999 and April of 2000 for treatment of SUI. Surgical outcome was determined by patient self-assessment, and included symptom, bother and quality of life questionnaires. Physicians were blinded to patient responses. All patients had a minimum 5-year followup. Every patient treated was included in reporting outcomes in the intent to treat analysis.

RESULTS

There were 69 patients treated a minimum of 5 years before the analysis. Cases lost to followup were defined as treatment failures. At a minimum followup of 5 years patient determined subjective success rate was 88%. More than 5 years after surgery 72% of patients reported no symptoms of SUI and 74% reported never being bothered by SUI. Patients reported an overall mean improvement of symptoms of 81%, and quality of life due to urinary symptoms between pleased and mostly satisfied.

CONCLUSIONS

The distal urethral polypropylene sling procedure has low morbidity and excellent durability in treating patients with SUI.

Perineocele: Symptom complex, description of anatomic defect, and surgical technique for repair

OBJECTIVES

To describe the patient characteristics, physical examination and magnetic resonance imaging findings, and method of surgical repair of perineocele. A perineocele is a rare condition of an isolated central defect and herniation of the posterior perineum in patients without diffuse vaginal prolapse.

METHODS

The evaluation consisted of history and physical examination and magnetic resonance imaging. With the patient in the dorsal lithotomy position, an inverted Y incision was made from the posterior vagina to the posterior rectum. The transverse perineal musculature, superficial perineal membrane, and external anal sphincter were approximated. The perineal distance from the posterior fourchette to the anus was measured preoperatively and postoperatively. Symptom and anatomic assessments were done at each postoperative visit.

RESULTS

A total of 6 patients were treated, with a mean follow-up of 9.5 months. The symptoms at presentation consisted of perineal pressure, severe constipation, and the need for manual perineal reduction for defecation. The physical findings included a lack of vaginal prolapse, convexity of the perineum, and an increase in the distance from the posterior fourchette to the rectum. Dynamic magnetic resonance imaging showed no anomaly of the vaginal wall. Preoperatively, the average perineal distance was 11.2 cm and postoperatively it was 4 cm. The perineocele was successfully repaired in all patients. All but 1 patient had significant relief of constipation.

CONCLUSIONS

Posterior levator defects can result in perineal hernia with perineal body attenuation, separation of the transverse perineal and anal sphincter musculature, and development of a perineocele. The relief of symptoms and correction of the anatomic defect can be achieved by reapproximation of these structures.

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.

Transvaginal paravaginal repair of high-grade cystocele central and lateral defects with concomitant suburethral sling: Report of early results, outcomes, and patient satisfaction with a new technique

Baden-Walker classification grade III-IV (pelvic organ prolapse quantification [POP-Q] system stage III-IV) cystocele is associated with a constellation of abnormalities including urethral hypermobility, lateral defect, central defect, and concomitant vault and posterior wall prolapse. We describe a new transvaginal paravaginal technique to correct this group of abnormalities and report on our early results. We prospectively evaluated patients with high-grade cystocele who underwent repair with the new transvaginal paravaginal repair. Preoperative evaluation included history and physical examination, dynamic pelvic magnetic resonance imaging, urodynamics, and symptom questionnaire. All patients first underwent a distal urethral polypropylene sling surgery. After repair of the central defect of the cystocele, a paravaginal repair of the lateral defect was performed by using a circular 5 cm x 5 cm soft polypropylene mesh attached proximally to the sacrouterine/cardinal ligament, distally to the bladder neck, and laterally to the infralevator obturator fascia. Postoperative evaluation at 3-month intervals included history and physical examination using the POP-Q system, a voiding dysfunction and incontinence symptom questionnaire, the validated short form of the Urogenital Distress Inventory (UDI-6), a validated global quality-of-life question, and a postvoid residual. We performed the repair in 98 patients with a mean age of 65 years (range, 40 to 86 years). Of these, 26% underwent concomitant vaginal hysterectomy, 45% had enterocele repair, and 94% had rectocele repair. There were 2 complications, including transient ureteral obstruction due to bladder wall hematoma and 1 patient who presented with a recurrent enterocele requiring surgical repair. No patient experienced urinary retention. De novo stress urinary incontinence was seen in 3 patients; de novo urge incontinence was seen in 2 patients. Postoperative POP-Q scores showed 85% of patients with stage 0-I, 13% with stage II, and 2% with stage III anterior vaginal wall prolapse. Of patients with preoperative stress urinary incontinence, 70% reported never experiencing symptoms under any circumstances. Quality of life improved from 4.7 to 1 (P < 0.005). Transvaginal paravaginal repair of grade III-IV cystocele using soft polypropylene mesh fixed to the obturator fascia, sacrouterine ligaments, and bladder neck area provides excellent support of the central defect repair as well as repair of the lateral defect. The operation is safe, simple, and outpatient based, and provides excellent anatomic results with minimal complications. Concomitant distal polypropylene sling did not increase the rate of complications and did not compromise results of stress urinary incontinence surgery.