[Clinical and urodynamic experience with intravesical hyaluronic acid in painful bladder syndrome associated with interstitial cystitis]

INTRODUCTION

few studies have been carried out on therapeutic options in patients with painful bladder syndrome associated with interstitial cystitis. The aim is to verify the safety and effectiveness of treatment with sodium hyaluronate through intravesical instillation in patients with painful bladder syndrome.

MATERIALS AND METHODS

a series of 18 female patients is presented, with a mean age of 51 years and prior diagnosis of painful bladder syndrome, who were treated by means of the weekly infusion of an intravesical solution of 40mg of sodium hyaluronate in sterile solution, over a period of eight weeks. The patients were examined clinically and urodynamically prior to their inclusion in the study and eight months after the instillations had concluded.

RESULTS

there was a statistically significant improvement in the urodynamic parameters and in the symptoms measured quantitatively by means of the questionnaire "Pelvic Pain and Urgency/Frequency" between the baseline situation and after the vesical instillation of sodium hyaluronate in patients with painful bladder syndrome. There was no toxicity arising from the treatment, given that no adverse effects were recorded in relation to it.

CONCLUSION

the clinical use of intravesical hyaluronic acid in patients with painful bladder syndrome possibly associated with interstitial cystitis has been demonstrated. The clinical improvement is also associated both with increased bladder capacity and improved bladder sensitivity. Tolerance was excellent. Clinical tests that more profoundly evaluate the therapeutic potential of this drug in this type of patients are required.

[Nocturia is not associated with falls among the elderly: a population study in the city of São Paulo]

INTRODUCTION

the present study aims to evaluate the association between nocturia and falls in a group of community-living elderly men in the city of São Paulo (Brazil).

MATERIAL AND METHODS

under the coordination of the Pan American Health Organization and World Health Organization, a multicenter study named Health, Welfare and Aging (SABE Study) is being conducted to evaluate the living and health conditions of older people in Latin America and Caribbean. In Brazil, this study is evaluating the elderly population (60 years or more) in São Paulo since 2000. The presence of nocturia was taken as the response "yes" to the question "Do you need to void three times or more at night?" .The presence of falls was also taken as the response "yes" to the question "Did you have any fall during the last 12 months?" The intergroup analysis used was the logistic regression.

RESULTS

total of 865 men was interviewed, mean age 68 years. It was observed high prevalence of nocturia and falls in all groups, with higher prevalence of both in the eldest group (p<0.001), however, the association of nocturia and falls was not statistically significant in any of the groups (p=0.45).

CONCLUSION

this is one of the pioneering studies that assess only the male population, showing that nocturia was not significantly associated with falls. Nocturia and falls are highly prevalent conditions in the elderly, but no association was found between both, so that these variables may be correlated to age and other clinical conditions.

[Behavioral group-based therapy improves quality of life in men recovering from radical prostatectomy]

BACKGROUND

This study evaluated the efficacy of 24-week, group-based, behavioral therapy in improving quality of life (QoL) among men treated for localized prostate carcinoma (PC) by means of radical prostatectomy (RP) who presented treatment-related dysfunctions: urinary incontinence (UI) and erectile dysfunction (ED).

PATIENTS AND METHODS

Thirty men were assigned to 24-week behavioral group therapy. The intervention was designed to improve QoL by helping participants to identify and effectively manage stressful experiences. It focused on treatment-related sequelae from PC. Differences in variables were compared between the beginning and end of the study by means of Student's t test for paired samples. Multiple analysis was carried out by stepwise multiple linear regression following bivariate Pearson's correlation analysis. This was achieved for all predictors (i.e. general health perception, ED and UI impact) and relevant covariates (i.e. age, work/retirement status, alcohol addiction, attitude towards cancer and surgery, sexual satisfaction, and future plans).

RESULTS

In all patients the time elapsed from surgery to attending the behavioral group therapy exceeded 24 months. There was no significant correlation between this time and the predictor variables. General health perception scores decreased by the end of the study (p = 0.000), as did the UI impact score (p = 0.023), thus denoting improvement in both factors. The difference in UI impact scores correlated negatively and significantly with both age (p = 0.04) and work/retirement (p = 0.05). Multiple stepwise regression showed that age was the most important variable (r2 = 26.0%). Considering age and work/retirement simultaneously, there was an increase of 10.3% (r2 = 36.3%). ED increased by the end of the study (p = 0.000), and the difference between the ED scores correlated positively and significantly with sexual satisfaction alone (p = 0.029), which signifies that previous sexual satisfaction had a positive influence over erectile dysfunction (r2 = 15.8%).

CONCLUSION

24-week behavioral group therapy was effective in improving the perceived QoL among men treated for PC. There were changes associated with the therapy, particularly the improvement in UI and ED.

[Urodynamic studies about the use of the valsalva maneuver in the urination of men with inguinal hernias above the age of fifty]

OBJECTIVE

To verify if the Valsalva Maneuver during urination in patients with inguinal hernias is associated with specific urodynamic findings.

METHOD

Men, of over 50 years of age, who had inguinal hernias and visited a general surgery unit between May 2003 and November 2005, underwent an urodynamic study. They were mainly evaluated according to average urethral resistance (URA), the detrusal isometric contractibility (Pw) and urinal residue. The patients were divided into two groups: in the first group the Valsalva maneuver was not used during urination (Group I) while in the second group the Valsalva maneuver was employed (Group II). Initially, the data was expressed using the averages of the analysed parameters; they were then dichotomised according to the reference values. In order to carry out the statistical analysis, the qui quadrant and non conditional logistic regression were used.

RESULTS

One hundred patients took part in the research with an average age of 64.2 years of age (SD of +/- 9.7 years). Group I was made up of 52 patients and Group II of 48 patients. The averages of the urodynamic parameters were compared between the two groups. It was found that the Group that carried out the Valsalva maneuver while urinating showed a damaged detrusal contractibility (p < 0.01) and an increased urinal residue (p < 0.02). When using logistic regression in order to express the odds ratios. The OR value was found to be 2.57 (IC 95%: 1.09-6.06) in the detrusal hypocontractibility group.

CONCLUSION

The Valsalva Maneuver during urination is associated with the presence of detrusal hypocontractibility in patients affected by inguinal hernia.

[Three dimensional anatomy and virtual surgery for transobturator approach]

INTRODUCTION

Stress Urinary Incontinence (SUI) may be managed by transobturator approach. We developed a three-dimensional model, for understanding the surgical anatomy and manual training as well, in order to reduce the learning curve for pelvic surgeries.

OBJECTIVE

To demonstrate in synthetic models, the anatomical basis for the management of SUI and cystocele.

METHOD

The anatomical model includes: pelvic bones, the main layers of the pelvic muscles, ligaments and fascias. The surgical devices were transobturator needles, synthetic slings and meshes for anterior vaginal wall repair. The workshop was carried out with an anatomical overview and hands-on training in this tridimentional models and finally surgery in animals. At the end, a questionnaire was applied to verify the impact of this tool in the learning process and trainee satisfaction.

RESULTS

As far as the anatomical concept, 90% (n=72) of the participants classified this model as very good and 10% (n=8) as good. As a tool for understanding the tridimentional pelvic floor anatomy applied to transobturator procedures there were 100% of approval.

CONCLUSIONS

This synthetic model allows for understanding the pelvic floor tridimentional anatomy and surgical procedures as well. Further skill is got in the animal model reducing the learning curve for transobturator procedures.

Evaluación de la función sexual femenina antes y después de un procedimiento para la corrección de la incontinencia urinaria de esfuerzo

The prevalence of urinary incontinence is around 20% of healthy middle-aged women. Incontinence causes a negative impact on the quality of life and sexuality. From August 2002 to January 2004, 30 patients (mean age 43 years) with stress urinary incontinence (59%), overactive bladder (15%) and mixed incontinence (26%) answered the ICIQ-SF(International Consultation on Incontinence Questionnarie-Short Form) and FSFI (Female Sexual Function Index) questionnaires before and after treatment for urinary incontinence. The follow-up ranged from 12 to 53 months. Mean ICIQ score was 17 and 7 before and after treatment respectivelly (p<0,001). Overactive bladder showed the worst scores in all domains. The patients who underwent surgery increased their scores of desire (p=0,02), satisfaction (p=0,05) and total score (p=0,02). Thirteen patients which ICIQ was zero increased: desire (p<0,01), satisfaction (p=0,05) and total score (p=0,01). Urinary incontinence significantly affects the quality of life. Therefore sexual evaluation in incontinence patients is recommended.

Corrección transobturatoria de los cistoceles

OBJECTIVE

We present our initial experience with the Perigee system for anterior vaginal wall prolapses repair.

MATERIAL AND METHOD

15 patients with anterior vaginal wall prolapse (mean age: 62 years old) underwent implanted with Perigee system which is composed by a mesh for correcting central defect and four self-attached horns for correcting lateral defect. The implanted procedure consist of four steps: 1) lateral vaginal wall dissection as far as isquiopubic branch; 2) performance of two upper marks at genitofemoral fold and two lower marks at 2 cm laterally and 3 cm lower; 3) insertion of the upper needles parallel to the isquiopubic branch and connection with the mesh's "arms" plus insertion of the lower needles vertically and connection with mesh's "legs"; 4) to adjust the mesh free tension. The system POP-Q was used as an objective measure of correction rate.

RESULTS

Preoperatively, the point Aa was 0.09. After 6 weeks and three months postoperatively was -3.00 and -2.73 respectively. Preoperatively, the point Ba was 1.73. After 6 weeks and three months postoperatively was -2.82 and -2.82 respectively. No major complications were presented. No vascular damage or significant bleeding was observed.

CONCLUSION

The transobturator correction of cystocele is an attractive alternative. The initial good outcome may be expected to be long lasting.

Correlación entre los prolapsos urogenitales y la presencia de detrusor hiperactivo

PURPOSE

To evaluate the urodynamic characteristics of a series of women with stress urinary incontinence presenting various rates of vaginal prolapse.

METHODS

92 female patients were included in this study, mean age was 48 years (range 29-75). All patients underwent urogynecologic physical examination (vaginal prolapse was graded) and complete urodynamic study in order to detect the presence of detrusor overactivity. Urodynamic terminology and measurements comply with the ICS (International Continence Society) standards. Statistical significance was established below 0.05.

RESULTS

65 women (70.6%) presented anterior vaginal prolapse and 31 (33.6%) posterior vaginal prolapse. Involuntary contractions of the detrusor muscle appeared in 13 patients (20%) who had an anterior vaginal prolapse and 6 women (19.3%) who had a posterior vaginal prolapse. The existence of involuntary contractions was not associated with the diagnosis of vaginal prolapse.

CONCLUSION

Our study did not show any correlation between existence of vaginal prolapse and detrusor overactivity.

Uretrolisis transvaginal tras cirugía correctora de la incontinencia urinaria de esfuerzo

PURPOSE

To analyse the success of transvaginal urethrolysis in resolving voiding dysfunction in patients following an anti-incontinence procedure.

MATERIALS AND METHODS

A retrospective chart review was performed on 20 patients who had undergone transvaginal urethrolysis for urethral obstruction following an anti-incontinence procedure. Preoperatively, a history was taken, pelvic examination and urodynamic were done. Mean patient age was 48 years, and the median time between the anti-incontinence procedure and the urethrolysis was nine months. Four patients had urinary retention and had irritative voiding symptoms. Previous surgery included pubovaginal sling in eleven patients, retropubic urethropexy in three and bladder neck suspension in six cases. Mean length of follow up after urethrolysis was 14 months. The urodynamic study demonstrated voiding flow rate of 9.9 ml/s and detrusor pressures at maximum flow of 48cmH20.

RESULTS

Of the 20 patients 14 (70%) had relief of symptoms after a single urethrolysis, while two patients underwent a second transvaginal urethrolysis, with placement of a Martius flap between the urethra and the symphysis. There was no correlation between preoperative parameters examined and the outcome from urethrolysis.

CONCLUSION

Our data support transvaginal urethrolysis for the treatment of urethral obstruction after anti-incontinence surgery. It is effective and minimally invasive technique with good results that should be considered if voiding dysfunction does not resolve spontaneously.

Safyre. Un nuevo concepto de cabestrillo ajustable mínimamente invasivo para la incontinencia urinaria por estrés femenina

INTRODUCTION

SAFYRE is a new readjustable and minimally invasive sling for the treatment of stress urinary incontinence (SUI). Attempts to restore the normal suburethral hammock using an anatomical approach have been made in recent years. The authors report their experience with this device, which associates the efficacy of slings with readjustability.

MATERIAL AND METHODS

A total of 100 consecutive patients with clinical and urodynamic diagnosis of SUI underwent SAFYRE sling procedure. The age range was from 40 to 71, mean age 63 years. Seventy-five patients (75%) presented previous failed anti-incontinence procedures. Physical clinical examination, stress test, pad use and a urodynamic study were performed before the surgery. All the patients presented symptoms of SUI and 30% also reported mild urgency.

RESULTS

The average follow up period was 14 months (12-30 months). The mean operative time was of 25 minutes. Dystopia repair was performed whenever necessary, during the same procedure. The average hospital stay was 24 hours. In 3% of the implants, bladder perforation occurred. During the postoperative period, 26 patients developed urgency symptoms. During that follow up period, 92% were found to be continent, 3% reported an improvement and 5% were dissatisfied.

CONCLUSION

SAFYRE is a safe and quick procedure that allows for postoperative readjustment. This technique may be an attractive alternative if the good result obtained so far proves to be long lasting.

The effect of ovariectomy and estradiol replacement on collagen and elastic fibers in the bladder of rats

The authors quantified the collagen and elastic fibers in the bladder wall of ovariectomized rats with and without estradiol replacement. This study was conducted on 60 3-month-old Wistar rats. Group 1 remained intact; group 2 underwent bilateral ovariectomy and were sacrificed after 30 days; group 3 were sham operated and sacrificed after 30 days; group 4 had a bilateral ovariectomy and after 30 days were started on subcutaneous injections of 17beta-estradiol (10 microg/kg body weight) for 90 days; group 5 were sham operated and after 30 days were on started subcutaneous sesame oil replacement (0.2 ml/day) for 90 days; group 6 had a bilateral ovariectomy and after 30 days were started on subcutaneous sesame oil replacement (0.2 ml/day) for 90 days. Sirius red and Weigert's resorcin-fuchsin were used to stain collagen and elastic fibers on paraffin-embedded rat bladder sections. The M-42 grid system was used to quantitatively analyze the fibers. Ovariectomy had no effect on the volumetric density and absolute volume of the collagen and elastic fibers in the bladder wall of rats, or on the weight of the bladder. Estradiol replacement in castrated animals did not demonstrate any significant difference in the stereological parameters compared to the castrated group without hormonal replacement.

Therapeutic effects of high dose yohimbine hydrochloride on organic erectile dysfunction

PURPOSE

We evaluated men with organic erectile dysfunction treated with placebo and high dose oral yohimbine hydrochloride.

MATERIALS AND METHODS

We selected 22 patients with organic erectile dysfunction (mean age 58 years) for treatment in the andrology outpatient clinic. These patients had been previously undergone neurological, vascular, hormonal and psychological testing, and were treated during an equal period of 30 days with placebo and daily single dose oral 100 mg. yohimbine. The response to treatment was evaluated via a questionnaire that comprised the outcome items of complete--normal penile rigidity enabling vaginal penetration, partial--erection improved but not sufficiently for appropriate vaginal penetration, none--no improvement and worse--erection deteriorated. The patients consented to treatment after being told of the severe adverse effects that might occur.

RESULTS

The most common side effects were anxiety, increase in cardiac frequency, increased urinary output and headache but in no case was treatment discontinued. Of the patients 3 (13.6%) and 12 (54.5%) reported complete or partial response to treatment, respectively. However, statistical analysis disclosed no significant difference when yohimbine was compared to placebo (p < 0.05).

CONCLUSIONS

Oral 100 mg. single dose daily yohimbine promotes no improvement in patients with organic erectile dysfunction.