Lower urinary tract dysfunction, such as incontinence or urinary retention, is one of the leading consequences of neurological diseases. This significantly impacts the quality of life for those ...affected, with implications extending not only to humans but also to clinical veterinary care. Having motor and sensory fibers, the pudendal nerve is an optimal candidate for neuromodulation therapies using bidirectional intraneural prostheses, paving the way towards the restoration of a more physiological urination cycle: bladder state can be detected from recorded neural signals, then an electrical current can be injected to the nerve based on the real-time need of the bladder. To develop such prostheses and investigate this novel approach, animal studies are still required since the morphology of the target nerve is fundamental to optimizing the prosthesis design. This study aims to describe the porcine pudendal nerve as a model for neuromodulation studies aiming at restoring lower urinary tract dysfunction. Five male farm pigs were involved in the study. First, a surgical procedure to access the porcine pudendal nerve without muscle resection was developed. Then, an intraneural interface was implanted to confirm the presence of fibers innervating the external urethral sphincter by measuring its electromyographic activity. Finally, the morphophysiology of the porcine pudendal nerve at the level of surgical exposure was described by using histological and immunohistochemical characterization. This analysis confirmed the fasciculate nature of the nerve and the presence of mixed fibers with a spatial and functional organization. These achievements pave the way for further pudendal neuromodulation studies by using a clinically relevant animal model with the potential for translating the findings into clinical applications.
Background:
Robotic sacrocolpopexy (RSCP) is an established option for the treatment of apical, anterior, and proximal posterior compartment pelvic organ prolapses (POP). However, there is lack of ...evidence investigating how lower bowel tract symptoms (LBTS) may change after RSCP.
Methods:
Data from consecutive patients treated with RSCP for stage 3 or higher POP from 2012 to 2019 at a single tertiary referral center with at least 1 year of follow-up were prospectively collected and retrospectively analyzed. RSCP was performed following a standardized technique which always employed both anterior and posterior hand-shaped meshes. Outcomes were collected at follow-up and analyzed. LBTS were evaluated through the Wexner questionnaire.
Results:
Overall, 114 women underwent RSCP. Eleven were excluded for missing data, whereas 12 had insufficient follow-up. Thus, 91 (79.8%) patients were included in this cohort. Median follow-up was 42 interquartile range (IQR), 19–62 months. Mean age was 65 ± 10 years. In our series, RSCP was mainly performed for anterior and apical/medium stage 3 POP (in 95.6% of patients). Anatomic success rate of RSCP was 97.8%, with 89 patients with POP stage 0–1 at 12-month follow-up. Two patients (2.2%) experienced POP recurrence and were treated with redo-SCP. No patient experienced clinically significant posterior vaginal wall prolapse after RSCP. When analyzing LBTS, there was no significant change in postoperative total Wexner’s score as compared to the preoperative value (p > 0.05). However, the manual assistance subscore was statistically significantly lower within the first-year follow-up (p = 0.04), but it spontaneously improved during the follow-up (p = 0.12).
Conclusion:
RSCP with simultaneous placement of both anterior and posterior mesh is safe and successful to treat high-stage POP in carefully selected patients. Of note, LBTS appear unaffected by posterior mesh placement, supporting its routine use to prevent posterior POP recurrence. Larger prospective studies are needed to confirm our results.
Aims:
To analyze the outcomes of urethral re-bulking in the treatment of female stress urinary incontinence.
Materials and Methods:
We performed a multicenter observational retrospective study, which ...included all consecutive patients treated with urethral re-bulking for the treatment of persistent stress or mixed urinary incontinence after a previous urethral bulking. Objective outcomes were evaluated with the 24 h pad-test, while PGI-I questionnaires were administered to evaluate subjective outcomes. Clinical outcomes were assessed before re-bulking procedure and at last follow-up. Mann–Whitney’s U test was used for subgroup analysis. Shapiro-Wilk’s tests were used as normality tests.
Results:
In total, 62 patients who underwent urethral re-bulking between 2013 and 2020 in a multicenter setting were included. Most patients did not reach complete continence after the first procedure (n = 56) while the remainder reported recurrence of urinary incontinence after initial benefit. Median age at surgery was 66 (IQR: 55-73). Median overall follow-up was 30 months (IQR: 24-41). Median time occurred between the first procedure and reintervention was 12 months (IQR: 7-27). Bulking agents for the re-bulking procedures were bulkamid(n = 56), macroplastique(n = 4), and Prolastic(n = 2). A statistically significant reduction of median 24 h pad test from 100 g(IQR: 40-200) to 35 g(IQR: 0-120) was observed (p = 0.003). Dry rate after rebulking was 36.6%, while 85.4% patients declared themselves ‘very much improved’ or ‘much improved’ (PGI-I 1-2). Very few low-grade complications were observed (n = 4). A single case of major complication occurred.
Conclusions:
Urethral re-bulking can be an effective technique for the treatment of stress urinary incontinence refractory to a previous urethral bulking and can determine a cumulative benefit after the first procedure.
Retrospective
To evaluate the mid-term urodynamic and clinical efficacy of mid-urethral synthetic sling (MUS) in females with neurogenic stress urinary incontinence (N-SUI) or neurogenic mixed ...urinary incontinence (N-MUI).
Between January and April 2021, we conducted a retrospective review of all adult neurological women with clinically and urodynamically proven N-SUI or N-MUI who were treated with retropubic (TVT) or transobturator (TOT) tension free vaginal tape. The outcomes were recorded in a database over a 14-year period.
The primary objective outcome measure was the absence of any N-SUI episodes at 3 days Bladder Diary (BD). A Patient Global Impression of Improvement (PGI-I) score ≤ 2 was a secondary endpoint for subjective success. Objective failure was defined as the detection of stress urinary incontinence during follow-up urodynamics.
Twenty-three women out of 65 were included. Mean follow-up was 72.2 ± 45.6 months. TVT was placed in 17/23 patients (74%) who were previously managed by intermittent catheters (IC) and TOT in those 6/23 women (26%) who spontaneously voided at baseline.
Dryness at 3 days BD was observed in 12/23 patients (52%). Twenty patients (86%) reported subjective benefits (mean PGI-I 1.4 ± 0.62), of whom eleven (55%) were extremely satisfied (PGI-I = 1).
Objective failure was documented in 2/23 women (8%) after surgery. Two patients shifted from IC to indwelling catheter during follow-up (respectively 6 and 8 years after surgery). De novo neurogenic detrusor overactivity was observed in two women at 3 months follow-up. No statistical differences were observed in cystometric parameters comparing baseline to follow-up.
To the best of our knowledge, this is the first study confirming the clinical efficacy and urodynamic safety over a 5-year follow-up, for N-MUI as well. According to our results both TOT and TVT can be used to treat women with N-SUI with or without concomitant NDO. The choice between the two procedures depended on baseline bladder management.
New, contextualized modern solutions must be found to solve the dilemma of catheter-associated urinary infection (CAUTI) in long-term care settings. In this paper, we describe the etiology, risk ...factors, and complications of CAUTI, explore different preventive strategies proposed in literature from the past to the present, and offer new insights on therapeutic opportunities. A care bundle to prevent CAUTI mainly consists of multiple interventions to improve clinical indications, identifying a timeline for catheter removal, or whether any alternatives may be offered in elderly and frail patients suffering from chronic urinary retention and/or untreatable urinary incontinence. Among the various approaches used to prevent CAUTI, specific urinary catheter coatings according to their antifouling and/or biocidal properties have been widely investigated. Nonetheless, an ideal catheter offering holistic antimicrobial effectiveness is still far from being available. After pioneering research in favor of bladder irrigations or endovesical instillations was initially published more than 50 years ago, only recently has it been made clear that evidence supporting their use to treat symptomatic CAUTI and prevent complications is needed.
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