A. Vianello

Preoperative Valsava leak point pressure may not predict outcome of mid-urethral slings: analysis from a randomized controlled trial of retropubic versus transobturator mid-urethral slings

OBJECTIVE To test the hypothesis that preoperative Valsalva leak point pressure (VLPP) predicts long-term outcome of mid-urethra slings for female stress urinary incontinence (SUI). MATERIALS AND METHODS One hundred and forty-five patients with SUI were prospectively randomized to two mid-urethra sling treatments: Tension free vaginal tape (TVT) or transobturator tape (TOT). They were followed-up at 3, 6, 12 months post-operatively and then annually for the primary outcome variable, i.e. dry or wet and secondary outcome variables such as scores on the urogenital distress inventory (UDI-6) and the impact of incontinence on quality of life (IIQ-7) questionnaire as well as patient satisfaction as scored on a visual analogue scale (VAS). Preoperative VLPP was correlated with primary and secondary outcome variables. RESULTS Mean follow-ups were 32 +/- 12 months (range 12-55) for TVT and 31 +/- 15 months (range 12-61) for TOT. When patients were analyzed according to VLPP stratification, 95 (65.5%) patients showed a VLPP > 60 cm H2O and 50 (34.5%) patients had a VLPP < or = 60 cm H2O. The overall objective cure rates were 75.8% for patients with VLPP > 60 cm H2O and 72% for those with VLPP < or = 60 cm H2O (p < 0.619). No significant differences in objective cure rates emerged when patients were stratified for pre-operative VLPP and matched for TOT or TVT procedures: VLPP > 60 cm H2O (82% vs. 68.9% p < 0.172); VLPP < or = 60 cm H2O (68% vs. 76% p < 0.528). CONCLUSIONS When patients were stratified for preoperative VLPP (< or = or > of 60 cm H2O), preoperative VLPP was not linked to outcome after TVT or TOT procedures.

Repeated White Light Transurethral Resection of the Bladder in Nonmuscle-Invasive Urothelial Bladder Cancers: Systematic Review and Meta-Analysis

BACKGROUND AND PURPOSE Transurethral resection of the bladder (TURB), the first step in treatment of patients with urothelial bladder cancers, is limited by technicalities, surgeon skill, and random chance. When high-risk superficial diseases are discovered, a repeated TURB is indicated. We reviewed current literature and performed a meta-analysis of the role of repeated TURB in the management of nonmuscle-invasive bladder cancers. METHODS PubMed, MEDLINE, ISI Web of Knowledge, EBSCO, EMBASE, and Biomed Central databases were searched for reports in English from 1980 to June 2010. The end point was prevalence of persistent urothelial bladder cancer of any stage and grade at repeated TURB, assessed separately for T(a) and T(1) lesions at TURB. Persistence was presence at repeated TURB of same or lower stage cancer as at TURB; upstaging was presence of higher stage. RESULTS There were 2327 original articles and 562 reviews retrieved. Data from 15 studies were pooled and analyzed. Prevalence of T(1) was reported in all and of T(a) in 8. Persistence rate prevalence at repeated TURB was 0.39 (95% confidence interval [CI]=0.26 to 0.54) for T(a) and 0.47 (95% CI=0.41 to 0.53) for T(1). Persistence was 19.4% to 56% and 15.2% to 55%, and upstaging occurred in 0% to 14.3% of T(a) and 0% to 24.4% of T(1) at repeated TURB, respectively. CONCLUSION High percentages of persistence and upstaging confirm a repeated TURB is needed in patients with high-risk nonmuscle-invasive bladder cancer. Further investigation is encouraged taking risk stratification into consideration to evaluate the role of repeated TURB in low- and mid- risk diseases.

Managing Mesh Erosion after Abdominal Pelvic Organ Prolapse Repair: Ten Years’ Experience in a Single Center

Objective: To report conservative and surgical strategies for treatment of mesh erosion after pelvic organ prolapse (POP) repair. Methods: Between 1998 and 2008, 179 patients underwent integral pelvic floor reconstruction for advanced POP in our tertiary urogynecological unit. Patients’ charts and follow-up data were entered into a computerized database and data analysis performed to search for mesh erosion/complications/surgery. Results: 12 patients were diagnosed and treated for mesh erosion: in 10 of 179, surgery was performed in our department and the mesh used was polypropylene (PP): 3 after colposacropexy (CSP) (5.5%), 5 after CSP + hysterectomy (Hys) (6.5%), and 2 after hysterosacropexy (HSP) (3.9%); in 1 case, Gore-tex mesh was used, and another case had undergone CSP in another hospital using PP mesh. Time to mesh erosion ranged from 2 to 66 months (mean 22.9), with 4 erosions (33%) within 6 months of POP repair. In 4 asymptomatic patients (33%) erosion was incidentally discovered during clinical check-ups at 4, 31, 36 and 66 months. Five cases (41%) presented with occasional vaginal bleeding, associated with dyspareunia in 2. Treatments were individualized but in all cases conservative treatment was unable to resolve the complications and surgery was needed. At a mean follow-up of 57 months (range 18–120) after surgical treatment all patients were asymptomatic and free from erosions. Conclusions: The surgeon who approaches management of complications after abdominal/laparoscopic sacropexy should possess a comprehensive understanding of pelvic floor anatomy and surgical skills in order to individualize the management of such complications.

Vascular therapy for radiation cystitis

The underlying pathology of radiation cystitis is cellular and vascular damage followed by increased fibrosis and inflammation. This study was to determine if neovascular‐promoting therapy could reduce the pathological changes in the bladder wall associated with pelvic irradiation.

Evaluation of electrospun bioresorbable scaffolds for tissue-engineered urinary bladder augmentation

Tissue engineering represents a potential and valuable approach for the treatment of urologic pathologies. Bioresorbable polymeric scaffolds can be regarded as effective platforms to surgically treat bladder diseases and subsequently guide the formation of novel tissue after implantation. To this aim, the evaluation of electrospun scaffolds made up of poly(ε-caprolactone) blended with poly(3-hydroxybutyrate-co-3-hydroxyvalerate) is presented here. Firstly, the microstructure and the viscoelastic/mechanical properties of the electrospun fabrics were investigated. Then, the in vivo response was assessed by performing a urinary bladder augmentation using female Wistar rats as an animal model. 15 days after the surgical procedure, the scaffolds were covered by regenerative urothelium up to 50%, which increased to 50-100% after 30 days. These encouraging results, collected in the 90-day follow-up, clearly showed the potential applications of tissue engineering in the urologic field. A longer in vivo evaluation is currently underway.

481 IS SURGICAL OUTCOME AT RISK DURING POST-GRADUATED EDUCATIONAL COURSES FOR STRESS URINARY INCONTINENCE (SUI) AND PELVIC ORGAN PROLAPSE (POP) REPAIR? A CASE CONTROL STUDY

®19 (21.3%) had grade 4 cystoceles. In addition to the CaPS procedure, 50 (57%) underwent additional prolapse surgery. Nine patients (10%) had recurrence of cystocele with a mean time to recurrence of 29.7 months (range 12-50). Of the 9 patients with cystocele recurrence, 3 patients (33%) had grade 4 cystocele, 5 patients (56%) had grade 3, and 1 patient (11%) had grade 2 cystocele. The mean SEAPI scores were 6.75 preoperatively and 2.22 postoperatively, representing a significant improvement (p <0.001). Of the 62 patients with preoperative stress urinary incontinence, 26 (42%) reported being completely dry (no incontinence episodes of any type). Fifty-three of the 65 (85%) reported at least 50% improvement in their incontinence. Of the 87 patients 61 (70%) were greater than 80% satisfied and 77 (86%) stated that they would undergo the CaPS procedure again. CONCLUSIONS: With a maximum follow-up of over 9 years in patients undergoing CaPS, results are excellent and durable with the use of cadaveric fascia lata for cystocele repair

Uterine Preservation or Hysterectomy for the Uterovaginal Prolapse

For many years uterine prolapse has been an indication for hysterectomy, quite apart from the presence or the absence of any uterine disease and independently of the patients’ desire. Many studies on pelvic statics showed the central role of uterus on the pelvic static itself. Aim of the study is to prospectively compare sacropexy with and without hysterectomy in patients with uterovaginal prolapse. Surgical techniques, efficacy and overall results are described. Material and Methods Fifty-six consecutive patients affected by grade III-IV uterovaginal prolapse underwent colposacropexy: hysterectomy followed by sacropexy (SP) in 29 and hysterocolposacropexy (ISP) in 27. Before surgery all patients provided a detailed case history and replied to a questionnaire on urinary symptoms (Urogenital distress inventory). Patients underwent a clinical urogynaecological examination (HSW), a pelvic ultrasound scan and urodynamic test. Check-ups were scheduled at 3, 6, 12 months and then annually. Results No significant differences emerged in demographic and clinical characteristic in the SP and ISP groups. Mean operating times, intraoperative blood loss and hospital stay are significantly less after ISP (p<0.001). No patient required surgery for recurrent prolapse. Urodynamic results showed the pressure/flow parameters improved significantly (p< 0.001). 24/27 patients (88.9%) in the ISP group and 25/29 (86.2%) in the SP are satisfied and would repeat surgery again. 5/7 patients who would not repeat surgery were incontinent. Conclusions Sacrocolpopexy provides a secure anchorage restoring an anatomical vaginal axis and a good vaginal length. ISP can be safely offered to women who request uterine preservation. Long-term results in terms of prolapse resolution, urodynamic outcomes, improvements in voiding and sexual dysfunctions are excellent.