Cheng-Yu Long

Comparative study of human eutopic and ectopic endometrial mesenchymal stem cells and the development of an in vivo endometriotic invasion model

OBJECTIVE To elucidate the role of endometrial stem-progenitor cells in the etiology of endometriosis and to develop an animal model to study the invasion ability of endometrial cells. DESIGN Gene expression and cell function studies were designed. SETTING Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan. PATIENT(S) Human endometrial mesenchymal stem cells (MSCs) were isolated from 22 different endometrium biopsies after surgery for treatment of endometriosis. INTERVENTION(S) Endometrial MSCs developed from eutopic and ectopic endometrial tissues. MAIN OUTCOME MEASURE(S) Characterization of MSC phenotypes (i.e., differentiation induction and gene expression by flow cytometric analysis); comparative study of cell functions (i.e., cell growth, migration, and invasion assays). The invasion of implants in an animal model was examined by histologic staining. RESULT(S) We compared the characteristics of eutopic and ectopic endometrial MSCs from the same endometrial donor. Although both showed similar mesenchymal cell phenotypes, ectopic endometrial MSCs showed distinctly greater ability of cell migration and invasion. Furthermore, in an in vivo cell invasion model using cells grown in scaffold and transplantation in immune-deficient mice, the ectopic endometrial MSCs were found to form many new blood vessels and to invade surrounding tissue. CONCLUSION(S) These results indicate unique invasion and angiogenesis characteristics of ectopic endometrial MSCs that may underlie the pathogenesis of ectopic endometriosis. The animal invasion model will be useful for future characterization of endometrial MSCs.

Comparison of tension-free vaginal tape and transobturator tape procedure for the treatment of stress urinary incontinence

Purpose of review The aim of this review was to assess the recent evidence on the effectiveness and complications of tension-free vaginal tape (TVT) and transobturator tape (TOT) procedures for female stress urinary incontinence between January 2008 and March 2009. Recent findings A meta-analysis of recent studies revealed that the short-term objective cure rate was borderline worse in the TOT group compared with TVT [odds ratio (OR) 0.62; 95% confidence interval (CI) 0.37–1.00; P = 0.05]. Bladder perforation (OR 12.23; 95% CI 2.86–52.34) was significantly more common, whereas groin/thigh pain was significantly less in the TVT group (OR 0.32; 95% CI 0.11–0.92; P = 0.022). Postoperative urinary retention was slightly more in women undergoing TVT than those undergoing TOT (OR 1.6; 95% CI 0.90–3.12; P = 0.06). The rates of vaginal erosion (OR 0.34; 95% CI 0.09–1.33), de-novo urgency (OR 1.21; 95% CI 0.52–2.79) and urinary tract infection (OR 0.88; 95% CI 0.56–1.38) were comparable in both procedures. In addition, TVT appeared to be more obstructive than TOT, as evidenced by ultrasonographic and urodynamic findings. Changes in sexual function need further investigation because this issue has not been well studied for either sling procedure. Summary TOT has the advantages over TVT with shorter operative time and a relatively lower complication rate. For women with intrinsic sphincter deficiency, however, TVT appears to be a better option because it is more obstructive.

Treatment for Unsuccessful Tension-Free Vaginal Tape Operation by Shortening Pre-Implanted Tape

PURPOSE We studied the efficacy of shortening the pre-implanted suburethral tape in patients with recurrent urodynamic stress incontinence after a TVT operation. MATERIALS AND METHODS A total of 14 women, including 6 with ISD, were treated for recurrent urodynamic stress incontinence after the initial TVT operation by performing the shortening procedure under local anesthesia. Urodynamics, a 1-hour pad test, introital ultrasonography of the urethra and a cotton swab test were done before the procedure and 1 year postoperatively. RESULTS All 14 patients completed the shortening procedure. Mean patient age was 47.2 years (range 43 to 66). Mean time between initial TVT and the shortening procedure was 4 months (range 3 to 14). Ten patients (71.4%) were objectively cured and treatment failed in 4 (2 with ISD and 2 with a fixed urethra). Mean operative time was 17 minutes (range 10 to 25). No intraoperative surgical complications were observed. The 1-hour pad test showed a decrease from a median of 9.0 gm to 1.0. Median postoperative hospital stay was 1 day (range 1 to 4). Spontaneous voiding with adequate post-void residual urine was noted in all patients before discharge home. CONCLUSIONS Shortening a pre-implanted TVT tape for the treatment of recurrent urodynamic stress incontinence is a safe, effective and minimally invasive option requiring only a short hospital stay. However, ISD and an immobile urethra seem to be risk factors for failure. Long-term followup is needed to determine if this surgery achieves long-lasting results.

Lateral excision of tension-free vaginal tape for the treatment of iatrogenic urethral obstruction.

OBJECTIVE: To report our experience on lateral excision of tape in women with iatrogenic urethral obstruction after the tension-free vaginal tape (TVT) procedure. METHODS: Seven women had iatrogenic urethral obstruction based on their clinical and urodynamic findings. All underwent lateral excision of the tape using the vaginal approach. Lower urinary tract symptoms, postvoid residual volume and urodynamic data were evaluated before and after excision. RESULTS: Before excision, all subjects had either irritative symptoms or increased postvoid residual volume (more than 100 mL), and 6 (85.7%) voided with strain. The mean time from initial surgery to tape excision was 28 days (range 4 to 108), with an average follow-up of 32 months (range 24–39). After the excision, voiding dysfunction was resolved in 6 of 7 patients. The remaining patient had significant improvement with only occasional symptoms of irritation. Two (28.6%) women reported recurrent stress incontinence and 1 (14.3%) required surgical treatment. The intervals for the 2 recurrent patients from TVT to excision were 4 days. The intervals for the 5 continent women were 15 to 108 days. CONCLUSION: Urethral obstruction after TVT is a relatively uncommon condition. It can be effectively treated with transvaginal lateral excision of the tape. Recurrent stress incontinence seems to be less likely to occur when the takedown procedure occurs beyond 14 days after the initial TVT operation. LEVEL OF EVIDENCE: III

Ultrasonographic assessment of tape location following tension-free vaginal tape and transobturator tape procedure

Background. The purpose of this study was to perform an ultrasonographic comparison of tension‐free vaginal tape (TVT) and the TVT‐obturator (TVT‐O) procedure in women with stress urinary incontinence (SUI). Methods. We retrospectively reviewed 159 women with SUI undergoing either TVT (n = 91) or TVT‐O (n = 68). All subjects underwent perineal ultrasonographies, pelvic examination, urinalyses, 1‐h pad tests, multichannel urodynamic studies and a personal interview using the Bristol Female Lower Urinary Tract Symptoms Questionnaire before and 1 year after surgery. Results. At rest or during Valsalva, the middle of the TVT‐O tape localised more distally than the TVT on ultrasound (p<0.01). A higher rate of urethral kinking during straining was observed in the TVT group compared with the TVT‐O group after surgery (86.9 versus 23.9%, p<0.01). Mean operative time was significantly shorter in the TVT‐O group (16.2 versus 28.6 min, p<0.01). The rate of objective cure was comparable for the TVT and TVT‐O groups (94.5 versus 88.2%, p<0.05). However, subjective cure rate was significantly lower for the TVT‐O than the TVT group (82.4 versus 93.4%, p = 0.042). There was no statistical difference between the 2 groups regarding patient characteristics and complication rates. Conclusions. TVT‐O tape results in a less acute angle and localises to a more distal part of the urethra, resulting in less urethral compression and a lower rate of urethral dynamic kinking.

Management of Symptomatic Urolithiasis during Pregnancy

Urinary calculi during pregnancy present not only a diagnostic challenge but also a management dilemma. In this retrospective study, we describe our experience with diagnosis and management of symptomatic urolithiasis in pregnant women. A total of 18 pregnant women were treated for urolithiasis at the Department of Urology, Kaohsiung Municipal Hsiao‐Kang Hospital, between 1999 and 2004. The incidence of symptomatic urolithiasis during pregnancy was 0.35%. Of the 20 stones found, nine were on the right side and 11 were on the left, and two patients had bilateral urinary stones. Most urolithiasis cases during pregnancy (55.5%) occurred in the third trimester. Flank pain (94.4%) was the most common clinical presentation. Conservative management was successful in 10 patients until the end of pregnancy and then definite treatment was performed. In four patients, a double‐J stent was inserted successfully for persistent pain. In three cases with persistent pain, failure of double‐J stent placement was treated with ureteroscopic lithotripsy under epidural anesthesia. One patient received percutaneous nephrostomy for persistent renal colic and pyonephrosis. Ultrasonographic evaluation of pregnant women with suspected renal colic is a reasonable diagnostic procedure. Ureteroscopy is another choice when conservative treatment fails.

Risk Factors for Major Depressive Disorder and the Psychological Impact of Hysterectomy: A Prospective Investigation

The authors prospectively evaluated the risk of major depressive disorder and the psychological impact of recent hysterectomy in 68 women who underwent hysterectomy for non-malignant conditions. Depression, anxiety, body image, sexual functioning, family support, life stress, and subjective gynecological symptoms were assessed 2 weeks before surgery and at 1 month and 4 months after surgery. Depression, anxiety, body image, and subjective gynecological symptoms improved after surgery; however, sexual functioning worsened after surgery. Previous emotional problems and poorer body image, sexual functioning, and higher stress 1 month after surgery are risk factors for post-hysterectomy major depressive disorder.

Laparoscopically Assisted Vaginal Hysterectomy versus Total Abdominal Hysterectomy: A Study of 100 Cases on Light-Endorsed Transvaginal Section

The objective of this study was to compare the results of a modified laparoscopically assisted vaginal hysterectomy (LAVH) procedure, using light-endorsed transvaginal section by two puncture trocars, with those of total abdominal hysterectomy (TAH) in a prospective, randomized, short-term study. A new, modified LAVH technique using Endo GIA stapler and two puncture trocars was established. For the laparoscopic phase, each adnexum was dissected, and the vesicouterine junction was identified clearly with the laparoscopic light from the vaginal side. Vaginal-phase surgery was performed as usual. Two hundred patients scheduled for abdominal hysterectomy were randomized to either LAVH (n = 100) or TAH (n = 100). Duration of hospitalization, time of surgery, dose of analgesics, and rates of complications were significantly lower in the LAVH group (p < 0.001). The average operating time was 77 ± 30 min for LAVH and 102 ± 18 min for TAH. The duration of hospitalization was 3.2 ± 0.7 days for LAVH and 5.5 ± 1.3 days for TAH. There were three complications in the LAVH group and 15 in the TAH group. Postoperative meperidine requirements (1.2 vs. 3.7 ampoules, 1 ampoule = 50 mg) were significantly fewer in the LAVH group. Regarding the training time, the mean operating time in the first 20 cases was 98 min, and in the last 20 cases it was 70.9 min. As compared with TAH and other modified LAVH procedures reported previously, the present technique is easy to learn and timesaving with fewer complications.

Working memory deficit in premenstrual dysphoric disorder and its associations with difficulty in concentrating and irritability

OBJECTIVE This study evaluates working memory deficit among women with premenstrual dysphoric disorder (PMDD) and whether such a deficit and its premenstrual aggravation is associated with difficulty in concentrating, irritability, and impaired daily function or not. METHOD Sixty women with PMDD (PMDD group) and 60 women without PMDD (control group) completed the assessment. Severity of irritability, difficulty concentrating, total symptoms, and functional impairment of PMDD were evaluated by the Premenstrual Symptoms Screening Tool. All participants performed N2 and N3 back tasks to assess working memory in both luteal and follicular phases. RESULTS The PMDD group had significantly poorer performance on N2 and N3 back tasks than the control group did in the luteal phase but not in the follicular phase. Compared to the control group, the PMDD group also exhibited more deterioration in performance of N3 back task in the luteal phase. Performance of N2 and N3 back tasks in luteal phase was significantly associated with irritability, symptom severity, and functional impairment by PMDD. CONCLUSIONS Working memory deficit is aggravated in the luteal phase among women with PMDD. Appropriate interventions are needed to prevent negative consequences of working memory deficit.

Ketamine-induced ulcerative cystitis and bladder apoptosis involve oxidative stress mediated by mitochondria and the endoplasmic reticulum

Ketamine abusers develop severe lower urinary tract symptoms. The major aims of the present study were to elucidate ketamine-induced ulcerative cystitis and bladder apoptosis in association with oxidative stress mediated by mitochondria and the endoplasmic reticulum (ER). Sprague-Dawley rats were distributed into three different groups, which received normal saline or ketamine for a period of 14 or 28 days, respectively. Double-labeled immunofluorescence experiments were performed to investigate tight junction proteins for urothelial barrier functions. A TUNEL assay was performed to evaluate the distribution of apoptotic cells. Western blot analysis was carried out to examine the expressions of urothelial tight junction proteins, ER stress markers, and apoptosis-associated proteins. Antioxidant enzymes, including SOD and catalase, were investigated by real-time PCR and immunofluorescence experiments. Ketamine-treated rats were found to display bladder hyperactivity. This bladder dysfunction was accompanied by disruptions of epithelial cadherin- and tight junction-associated proteins as well as increases in the expressions of apoptosis-associated proteins, which displayed features of mitochondria-dependent apoptotic signals and ER stress markers. Meanwhile, expressions of mitochondria respiratory subunit enzymes were significantly increased in ketamine-treated bladders. Conversely, mRNA expressions of the antioxidant enzymes Mn-SOD (SOD2), Cu/Zn-SOD (SOD1), and catalase were decreased after 28 days of ketamine treatment. These results demonstrate that ketamine enhanced the generation of oxidative stress mediated by mitochondria- and ER-dependent pathways and consequently contributed to bladder apoptosis and urothelial lining defects. Such oxidative stress-enhanced bladder cell apoptosis and urothelial barrier defects are potential factors that may play a crucial role in bladder overactivity and ulceration.