D.D. Gruber

Histo-mechanical properties of the swine cardinal and uterosacral ligaments

The focus of this study was to determine the structural and mechanical properties of two major ligaments that support the uterus, cervix, and vagina: the cardinal ligament (CL) and the uterosacral ligament (USL). The adult swine was selected as animal model. Histological analysis was performed on longitudinal and cross sections of CL and USL specimens using Masson׳s trichrome and Verhoeff-van Giesson staining methods. Scanning electron microscopy was employed to visualize the through-thickness organization of the collagen fibers. Quasi-static uniaxial tests were conducted on specimens that were harvested from the CL/USL complex of a single swine. Dense connective tissue with a high content of elastin and collagen fibers was observed in the USL. Loose connective tissue with a considerable amount of smooth muscle cells and ground substance was detected in both the CL and USL. Collagen fibers, smooth muscle cells, blood vessels, and nerve fibers were arranged primarily in the plane of the ligaments. The USL was significantly stronger than the CL with higher ultimate stress and tangent modulus of the linear region of the stress-strain curve. Knowledge about the mechanical properties of the CL and USL will aid in the design of novel mesh materials, stretching routines, and surgical procedures for pelvic floor disorders.

Coccygeal Fracture Pain Cured by Sacral Neuromodulation: A Case Report

To the Editor: There are many painful syndromes that are often difficult to treat. One option is electrotherapy, also known as neurostimulation. The Gate Control Theory first described by Melzack and Wall (1) in 1965 postulated that nerves carrying painful peripheral stimuli and nerves carrying touch and vibratory sensation both terminate in the dorsal horn, which acts as the gate of the spinal cord. They hypothesized that input to these nerves could“close the gate”to the painful stimuli, thereby eliminating pain. Based on the Gate Control Theory, Shealy et al. (2) in 1967 showed success in treatment of chronic pain using the first spinal cord stimulator. Continuing this work, Shimoji et al. (3) in 1993 created epidural spinal cord stimulation (SCS) that displayed analgesic properties. SCS use has been widespread, and is Food and Drug Administration (FDA) approved for numerous conditions. In addition to cervical, thoracic, and lumber stimulators, there is also sacral neuromodulation. Sacral neuromodulation (InterStim, Medtronic, Minneapolis, MN) has been indicated by the FDA for the treatment of urinary urgency, urinary frequency, and fecal incontinence. It is the only approved sacral neuromodulator. However, very little data exist on its use for chronic pain or lower back pain. We describe a case where InterStim was used to treat urinary urgency/frequency symptoms and incidentally relieved chronic lower back pain from a previous pelvic fracture.

Does glycopyrrolate at anesthesia induction increase temporary postoperative urinary retention after a midurethral sling

STUDY OBJECTIVE To determine whether patients receiving perioperative glycopyrrolate during midurethral sling surgery had more acute but temporary postoperative urinary retention. DESIGN Retrospective cohort from 2006 to 2011. SETTING Northern Virginia community urology practice. MEASUREMENTS To minimize variability in surgical technique and postoperative care, all cases were from a single fellowship-trained urologist who performed most of the female incontinence procedures. Inclusion criteria were charts of women, 18 years of age or older, who had a primary preoperative diagnosis of stress urinary incontinence (SUI) and who underwent a midurethral sling procedure. Of 151 patients charts, 135 met study eligibility: 57 (42.2%) patients received glycopyrrolate; 78 (57.8%) did not. The postoperative course of those who did and did not receive glycopyrrolate was compared and formed the basis of group allocation. Data collected included age, body mass index, incontinence type, smoking status, diabetes mellitus, surgery performed, anesthesia type, estimated blood loss, intraoperative fluids, surgery end time to void, and postoperative urinary retention. MAIN RESULTS No differences existed between the groups in baseline or surgical data. Seven patients (5.2%) had acute temporary postoperative retention, two of whom received glycopyrrolate and 5 did not (3.51% vs 6.41%; relative risk [RR] 0.55, 95% CI 0.11 -2.72, P = 0.70). Excluding those with continued persistent voiding dysfunction beyond 48 hours from surgery, only 3 patients (2.22%) had acute temporary postoperative urinary retention: one received glycopyrrolate and two did not (1.75% vs 2.56%; RR 0.68, 95% CI 0.064 - 7.36; P = 0.99). CONCLUSION Acute temporary postoperative urinary retention is rare after midurethral slings. Glycopyrrolate during anesthesia induction does not appear significantly to increase this rate.