Felicia L. Lane

Randomized prospective crossover study of interstim lead wire placement with curved versus straight stylet

To assess whether InterStim lead wire placement with the curved stylet achieves motor response at lower amplitudes compared to straight stylet use.

Does pelvic organ prolapse quantification exam predict urethral mobility in stages 0 and I prolapse

Objective: To determine if women with anterior support stages 0 or I by pelvic organ prolapse quantification (POP-Q) system require Q-tip testing to assess urethral mobility. Methods: A prospective study of 134 women presenting for urogynecologic evaluation were examined and assigned stages of anterior wall support according to the POP-Q system. A Q-tip test was performed and urethral hypermobility was defined as a straining angle ≥30°. The Spearman correlation coefficient was used to assess degree of correlation between POP-Q point Aa position and Q-tip values. Results: The correlation coefficient between point Aa position and Q-tip angle was r=0.787 (P<0.001). Urethral hypermobility was noted in 91% of stage I and 100% of stage II–IV patients. The positive predictive value of Q-tip angle ≥30° in stage I–IV prolapse was 99%. Conclusion: The POP-Q system is highly predictive of straining urethral angle in all stages of prolapse.

In vivo recovery of the injured anal sphincter after repair and injection of myogenic stem cells: an experimental model.

OBJECTIVE: This study aims to evaluate in vivo function of the external anal sphincter after transection and repair augmented with myogenic stem cells, and to establish normative electromyography parameters of the rodent external anal sphincter. DESIGN AND SETTING: Thirty-three Sprague-Dawley rodents underwent baseline needle electromyography of the external anal sphincter. Motor unit action potentials were obtained and normative parameters established. Animals were randomly assigned to a myogenic stem cell group (n = 24) or control group (n = 9). All underwent proctoepisiotomy. The control group underwent layered repair with phosphate-buffered saline injection to the external anal sphincter. The treatment group underwent identical repair with injection of myogenic stem cells 5.0 × 106. Baseline anal pressure recordings were collected and repeated 2 weeks postintervention, and electromyography was repeated at 2 and 4 weeks. Groups were compared across 3 time points with the use of repeated measures ANOVA. MAIN OUTCOME MEASURES: The primary outcomes measured were the functional recovery of rat anal sphincters after stem cell transplantation as assessed by objective electromyography and anal pressure measures. RESULTS: A mean of 17 motor unit action potentials were sampled per animal. At 2 weeks postrepair, there was a significant difference between control and transplant groups with respect to amplitude, duration, turns, and phases (p < 0.01 for each). No significant electromyography differences were seen at 4 weeks. Resting and peak anal pressures declined significantly at 2 weeks postinjury in the control but not in the stem cell group. LIMITATIONS: Use of a murine animal population limited the subjective feedback and wider applicability. CONCLUSIONS: In vivo functional studies show recovery of anal sphincter pressures and electromyography to preinjury levels by day 14 in the myogenic stem cell group but not controls. At 4 weeks, all electromyography parameters returned to baseline irrespective of group. Restoration of function may be accelerated by the transplantation of myogenic stem cells and associated trophic factors.

Stem cells in gynecology

Stem cell based therapies hold promise for the obstetrician and gynecologist. This article reviews the history of stem cells and some of their current applications in gynecology. Currently, mesenchymal and muscle-derived stem cells are being explored for the treatment of urinary and anal incontinence. Potential stem cell treatments include fistula repair, vaginal tissue engineering, and graft material enhancement. Published animal and human pilot studies demonstrate improved histologic and functional outcomes in those receiving stem cells. Transplanted cells may improve function by local engraftment, trophic factors, or modulation of inflammation. Further clinical and safety studies are needed before clinical application.

Effects of the incontinence dish pessary on urethral support and urodynamic parameters

OBJECTIVE To evaluate the effects of the incontinence dish pessary (IDP) on urethral mobility and urodynamics. STUDY DESIGN Prospective study of women with symptoms of stress incontinence. Q-tip test was performed recording the resting and straining angles with and without an IDP. Changes in resting and straining angles were calculated. Those with evidence of urodynamic stress incontinence had urodynamics with the IDP. Paired t-test was used to compare the difference in Q-tip angles with and without the pessary. RESULTS Mean Q-tip straining angle without and with the pessary, respectively, was 57.8 (+19.5) and 34.4 (+29.7). Mean change was 23.5 (+18.5) P < .00001. Maximum urethral closure pressure (MUCP) was significantly increased by 19.7 cm H(2)0 P < .001. Overall, 60% of the subjects did not leak with the IDP. CONCLUSION The IDP eliminates >60% of USI. The mechanism of action may be a combination of improved UVJ support and increased MUCP.

Allogenic myoblast transplantation in the rat anal sphincter.

Objectives: To determine the feasibility of injecting rat myoblasts into the intact anal sphincter as a potential treatment for anal incontinence, and to detect transferred myoblast survival and integration. Study Design: A pilot study using nonpregnant female Sprague Dawley rodents of 8 to 10 weeks of age. A biopsy of skeletal muscle was harvested from a study animal and recovered myoblasts were expanded in vitro over 10 days. Myoblasts were then tagged with a cytomegalovirus promoter to transduce green fluorescent protein (GFP) into the myoblasts. The cell aspirate was injected directly into the intact external anal sphincter using an electromyographic guidance. The animals received 1.5 or 4.5 × 106 cells of GFP-labeled myoblasts, dividing the dose between three injection sites. The remaining in vitro myoblasts were still viable 28 days post-harvest. Ten days after transplantation the anal sphincter complex was surgically extracted. Results: The presence of GFP-labeled myoblasts was confirmed within the external anal sphincter. Conclusions: This demonstrates that myoblasts can be successfully extracted, cultivated in vitro, transplanted and will integrate into the host tissue.

Reconstructive pelvic surgery and plastic surgery: safety and efficacy of combined surgery

OBJECTIVE The purpose of this study was to address the safety of combining aesthetic and pelvic floor reconstructive procedures. STUDY DESIGN Fifty-four subjects were included in a case-control study; 18 patients undergoing combined pelvic and plastic reconstructive surgery, age and procedure matched to 18 pelvic surgery and 18 plastic surgery only controls. Chi-square, t test, and Kruskal-Wallis analysis were used to compare the estimated blood loss (EBL), body mass index (BMI), hospital days, operative times, and complications between the groups. RESULTS No differences were seen with regards to age, BMI, or EBL. There was, however, a significant increase in minor complications and hospital stay after combined procedures relative to the pelvic surgery control group but not the aesthetic control group. Operative times were only greater during combined procedures relative to isolated pelvic floor procedures. CONCLUSION Combining pelvic and aesthetic procedures may increase complications, operative times, and length of hospital stay when compared to pelvic reconstructive surgery alone.

Use of combined anticholinergic medication and sacral neuromodulation in the treatment of refractory overactive bladder.

Objectives: The objectives of this study were to determine the number of patients implanted with sacral neuromodulation (SNM) for overactive bladder (OAB) who required supplemental or continued anticholinergic (ACH) therapy for improved response and to identify factors predictive of requiring supplemental ACH. Materials and Methods: This is a retrospective chart review of 148 patients who underwent SNM from 1999 to 2007. Patients included were those implanted for urgency, frequency, or urge incontinence. Eighty-eight patients were included in the analysis. A stepwise regression analysis was performed to identify factors predictive for restarting ACH medication. Results: All patients underwent SNM implantation for frequency-urgency and urge incontinence. Of all patients, 16 (18%) required supplemental ACH therapy for improved symptom control. Overall, 26 patients (25%) either continued or were started on ACH therapy in addition to SNM for improved outcomes. Conclusions: A subset of patients had improved therapeutic response with combined SNM and ACH therapy. The only factor associated with supplemental ACH use was body mass index.

Ischiorectal fossa abscess after pelvic floor injection of botulinum toxin

Botulinum toxin is used to treat pelvic floor tension myalgia; however, its safety profile is poorly understood. We report an ischiorectal fossa abscess after pelvic floor injections of botulinum toxin. Physicians need to be aware of this possible complication, consider alternate injection techniques and antiseptic preparation before injection.

Use of composite grafts in abdominal sacrocolpopexy.

Objective: The ideal graft material for pelvic reconstructive surgery remains undetermined. The purpose of this study was to present data on novel composite biologic/synthetic grafts during use in abdominal sacrocolpopexy. Methods: A case series of 90 patients undergoing abdominal sacrocolpopexy with composite biologic/synthetic grafts was conducted. The primary outcome was graft erosion. Assuming a 3% risk of reoperation for mesh erosion, the number needed to treat with a composite graft in order to avoid erosion risk from a synthetic-only graft was calculated. The cost of a composite graft was compared to reoperation costs for mesh erosion of a synthetic-only graft. Results: Zero patients (N = 90) undergoing abdominal sacrocolpopexy with a composite biologic/synthetic graft experienced graft erosion. Based on existing data, thirty-three patients would need to be treated with a composite graft to avoid one mesh erosion from a synthetic-only graft. If a