Gamal Ghoniem

An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for reporting outcomes of surgical procedures for pelvic organ prolapse

Introduction and hypothesisStandardized terminology has yet to be developed for reporting the outcomes for surgery for pelvic organ prolapse (POP).MethodsThis report combines the input of the Terminology and Standardization Committees of the International Urogynecological Association (IUGA) and the International Continence Society (ICS) and a joint Working Group on this topic, as well as expert external referees. The aim was to present a standardized terminology for the definitions of surgery and propose a structure for reporting the outcomes of surgical procedures for POP. An extensive drafting and review process was undertaken, as well as open review on both IUGA and ICS websites.ResultsA terminology report was developed outlining the recommended structure for reporting outcomes of surgical trials involving POP. This document does not define success and failure. The report includes patient-reported, subjective and objective outcomes to enable researchers to report on their results and compare them with other studies.ConclusionsA consensus-based method for standardizing terminology for reporting outcome measures of POP surgery was developed to aid clinicians working in this area of research.

Differential profile analysis of urinary cytokines in patients with overactive bladder

Introduction and hypothesisWe hypothesize that overactive bladder (OAB) can produce inflammatory cytokines due to afferent neural plasticity or urothelial dysfunction. This study aimed to detect abnormal cytokine levels in urine of patients with OAB compared to urinary tract infections (UTI) and controls.MethodsThis was a prospective, single blind study including 20 premenopausal women (control), 20 with OAB and 16 with UTI. Urine samples were collected, centrifuged, and stored (−80°C). Urinary total proteins were quantified and detected by antibody-based array chip for release of 120 human cytokines in the two groups relative to the controls.ResultsMajority of cytokines showed the same expression in the OAB compared with the controls. Cytokines exclusively expressed in OAB were: monocyte chemoattractant protein (MCP) 1, TARC, PARC, and Fas/TNFRSF6. MCP-2, MCP-3, tumor necrosis factor-β, GCSF and eotaxin-3 showed a shared expression in UTI and OAB. Conversely, few of the cytokines were downregulated in OAB (IL-5, IL-6, IL-7, and GM-CSF).ConclusionsTaken together, the results suggest that a subset of inflammatory cytokines and chemokines provides a framework for development of highly optimized urinary biomarker assay for differential diagnosis and treatment of OAB.

An international urogynecological association (IUGA)/international continence society (ICS) joint report on the terminology for reporting outcomes of surgical procedures for pelvic organ prolapse

Standardized terminology has yet to be developed for reporting the outcomes for surgery for pelvic organ prolapse (POP).

The management of genitourinary fistula in the third millennium

Abstract Background: A vesicovaginal fistula (VVF) is an abnormal fistulous tract between the bladder and vagina, causing continuous loss of urine via the vagina. VVF is a relatively uncommon condition, but there is a drastically higher prevalence in the developing world. Furthermore, iatrogenic postoperative VVF is most common in developed countries, compared to mainly obstetric trauma in developing countries. In this review we focus on the development of current management techniques for VVF. Methods: Medline was searched to identify articles related to urogenital fistulae, including VVF. Based on these reports we focus on the aetiology, clinical presentation, diagnosis and management of VVF. This in-depth review includes the optimal surgical timing, different surgical approaches (including minimally invasive techniques such as laparoscopic and robotic surgery), recommendations for postoperative care, surgical complications, and the need for further research in the use of robotic surgery to treat this condition. Results: In all, 60 articles were identified and included in this review; eight were related to the aetiology, 12 to diagnosis, and 40 to the management of VVF. A thorough evaluation of VVF is imperative for planning the repair. Although the surgeonís experience typically influences the surgical approach, special situations will dictate the best approach. Conclusion: The treatment of genitourinary fistulae with robotic assistance continues to develop, but further research is necessary to fully understand the use of this technology.

Redefining the Autonomic Nerve Distribution of the Bladder Using 3-Dimensional Image Reconstruction

PURPOSE We sought to create a 3-dimensional reconstruction of the autonomic nervous tissue innervating the bladder using male and female cadaver histopathology. MATERIALS AND METHODS We obtained bladder tissue from a male and a female cadaver. Axial cross sections of the bladder were generated at 3 to 5 mm intervals and stained with S100 protein. We recorded the distance between autonomic nerves and bladder mucosa. We manually demarcated nerve tracings using ImageScope software (Aperio, Vista, California), which we imported into Blender™ graphics software to generate 3-dimensional reconstructions of autonomic nerve anatomy. RESULTS Mean nerve density ranged from 0.099 to 0.602 and 0.012 to 0.383 nerves per mm2 in female and male slides, respectively. The highest concentrations of autonomic innervation were located in the posterior aspect of the bladder neck in the female specimen and in the posterior region of the prostatic urethra in the male specimen. Nerve density at all levels of the proximal urethra and bladder neck was significantly higher in posterior vs anterior regions in female specimens (0.957 vs 0.169 nerves per mm2, p<0.001) and male specimens (0.509 vs 0.206 nerves per mm2, p=0.04). CONCLUSIONS Novel 3-dimensional reconstruction of the bladder is feasible and may help redefine our understanding of human bladder innervation. Autonomic innervation of the bladder is highly focused in the posterior aspect of the proximal urethra and bladder neck in male and female bladders.

Renaissance of the autologous pubovaginal sling

Autologous tissue has been used to treat female stress urinary incontinence (SUI) for almost a century, with many operative modifications introduced throughout the years of the standard procedure known as pubovaginal sling (PVS) [1]. Currently, either rectus fascia or fascia lata are used to create a hammock on which the bladder neck and urethra can rest. The use of other biological tissues, however, failed the test of time, albeit the earlier good results. During the past decade, the US Food and Drug Administration (FDA) public communications caused a dramatic increase in litigation and malpractice claims related to synthetic mesh use for midurethral slings (MUS). As a direct result, the use of these slings significantly decreased, partly because their production was abandoned by many manufactures, and partly due to the growing concern among women about having this type of surgery [2]. This factor was responsible for the resurgence of interest in recent years to adopt the autologous PVS or fascial sling as an alternative surgical option for treatment of SUI when there is concern about tissue quality, possible litigation, and when patients refuse synthetic slings. The low rate of adverse events with PVS, such as vaginal erosion, infection, and urethral damage attributable to synthetic mesh, also supported this decision. The PVS can thus be used in patients when placement of a synthetic mesh sling is contraindicated, such as with concomitant urethral diverticulectomy, repair of urethrovaginal fistulae, prior pelvic radiation, or history of prior or concurrent urethral mesh erosion [2]. Traditionally, the PVSwas reserved for recurrent SUI due to intrinsic sphincteric deficiency because of the technical difficulty involved and the special surgical skills required for performing the procedure. More recently, the operation has been successfully used for primary SUI, as continence rates were better with greater patient satisfaction despite the higher incidence of postoperative voiding dysfunction compared with Burch colposuspension [3]. This finding is supported by results of a recent meta-analysis of 15,855 patients showing that both synthetic and PVS had similar objective cure rates that were superior to Burch colposuspension [4]. SUI in women should be considered as a continual process directly related to internal sphincter competence. In women with SUI and normally functioning internal sphincter, a higher intra-abdominal pressure is required to forcibly open the bladder outlet, but a lower increase of abdominal pressure will cause outlet opening and incontinence if the sphincter function is compromised. Positioning an anti-incontinence sling at the bladder neck and proximal urethra provides support to the bladder outlet with increased intra-abdominal pressure, thus restoring continence. Using videofluorourodynamic studies with the patient in the standing position, a moderate increase of posterior urethral pressure was observed with SUI that is enough to maintain continence during rest. The specific dynamic action of the sling was, however, demonstrated during increased abdominal pressure with coughing and Valsalva maneuver. The rectusmuscle contracted, pulling the sling slightly forward (anteriorly), with rotation of the bladder base posteriorly and inferiorly causing compression and kinking of the bladder outlet and preventing incontinence. Understanding this selective dynamic continence mechanism is essential to the pelvic surgeon to avoid excessive tightening of the sling, which will lead to voiding dysfunction. If the high residual urine or urinary retention resulting from voiding dysfunction does not resolve after 3 months postoperatively, a sling incision may be required. In certain women with severe SUI due to damaged or impaired internal sphincteric mechanism, an occlusive sling or crossover bladder-neck wrap sling may be required. Examples of these cases include extensive sphincter fibrosis following multiple pelvic surgery or neurogenic patients with a wide-open bladder neck. Pelvic reconstructive surgeons are expected to discuss surgical options with women with SUI in detail so that an informed decision can be made by both parties regarding which surgery to choose. The pros and cons of PVS, including additional incision to harvest the fascia and more storage * Gamal M. Ghoniem gghoniem@uci.edu

The challenges in the diagnosis of detrusor underactivity in clinical practice: A mini-review

Abstract Objective: To review the current definitions, terminology, epidemiology and aetiology of detrusor underactivity (DU), with specific attention to the diagnostic criteria in use. In addition, we address the relation and the overlap between DU and bladder outlet obstruction (BOO). In this mini-review, we hope to help identify DU patients and facilitate structured clinical evaluation and research. Methods: We searched the English literature using ScienceDirect and PubMed for relevant articles. We used the following terms: ‘detrusor underactivity’, ‘underactive bladder’, ‘post voiding residual’, ‘post micturition residual’, ‘acontractile bladder’, ‘detrusor failure’, and ‘detrusor areflexia’. Result: DU is one of the most common conditions causing lower urinary tract symptoms (LUTS). Unfortunately, it is also the most poorly understood bladder dysfunction with scant research. To our knowledge there is no clear definition and no non-invasive method to characterise this important clinical condition. DU may result from the normal ageing process; however, it has multiple aetiologies including neurogenic and myogenic dysfunction. In many cases the symptoms of DU are similar to those of BOO and it usually requires invasive urodynamic study (UDS) for diagnosis to differentiate the two diagnoses. A number of diagnostic tests may be used including: UDS testing, the Schafer pressure/flow nomogram, linear passive urethral resistance relation, Watts factor, and the bladder contractility index. Of these, UDS testing is the most practical as it determines both the maximum urinary flow rate and the pressure exerted by the detrusor muscle relative to the maximal flow of urine, allowing for precise characterisation of detrusor function. Conclusion: Currently, the diagnosis of DU is based on invasive urodynamic parameters as defined by the International Continence Society in 2002. There is no consensus for the definition of DU prior to 2002. As there is significant overlap between the symptoms of DU and BOO, it is difficult to diagnose DU clinically.

Paraurethral Leiomyoma in a 20 Year-old Woman: A Case Report

We present the case of a 20 year-old woman with a vulvar mass, found to be a paraurethral leiomyoma. She subsequently underwent supermedial-approach paraurethral mass excision, distal urethral reconstruction and cystourethroscopy. Paraurethral leiomyoma make up approximately five percent of urethral tumors. This case depicts the presentation and treatment of a paraurethral leiomyoma in one of the youngest women reported in the literature.

Role of Urodynamics in the Evaluation of Elderly Voiding Dysfunction

Voiding dysfunction is a common condition in the elderly that can affect both men and women. Due to the age-associated changes in the lower urinary tract, voiding dysfunction in the elderly is usually complex and multifactorial, necessitating more objective testing sometimes. In this chapter, we will focus on the role of urodynamics in the setting of voiding dysfunction in the elderly. The term voiding dysfunction will be used to refer both to storage and obstructive lower urinary tract symptoms.

Long-Term Outcomes of Augmentation Enterocystoplasty with a Catheterizable Channel in the Adult Neurogenic Population

Augmentation enterocystoplasty with a continent catheterizable stoma is a common approach to refractory neuropathic bladder, incontinence and end-stage bladder disease that aims to provide a large capacity, low-pressure reservoir and continent stoma. The goal is to not only to prevent renal deterioration, but also provide the patient with an improved quality of life. Several recent studies, reviewed in this chapter, have assessed the long-term outcomes of these procedures, demonstrating durable improvement in bladder capacity, bladder compliance, continence and quality of life. The long-term complications of the surgery include stomal complications such as stenosis and prolapse, channel related complications leading to difficult catheterization, bladder stones, recurrent urinary tract infections, bladder rupture, metabolic derangement and in very rare cases, malignant transformation. Successful surgery and good outcomes depend on proper patient selection, surgeon and center experience with the procedure, and close follow-up.