Hari S.G.R. Tunuguntla

Female Sexual Dysfunction Following Vaginal Surgery: A Review

PURPOSE Depending on age it has been estimated that up to 40% of women have complaints of sexual problems, including decreased libido, vaginal dryness, pain with intercourse, decreased genital sensation and difficulty or inability to achieve orgasm. In this review we address the etiologies and incidence, evaluation and treatment of female sexual dysfunction following vaginal surgery for indications such as stress urinary incontinence and pelvic organ prolapse; anterior/posterior colporrhaphy, perineoplasty and vaginal vault prolapse. MATERIALS AND METHODS Literature on the mechanisms by which vaginal surgery affects female sexual function are discussed along with related pathophysiology to potential causes. The anatomy, neurovascular supply of the clitoris and introitus, and intrapelvic nerve supply are discussed as related to vaginal surgery. Techniques to avoid neurovascular damage during pelvic floor surgery were corroborated by supporting literature. Literature regarding female sexual dysfunction following other procedures, such as vaginal hysterectomy, Martius flap interposition, and vesicovaginal and rectovaginal fistula repair were also discussed. RESULTS Current literature does not support an association between vaginal length following vaginal surgery and sexual function. The proportion of women who are sexually active does not appear to be affected by vaginal surgery. Sling surgery for urinary incontinence does not appear to adversely affect overall sexual function, although individual parameters of sexual function scores may vary, eg a significant percent of women report pain during intercourse. Some patients experience improved overall sexual function due to complete relief from coital incontinence CONCLUSIONS Symptomatic vaginal narrowing is rare even in women undergoing simultaneous posterior repair. Overall sexual satisfaction appears to be independent of therapy for urinary incontinence or prolapse. Data indicate that defect specific posterior colporrhaphy with the avoidance of levator ani plication may improve sexual function. The possible etiological factors for sexual dysfunction following vaginal surgery deserve further investigations.

Predictors of Success for First Stage Neuromodulation: Motor Versus Sensory Response

PURPOSE We investigated whether intraoperative motor or sensory response is more predictive of successful sacral neuromodulation using the InterStim system. MATERIALS AND METHODS A total of 35 patients with medically refractory frequency, urgency and urge incontinence were enrolled in the study. All patients underwent lead placement for quadripolar test stimulation under local anesthesia with intravenous sedation. Confirmation of correct lead placement was by observation of known motor and sensory responses that result from third sacral nerve stimulation. Motor and sensory responses were documented intraoperatively. Patients had a 1-week trial of stimulation, and those who had greater than 50% improvement in symptoms had placement of the implantable pulse generator. Those without at least 50% improvement in their symptoms had the quadripolar lead removed. RESULTS Of the 35 patients enrolled 21 had successful quadripolar test stimulation and went on to permanent implantable pulse generator placement. Of the patients who had successful quadripolar test stimulation 95% demonstrated positive intraoperative motor response whereas only 21.4% of patients with unsuccessful quadripolar test stimulation demonstrated positive motor response. If only a positive sensory response was elicited, patients had only a 4.7% chance of having a positive quadripolar test stimulation. CONCLUSIONS A positive quadripolar test stimulation (greater than 50% improvement in symptoms) with InterStim sacral neuromodulation is more likely when intraoperative lead placement results in positive motor response vs only sensory response.

Diagnostic and Prognostic Molecular Markers in Renal Cell Carcinoma

PURPOSE We reviewed the contemporary literature on molecular biomarkers in renal cell carcinoma and their prognostic significance. MATERIALS AND METHODS Articles published during 1981 to 2007 in English on renal cell carcinoma were surveyed using the MEDLINE/PubMed database. The subject headings included were genetics, biomarkers, prognosis and risk models of renal cell carcinoma. We present a synthesis of currently known renal cell carcinoma biomarkers at various stages of development and their clinical significance, and prognostic nomograms incorporating biomarkers. RESULTS The beneficiary role of biomarkers in renal cell carcinoma is challenged by the relatively low prevalence of the disease. Even if a biomarker for renal cell carcinoma had 100% sensitivity and 99.4% specificity, the positive predictive value of the marker in men older than 65 years would be only 10%. Several biomarkers are being investigated in renal cell carcinoma, of which many relate to pathogenic molecular changes that are currently therapeutic targets. Carbonic anhydrase IX is a von Hippel-Lindau mediated enzyme that is expressed in most renal cell carcinoma cases. High (greater than 85%) expression of this marker indicates favorable prognosis and may predict the response to interleukin-2 therapy. B7-H1 expression in renal cell carcinoma cells/lymphocytes may indicate worse survival, possibly through impaired host antitumor immunity. Prognostic nomograms incorporating clinical variables and molecular markers to refine the prediction of treatment outcomes are in active development and await prospective clinical validation. CONCLUSIONS Several renal cell carcinoma molecular markers appear promising to refine the prognosis and prediction of localized, advanced or metastatic renal cell carcinoma. Currently carbonic anhydrase IX is the best studied and promising marker. Prospective, multicenter clinical validation aimed at the practical clinical usefulness of renal cell carcinoma biomarkers is warranted.

Management of neobladder-vaginal fistula and stress incontinence following radical cystectomy in women: a review

Contemporary literature regarding the management of neobladder-vaginal fistula and stress urinary incontinence following radical cystectomy and neobladder reconstruction in women is reviewed in this article. Neobladder-vaginal fistula is uncommon but mandates meticulous repair. Compared to the native bladder, the wall of the neobladder is much thinner that may render it vulnerable to fistulization. Preservation of the anterior vaginal wall during radical cystectomy decreases the likelihood of pouch-vaginal fistula. Omental flap interposition between the vaginal stump and neobladder at cystectomy may not always prevent fistulization if anterior vaginal wall is violated or overlapping suture lines are not avoided. Surgery for intractable stress incontinence following neobladder reconstruction is fraught with severe complications and requires judicious use of allograft pubovaginal slingplasty possibly with bone anchors. Martius flap interposition appears to play a crucial role in improving the outcome following transvaginal repair of the neobladder-vaginal fistula in multiple non-overlapping layers.

Construction-related Differences Seen in Ureteral Access Sheaths: Comparison of Reinforced Versus Nonreinforced Ureteral Access Sheaths

OBJECTIVES Ureteral access sheaths (UASs) are used to facilitate ureteroscopic procedures. Difficulties with use have been reported. Manufacturers have redesigned these devices to ameliorate these problems, including reinforcement of the sheath wall. This study compared reinforced (RUASs) and nonreinforced UASs (NRUASs) of the same manufacturer to determine whether RUASs expedite ureteroscopy and how relevant the reinforced structure is in terms of overall success. METHODS We prospectively followed up patients undergoing ureteroscopy for urolithiasis with 1 of 2 UASs; the Applied NRUAS and the Applied RUAS. The demographics, operative parameters, and outcomes were assessed. Statistical analysis was performed. RESULTS A total of 98 UASs were used in 68 male and 30 female patients (47 NRUASs and 51 RUASs). No significant differences were found between the groups in terms of demographic parameters, operative parameters, or successful sheath deployment. The overall success rate for sheath deployment was 95%. A pre-existing stent was significantly associated with successful deployment (P = .004). The sheath-specific limitations included kinking (NRUASs, 10%) and sheath angulation/deformity (RUASs, 21%). The mean follow-up time was 43.4 months; and 93.9% of the patients had radiologic follow-up. No ureteral strictures were noted. CONCLUSIONS No significant difference was found in the overall success rates between the use of Applied NRUASs and RUASs. The presence of a pre-existing stent was significantly associated with successful sheath deployment. Each UAS design had its own unique limitations, seen with low frequency. Successful sheath use might relate to both the sheath itself and the patient/operative parameters.