Marcelo Thiel

A stereological analysis of fibrosis and inflammatory reaction induced by four different synthetic slings

To analyse quantitatively, using stereological methods, the density of the collagen fibres induced by four types of sling materials, and verify by a histopathological analysis the corresponding inflammatory reaction, as fibrosis secondary to sling implantation is considered responsible for restoring urethral support and re‐establishing continence in women with stress urinary incontinence, and new synthetic materials that promote adequate fibrosis with the least intensity and duration have been proposed to substitute the aponeurotic sling.

Safyreä: a readjustable minimally invasive sling for female urinary stress incontinence

Introduction: SAFYRE TM is a readjustable and minimally invasive sling for the treatment of stress urinary incontinence (SUI). It is as a pubovaginal sling placed in the medial third of the urethra. The initial experience is described. Materials and Methods: Forty-five patients (mean age = 59 years) underwent a SAFYRE TM implant to treat SUI. Physical examination and urodynamic study were performed before surgery. All patients presented symptoms of SUI and 20% also reported mild urgency. Approximately 60% of this group had a previously failed anti-incontinence procedure. Urethral hypermobility was diagnosed in 40% of the patients and intrinsic sphincter deficiency (ISD) in 60% of the cases. Results: The average follow up period was 10 months. The mean operative time was 20 minutes. Dystopia repair was performed whenever necessary, during the same procedure. The average hospital stay was 24 hours. In 11% of the implants, bladder perforation occurred. During the postoperative period, 9 patients (20%) developed transient urgency symptoms. During the initial follow up period, 90% were found to be continent, 3% reported an improvement and 7% were unchanged. Conclusion: SAFYRE TM is a safe and quick procedure that allows postoperative readjustment. This technique may be an attractive alternative in the management of SUI, should the good result obtained so far prove to be long lasting.

RESINIFERATOXIN FOR DETRUSOR INSTABILITY REFRACTORY TO ANTICHOLINERGICS

PURPOSE We have evaluated the clinical and urodynamic effects of intravesical instillation of resiniferatoxin in patients with idiopathic detrusor instability refractory to anticholinergics. MATERIALS AND METHODS There were 30 women, median age 56 years old with detrusor instability for over 6 months and a history of anticholinergic use with no response or intolerable collateral effects. A 50 nM solution of resiniferatoxin was prepared for intravesical instillation. All patients were evaluated for urinary symptoms, as well as for urodynamic assessments before and 30 days after instillation. Tolerability was analyzed during the instillation. RESULTS A clinical improvement was observed in 30% of the patients with urinary urgency and in 33% of the patients with urge-incontinence. The mean maximum cystometric capacity before application was 303.9 +/- 78.9 and after application 341 +/- 84.6. No significant difference was observed (p = 0.585). The mean maximum amplitude of the contractions diminished from 47.86 +/- 29.64 to 38.72 +/- 30.77 (p = 0.002). CONCLUSIONS Resiniferatoxin, in this concentration, proved to be useful in a small percentage of patients regarding clinical detrusor instability. Maximum amplitude of the involuntary contractions was significantly reduced and in 33% patients the involuntary contractions disappeared. Further studies with different concentrations are recommended.

Readjustable transobturator sling: a novel sling procedure for male urinary incontinence.

Post-prostatectomy incontinence remains a significant problem for both patients and urologists. We report a case and the surgical technique of successful sling in the treatment of post-prostatectomy urinary incontinence. Sling surgery was performed on a 69-year-old male patient with severe urinary incontinence (6 pads/day) following radical prostatectomy. The procedure was conducted through the transobturator approach using a sling with a silicone foam pad to protect the urethra. At the 7-month follow-up the patient is using only 1 pad/day. We consider this operation an alternative to artificial urinary sphincter in cases of male sphincter incontinence.

The Ibero-American experience with a re-adjustable minimally invasive sling.

To report our experience with the SafyreTM (Promedon, Córdoba, Argentina), a new re‐adjustable and minimally invasive sling for treating stress urinary incontinence (SUI), which combines the efficacy of slings with re‐adjustability.

Safyre. Un nuevo concepto de cabestrillo ajustable mínimamente invasivo para la incontinencia urinaria por estrés femenina

Resumen Introduccion SAFYRE es un nuevo cabestrillo (dispositivo de suspension) reajustable y minimamente invasivo para el tratamiento de la incontinencia urinaria por estres (IUE). En los ultimos anos se ha intentado restaurar el lecho suburetral normal utilizando una tecnica anatomica. Los autores comunican su experiencia con este dispositivo, que ademas de poseer la eficacia de los cabestrillos tiene capacidad de reajustacion. Materiales y metodos Un total de 100 pacientes consecutivas con diagnostico de IUE desde el punto de vista clinico y urodinamico se sometieron al procedimiento de implantacion del cabestrillo SAFYRE. Su rango de edad era de 40 a 71 anos, con una edad media de 63 anos. Previamente, 75 pacientes (75%) se habian sometido a procedimientos para la incontinencia que habian fracasado. Antes de la cirugia se realizaron una exploracion fisica clinica, una prueba de estres, un estudio urodinamico y un estudio sobre el uso de almohadillas. Todas las pacientes presentaban sintomas de IUE y el 30% tambien tenian tenesmo leve. Resultados El periodo de seguimiento medio fue de 14 meses (12 – 30 meses). El tiempo medio de la operacion fue de 25 minutos. Durante el mismo procedimiento se reparo la distopia cuando se considero necesario. La estancia hospitalaria media fue de 24 horas. En el 3% de los implantes se produjo perforacion de la vejiga. Durante el periodo posoperatorio 26 pacientes presentaron sintomas de tenesmo. Durante ese periodo de seguimiento, el 92% presentaron continencia urinaria, el 3% mejoraron y el 5% no estuvieron satisfechas con el procedimiento. Conclusion SAFYRE es un procedimiento seguro y rapido que permite el reajuste posoperatorio. Esta tecnica puede ser una alternativa atractiva si se demuestra que los buenos resultados obtenidos hasta ahora son de larga duracion.

Evaluación de la función sexual femenina antes y después de un procedimiento para la corrección de la incontinencia urinaria de esfuerzo

The prevalence of urinary incontinence is around 20% of healthy middle-aged women. Incontinence causes a negative impact on the quality of life and sexuality. From August 2002 to January 2004, 30 patients (mean age 43 years) with stress urinary incontinence (59%), overactive bladder (15%) and mixed incontinence (26%) answered the ICIQ-SF(International Consultation on Incontinence Questionnarie-Short Form) and FSFI (Female Sexual Function Index) questionnaires before and after treatment for urinary incontinence. The follow - up ranged from 12 to 53 months. Mean ICIQ score was 17 and 7 before and after treatment respectivelly (p<0,001). Overactive bladder showed the worst scores in all domains. The patients who underwent surgery increased their scores of desire (p=0,02), satisfaction (p=0,05) and total score (p=0,02). Thirteen patients which ICIQ was zero increased: desire (p<0,01), satisfaction (p=0,05) and total score (p=0,01). Urinary incontinence significantly affects the quality of life. Therefore sexual evaluation in incontinence patients is recommended.

Effect of purified collagen on lipograft survival: experimental basis for periurethral lipoinjections.

PURPOSE To assess whether the use of collagens with lipografts improves graft survival. MATERIALS AND METHODS Thirty isogenic New Zealand rabbits were injected in the auricular area with either autologous fat alone or autologous fat associated with collagen. The animals were evaluated at 7, 30, and 90 days by histologic and morphometric methods together with measurements of the graft area and the number of adipocytes. RESULTS Addition of collagen to the lipoinjection reduced the local inflammatory reaction and improved the grafts survival; e.g., for stress urinary incontinence. CONCLUSION These results suggest that it is possible to increase the survival rate of the lipografts and improve their clinical applicability.

Uretrolisis transvaginal tras cirugía correctora de la incontinencia urinaria de esfuerzo

Resumen Objetivos Analizar los resultados de la uretrolisis transvaginal como medida terapeutica para la disfuncion miccional, en pacientes sometidas previamente a cirugia anti-incontinencia. Materiales y Metodos Fue realizado un estudio retrospectivo, en 20 pacientes quienes fueron sometidas a uretrolisis por obstruccion uretral secundaria a una cirugia anti-incontinencia. Pre-operatoriamente fueron realizados historia, examen fisico y estudio urodinamico. La edad media de las pacientes fue 48 anos. El tiempo de evolucion entre la cirugia y la uretrolisis, vario de 3 meses a 8 anos. Cuatro pacientes presentaron retencion urinaria y las demas referian sintomas irritativos. Las cirugias previas incluian: sling pubo vaginal en 11 pacientes, uretropexia retropubica en 3 y suspension del cuello vesical con aguja en 6. El seguimiento posterior a la realizacion de la uretrolisis fue de 14 meses. La evaluacion urodinamica demostro un flujo urinario promedio de 9,9 ml/s y presion detrusora media en el flujo maximo de 48cmH2O. Resultados Aproximadamente 70% de las pacientes presentaron mejoria subjetiva total de los sintomas. Dos pacientes presentaron falla del metodo y fueron sometidas a nueva uretrolisis con interposicion de flap de Martius. No hubo correlacion entre los parametros clinicos y urodinamicos encontrados en el pre operatorio y los resultados posteriores a la uretrolisis. Conclusion Tratamos de demostrar que la uretrolisis posterior a cirugia anti-incontinencia es un procedimiento efectivo, minimamente invasivo que permite resultados satisfactorios para el tratamiento de la disfuncion miccional que no se resuelve espontaneamente.

Experimental Animal Model for Training Transobturator and Retropubic Sling Techniques

Introduction: Suburethral slings have become the treatment of choice for stress urinary incontinence. However, the lack of experimental models for surgical training is a problem for beginners. We present a model for sling training and evaluate its acceptance by surgeons who have had prior experience. Materials and Methods: There were 32 surgeons who performed the training program and filled out a questionnaire to evaluate the animal model. Eleven-month-old Santa Inês sheep were selected. The techniques used for minimally invasive transobturator and retropubic sling implantation were reproduced followed by cystoscopy. The anatomical similarities of sheep and humans were evaluated, in addition to the reproducibility of surgical techniques. Results: As far as anatomical similarities of vaginal structures are concerned, 13 surgeons (40.6%) reported similarities and 18 (56.2%) reported a strong correlation. Concerning cystoscopy, 18 (56.2%) found similarities and 13 (40.6%) a strong similarity. As for the transvaginal sling, 10 (3.1%) reported similarities and 19 (59.3%) a strong similarity. Among those who had previous experience with transobturator slings, 91.6% considered that the model presented a similarity or strong similarity. Regarding the degree of recommendation, 9 surgeons (28.1%) would recommend it and 22 (68.7%) would strongly recommend it. Conclusion: Ninety-seven percent of the surgeons would recommend this experimental model for training purposes. To our knowledge this is the first description of a successful animal model for transobturator sling training.