Michael E. Franks

Technique of combined pubovaginal sling and cystocele repair using a single piece of cadaveric dermal graft

OBJECTIVES To investigate the feasibility of using a single piece of cadaveric dermal allograft for the repair of stress urinary incontinence (SUI) with concurrent cystocele. METHODS Nineteen patients with combined SUI and symptomatic grade III cystoceles were treated. Eleven of 19 patients had undergone prior repairs for SUI. All patients underwent a combined pubovaginal sling procedure and cystocele repair using a single piece of cadaveric dermal allograft (3 x 7 cm). The single strip of dermal graft was placed in a longitudinal direction along the anterior vagina. The distal segment of the allograft supported the urethra, and the proximal portion supported the central cystocele defect and was sutured to the pubocervical fascia. The mean follow-up was 28 +/- 4 months and patients were monitored by physical examination, videourodynamic studies, and completion of the bladder bothersome visual analog scale. RESULTS Of the 19 patients, 1 developed an acute infection and failure of the graft after presenting with fever, discharge, dysuria, and incontinence. The autolysed graft was removed, and she subsequently underwent successful autologous fascial repair. Of the remaining 18 patients, 17 were cured of their SUI, including 10 who had had prior repairs, and 16 had no recurrence of cystocele and 2 had asymptomatic grade I and II cystoceles. One patient developed de novo detrusor instability that was successfully treated with anticholinergic medication. No cases of urethral obstruction occurred. CONCLUSIONS Although the follow-up was short, the use of a single piece of cadaveric dermal graft slings for concomitant pubovaginal sling and cystocele repair is feasible and simple to perform. At more than 2 years of follow-up, documented by videourodynamic studies, neither urethral obstruction nor symptomatic cystocele recurrence was found.

Gene Therapy for Bladder Overactivity and Nociception with Herpes Simplex Virus Vectors Expressing Preproenkephalin

Interstitial cystitis/painful bladder syndrome (IC/PBS) is a major challenge to treat. We studied the effect of targeted and localized expression of enkephalin in afferent nerves that innervate the bladder by gene transfer using replication-defective herpes simplex virus (HSV) vectors in a rat model of bladder hyperactivity and pain. Replication-deficient HSV vectors encoding preproenkephalin, which is a precursor for Met- and Leu-enkephalin, or control vector encoding the lacZ reporter gene, were injected into the bladder wall of female rats. After viral vector injection, quantitative polymerase chain reaction showed high preproenkephalin transgene levels in bladder and dorsal root ganglia innervating the bladder in enkephalin vector-treated animals. Functionally, enkephalin vector-treated animals showed reductions in bladder hyperactivity and nociceptive behavior induced by intravesical application of capsaicin; however, vector-mediated expression of enkephalin did not alter normal voiding. This antinociceptive effect of enkephalin gene therapy was antagonized by naloxone hydrochloride administration. Together, our results with HSV vectors encoding preproenkephalin demonstrated physiological improvement in visceral pain induced by bladder irritation. Thus, gene therapy may represent a potentially useful treatment modality for bladder hypersensitive disorders such as IC/PBS.

Technique of parastomal hernia repair using synthetic mesh

We describe a reliable and simple technique of parastomal hernia repair using primary fascial repair with synthetic mesh that minimizes the known complications of infection and stomal stenosis while eliminating the need for peritoneal exploration, lysis of adhesions, and relocation of the stoma. We applied this technique to 6 patients (aged 65 to 83 years) with symptomatic, first-time parastomal hernias. The results are discussed.

Metastatic osteomyelitis after pubovaginal sling using bone anchors.

We report a case of osteomyelitis with metastasis to the T10 vertebra related to bone anchor use with pubovaginal sling. The morbidity was significant: long-term intravenous antibiotics, multiple surgeries to correct the problem, and subsequent chronic pelvic pain. Given that this complication is unheard of after standard fascia or allograft sling, consideration should be given before bone anchor use in women at risk for wound infection (diabetes, obesity, or reoperation). Minimally, patients should be told of the possibility of this severe complication in the informed consent with bone anchor use.

Surgical Enucleation for the Treatment of Renal Tumors

Introduction: We analyzed our institutional experience with surgical enucleation for the primary treatment of small renal tumors. Materials and Methods: Patient demographics, histological features, effect of different types of vascular control and outcome from surgery were analyzed in 45 patients. A majority of the tumors (67%) were diagnosed incidentally. Results: All were stage T1, 77% were low grade (I–II) and 23% were high grade (III–IV). Complication occurred in 12% of patients. At a mean follow-up of 34 months (range 7–97), 28 of 33 patients (84%) with malignant tumors were alive without evidence of disease. One patient with a solitary kidney developed recurrent tumor after enucleation that required nephrectomy. Mean operative time was significantly lower with the compression technique versus direct vascular control (164 ± 12 min vs. 233 ± 15 min, p = 0.002). There were no differences in outcome between the two techniques. Conclusions: Surgical enucleation is a safe and viable procedure for the treatment of small renal tumors. Manual compression of the kidney appears to be at least as effective as clamping of the renal vessels in obtaining vascular control during the procedure and is more expeditious.

HEPATOCELLULAR CARCINOMA METASTATIC TO THE BLADDER AFTER LIVER TRANSPLANTATION

Urological involvement of hepatocellular carcinoma (hepatoma) is rare. Autopsy studies of patients with hepatoma revealed renal metastases in less than 5%1 but to date only 1 with bladder spread has been reported to our knowledge. We report another case of hepatocellular carcinoma metastatic to the bladder, and discuss the presentation, management and followup of this unusual neoplasm.

PD71-01 DECIPHER TEST IMPACTS DECISION-MAKING AMONG PATIENTS CONSIDERING ADJUVANT AND SALVAGE TREATMENT FOLLOWING RADICAL PROSTATECTOMY: INTERIM RESULTS FROM THE MULTICENTER PROSPECTIVE PRO-IMPACT STUDY

Menopause women are known to be sensitive to cold stress, but the mechanism is not clearly known. The aim of this study is to show that menopause causes impairment of micro blood flow in the bladder mucosa and dermis under the skin and up-regulates TRPM8 channels which induces cold stress related frequency in rats. METHODS: A total of 18 Spontaneously Hypertensive rats at postnatal week 10 were used in the experiments. The rats were randomly divided into 2 groups, including 9 with sham operation and 9 with bilateral ovariectomy. At 4 weeks after surgery, cystometography (CMG) was performed. CMG was first performed in room temperature (RT) for 20 minuets. Rats were then put into low temperature (LT) for 40 minutes. After LT, rats were put into RT for 20 minutes. After CMG, the whole bladder and dermis under the lumbar skin was harvested and real-time RT-PCR was performed. Immunohistochemistry was also performed and impairment of micro blood flow was evaluated by hypoxia-inducible factor-1 (HIF-1) staining. RESULTS: Results of the CMG are shown in Fig 1. Basal pressure and micturition pressure did not show a difference between control rats and ovariectomy rats, but change rate with cold stress in voiding interval and micturition volume showed a significant exacerbate. Results of real-time RT-PCR are shown in Fig 2. Up-regulation of TRPM8 in the dermis and TRPV1 in the bladder mucosa was seen in ovariectomy rats. Immunohistochemistry showed increase of HIF-1 in the bladder mucosa and dermis. CONCLUSIONS: Ovariectomy causes impairment of micro blood flow in the bladder mucosa and dermis which induces cold stress frequency by up-regulating TRPM8 channels.