Ph.E.V. Van Kerrebroeck

Long-term efficacy and safety results of the two-stage implantation technique in sacral neuromodulation

Objective u2002To assess the long‐term efficacy and safety of two‐stage sacral neuromodulation with an implantable pulse generator (IPG) in patients treated for urinary urge incontinence (UI) and/or urinary retention (UR).

Systematic Review: Efficacy of Silicone Microimplants (Macroplastique®) Therapy for Stress Urinary Incontinence in Adult Women

OBJECTIVEnTo assess the efficacy of silicone microimplants (Macroplastique; polydimethylsiloxane) therapy for stress urinary incontinence in adult women, using a systematic review of identified studies.nnnMATERIALS AND METHODSnA computer-aided and manual search for published studies investigating silicone microimplants therapy for stress urinary incontinence in adult women. The methodological quality of the included studies was assessed using criteria based on generally accepted principles of interventional research.nnnRESULTSnOnly two RCTs, only published as an abstract, were found. Eleven pre-experimental or observational studies were identified. Overall, the methodological quality was low. The main methodological shortcomings of the studies were: no random allocation procedure, lack of prestratification on prognostic determinants, no blinding, small sample sizes, and lack of proper analysis and presentation of results. There was variability in the indication for implantation, implantation procedure, rate and volume of silicone microimplants. The use of different outcome measures in most of the trials made comparison between studies difficult.nnnCONCLUSIONSnBecause of the low methodological quality of included studies, results should be interpreted with caution and no firm conclusions about the efficacy of silicone microimplants were possible. Randomized clinical trials, using valid and reliable subjective and objective measurements, are necessary to establish the efficacy of silicone microimplants therapy in treating stress urinary incontinence in adult women.

Effects of Macroplastique® Implantation System for stress urinary incontinence and urethral hypermobility in women

A study was carried out to evaluate efficacy of Macroplastique® (MPQ) Implantation System (MIS) in women with urodynamic stress urinary incontinence (SUI) and urethral hypermobility after an unsuccessful conservative treatment. This is a prospective randomized controlled trial in women without previous incontinence surgery. Twenty-four women received MPQ. Twenty-one controls underwent a pelvic floor muscle exercises home program. Follow-up was at 3xa0months and the MPQ group also at 12xa0months. At 3xa0months, pad usage decreased significantly more in the MPQ group than in the control group (pu2009=u20090.015). According to physician and patient self-assessment, respectively, 71% and 63% women in the MPQ group were considered cured or markedly improved. This was significantly higher compared to controls. There was a significant higher increase of Incontinence Quality-of-Life questionnaire score in the MPQ group compared to controls (pu2009=u20090.017). Improvements in MPQ group at 3xa0months are sustained to 12xa0months. Adverse events were mild and transient. MIS is an acceptable option for women with SUI and urethral hypermobility.

Urodynamic results of sacral neuromodulation correlate with subjective improvement in patients with an overactive bladder.

OBJECTIVESnStandard urodynamic investigations showed no correlation between the efficacy of sacral neuromodulation (SNS) and urodynamic data. Ambulant urodynamic investigations (ACM) are presented as more sensitive and reliable in detecting and quantifying bladder overactivity. In this study we looked at the correlation and results of ambulant urodynamic data and the clinical effects of SNS.nnnMETHODSnData of patients with bladder overactivity, who underwent an ACM before and during SNS were investigated. Blind analyses of the ACM were performed and the detrusor activity index (DAI) was calculated as the degree of bladder overactivity of the detrusor. The ACM parameters, before and during SNS, were analyzed and correlated to the clinical effect of SNS.nnnRESULTSnIn 22 of the 34 patients a DAI before and during stimulation could be calculated because of quality aspects. In all other patients, the other ambulatory urodynamic parameters could be analyzed and a significant reduction was found in bladder overactivity. A significant correlation (p = 0.03) was found in DAI reduction of the ACM before and during SNS as compared to the clinical improvement in overactive bladder symptoms.nnnCONCLUSIONSnThe objective and subjective results show a decrease in bladder overactivity during SNS. During SNS bladder instabilities are still present, which is in accordance with the published literature. The reduction of the DAI during SNS as compared to before SNS correlates significantly to the clinical effect of SNS.

Quality of Life, Functional Outcome and Durability of the AMS 800 Artificial Urinary Sphincter in Patients with Intrinsic Sphincter Deficiency

Objective: To evaluate the quality of life, functional outcome and durability of the AMS 800 artificial urinary sphincter (AUS) in patients with urinary incontinence due to intrinsic sphincter deficiency of mixed origin. Patients and Methods: Between 1991 and 2000, 34 AUS were implanted in 31 patients (24 males/7 females) with mean age of 59 (range 15–75) years. Using a questionnaire, patients’ urinary function and quality of life were assessed in 22 patients with an AUS in situ. To evaluate efficacy and durability of the device, the primary adequate function (P-AF) and additional procedure-assisted adequate function (APA-AF) rates were determined on the basis of a Kaplan-Meier survival analysis. Results: The social continence rate (0–1 pads/24 h) was 55% with a mean follow-up of 46 months. The revision rate was 26% and the explantation rate 35%. The 5-year P-AF and APA-AF rates were 41 and 44%, respectively. The pad score decreased from 2.95 to 1.23 after AUS implantation (p < 0.0001) leading to a high mean patient satisfaction (rated as 4.0 on a visual analog scale of 0–5). Twenty-one patients (95%) would undergo the procedure again under the same circumstances. Patients with previous anti-incontinence procedures showed a significantly higher explantation rate (p = 0.004). Conclusion: In spite of a relatively high re-operation rate and moderate social continence state, patient satisfaction was found to be great mainly due to the relative improvement in incontinence. The AMS 800 AUS is a reliable device with few mechanical complications. Extensive preoperative counseling is mandatory.

Robotic extravesical anti-reflux operations in complex cases: technical considerations and preliminary results.

Objectives: To evaluate technical aspects and outcome of robotic laparoscopic extravesical anti-reflux surgery in the treatment of high-grade vesicoureteral reflux (VUR) with associated complicating conditions. Materials and Methods: Retrospective database and chart reviews were performed to identify a subgroup of patients with high-grade VUR who underwent robot-assisted anti-reflux surgery using the extravesical Lich-Gregoir repair and who additionally had preoperatively known complicating factors. Five such patients were operated on from 2005 to 2009. All had bilateral VUR, bladder dysfunction, breakthrough infections, renal scarring or at least one of the following complicating factors: posterior urethral valve bladders, duplex systems or para-ostial diverticula. Outcome and surgical aspects were assessed. Results: At follow-up 9 of 10 ureters were free of reflux and diverticulae had disappeared completely. No lasting urinary retentions occurred but two boys needed reinsertion of a catheter for 24 h after surgery. No further complications were noted. There were no signs of obstruction, infections did not persist and there was no negative effect on bladder function. Dissection of para-ostial diverticula seemed the only additional technical challenge. Conclusions: Robot-assisted extravesical anti-reflux surgery seems a promising technique in the operative management of this unfavorable subset of patients. Reflux cure rate is higher than expected using injection therapy and at the same time morbidity seems lower than with open surgery. Further experience is needed to confirm these first impressions.

A treatment algorithm for the overactive bladder

The first problem with the available reports is the lack Current therapy for the overactive bladder is very unsatisfactory; this reflects the complicated pathophysioof uniformity in the definition of the ‘overactive bladder’ [1]. The results of any treatment may diCer depending logical background of the problem and the lack of eBcacy of available treatment modalities. However, on the accuracy of the diagnosis. Moreover, results based on patients’ symptoms may diCer significantly from diCerent surgical treatments, conservative and minimally invasive, are available for this condition. No single results based on urodynamic changes. Often trials are performed in biased groups of patients in specialized therapy is suBciently superior to any other as to be the first choice, based on therapeutic eBcacy alone. centres. To what extent these results can be extrapolated into clinical practice is debatable. Therefore, combined therapy is often necessary to achieve acceptable results. Therapeutic trials in this Reducing the number of micturitions through bladder training is considered a first step in the treatment of an field are diBcult even with monotherapy and even more so with combined therapies. Therefore, the final treatoveractive bladder. The published success rates are high, at 57–76%, but diCerent treatment regimens are availment plan and the timing of the diCerent elements of therapy are often based on the treatment modalities able, from simple schedules based on micturition diaries collected at home, to more sophisticated methods that available, the costs involved, the organization of healthcare and personal experience. No adequate treatmay require hospitalization [2,3]. The results will depend on the patients’ motivation and compliance. In general, ment algorithm is available; based on the individual situation of any patient, every treatment algorithm a minimum of 6 weeks is necessary for any eCect to become apparent, but a 3–6-month period may be needs to be matched with the patient’s needs and wishes. The potential experience of the treating physnecessary to produce a significant and permanent change. Even then, there is a high recurrence rate with ician should also be considered. In this article, I attempt to devise the basis for such an algorithm. this regimen. Additional training methods using biofeedback techniques and pelvic muscle exercises can be added to basic bladder training. No publications have Methods confirmed that this improves the final results, but it is obvious that this facilitates a wider approach to the There are many reports of the results of diCerent therapeutic treatments for the overactive bladder. However, problem. Treatment regimens of up to 8 weeks have been studied, with excellent results [4]. However, these fewer articles report the results of prospective trials with an adequate sample size from which to draw valid techniques are more expensive and require skilled paramedical co-workers with special training. Behavioural conclusions. Very few studies compare the results of diCerent types of therapy and a few deal with the results therapy can enhance the results of the training programme, but a high proportion of patients refuse to of the combination of therapies. The present study began with a review of the available literature on individual accept this treatment modality [5]. Again, highly trained professionals are needed and the full programme can treatments, comparisons of individual treatments of the same type and of diCerent types of treatment. The take 3–6 months. The use of non-invasive electrical stimulation in the existing information on combined therapy was also collected. From these data the value of individual and treatment of bladder overactivity has been extensively studied [6]. However, the results reported vary considercombined treatments was defined, based on estimates of eBcacy and safety matched with feasibility. Furthermore, ably and diCerent treatment schedules are used. Specialized staC are essential and treatment can also an indication of the timing for diCerent therapies was suggested and eventually a sequence based on shorttake up to 3 months to produce a significant eCect. Pharmacological therapy is one of the keystones in and long-term results constructed.

Urogenital and Sexual Complaints in Female Club Cyclists—A Cross-Sectional Study

INTRODUCTIONnCycling has gained increased popularity among women, but in contrast to men, literature on urogenital overuse injuries and sexual dysfunctions is scarce.nnnAIMnTo determine the prevalence and duration of urogenital overuse injuries and sexual dysfunctions in female cyclists of the largest female cycling association in The Netherlands.nnnMETHODSnA cross-sectional questionnaire survey was sent to 350 members of the largest female Dutch cycling association and 350 female members of a Dutch athletics association (runners).nnnMAIN OUTCOME MEASURESnThe prevalence and duration of urogenital overuse injuries and sexual complaints were assessed using predefined international definitions.nnnRESULTSnQuestionnaire results of 114 cyclists (32.6%) and 33 runners (9.4%) were analyzed. After at least 2 hours of cycling, dysuria, stranguria, genital numbness, and vulvar discomfort were present in 8.8%, 22.2%, 34.9%, and 40.0%, respectively (maximum duration 48 hours). These complaints are not present in the controls (P < .001). In multivariable logistic regression analysis, increased saddle width was significantly associated with the presence of dysuria and stranguria. Older age was significantly associated to the presence of vulvar discomfort. Of the cyclists, 50.9% has at least one urogenital overuse injury. Insertional dyspareunia was present in 40.0% of cyclists and lasted until 48 hours after the effort. The latter complaint was not present in runners (P < .001). Uni- or bilateral vulvar edema was reported by 35.1% of cyclists. As for general complaints, 18.4% of cyclists reported a change in sexual sensations and 12.8% reported difficulties in reaching orgasm owing to cycling-related complaints. Limitations include population size and the use of non-validated questionnaires.nnnCONCLUSIONSnThe results of this study suggest that urogenital overuse injuries and sexual complaints are highly prevalent in female cyclists who are active participants in riding groups.

Distribution and sub-types of afferent fibre in the mouse urinary bladder.

AIMnIncreased afferent fibre activity contributes to pathological conditions such as the overactive bladder syndrome. Nerve fibres running near the urothelium are considered to be afferent as no efferent system has yet been described. The aim of this study was to identify sub-types of afferent nerve fibres in the mouse bladder wall based on morphological criteria and analyse regional differences.nnnMATERIALS AND METHODSn27 bladders of six month old C57BL/6 mice were removed and tissues were processed for immunohistochemistry. Cryostat sections were cut and stained for Protein Gene Product 9.5 (PGP), calcitonin gene related polypeptide (CGRP), neurofilament (NF), vesicular acetylcholine transporter (VAChT) and neuronal nitric oxide synthase (nNOS).nnnRESULTSnIn the sub-urothelium, different types of afferent nerve fibre were found, i.e. immunoreactive (IR) to; CGRP, NF, VAChT, and/or nNOS. At the bladder base, the sub-urothelium was more densely innervated by CGRP-IR and VAChT-IR nerve fibres, then at the lateral wall. NF- and nNOS nerves were sparsely distributed in the sub-urothelium throughout the bladder. At the lateral wall the inner muscle is densely innervated by CGRP-IR nerve fibres. NF, VAChT and nNOS nerves were evenly distributed in the different muscle layers throughout the bladder. Nerve fibre terminals expressing CGRP and NF were found within the extra-mural ganglia at the bladder base.nnnCONCLUSIONSnDifferent types of afferent nerve fibres were identified in the sub-urothelium of the mouse bladder. At the bladder base the sub-urothelium is more densely innervated than the lateral wall by CGRP-IR and VAChT-IR afferent nerve fibres. CGRP and NF afferent nerve fibres in the muscle layer probably relay afferent input to external ganglia located near the bladder base. The identification of different afferent nerves in the sub-urothelium suggests a functional heterogeneity of the afferent nerve fibres in the urinary bladder.

Phosphodiesterase type 2 distribution in the guinea pig urinary bladder.

AbstractIntroductionnNitric oxide-stimulated cGMP synthesis represents an important signalling pathway in the urinary bladder. Inhibitors of the PDE1 and PDE5 enzyme have been studied to treat storage and voiding disorders in clinical settings. The distribution of PDE2 in the bladder is unknown. This study focuses on the distribution and site of action of PDE2 within the guinea pig urinary bladder wall.nMethodsSix male guinea pig bladders were dissected and treated in 2xa0ml Krebs’ solution and 10xa0µM of the specific PDE2 inhibitor, Bay 60-7550 at 36xa0°C for 30xa0min. After stimulating tissues with 100xa0µM of diethylamine-NONOate for 10xa0min, the tissues were snap frozen and cut in 10xa0µm sections which were examined for cGMP immune-reactivity, co-stained with either vimentin, synaptic vesicle protein 2, calcitonin gene-related protein and protein gene product 9.5.ResultsPDE2 inhibitor Bay 60-7550 inhibits cGMP breakdown the most in the urothelial and suburothelial layers, as well as on the nerve fibres. After inhibition by Bay 60-7550, cGMP was mainly expressed in the intermuscle interstitial cells and the nerve fibres of the outer muscle layers of lateral wall, indicating the presence of PDE2 activity.Discussion and conclusionOur study is the first to show the distribution of PDE2 in the bladder which was shown to be present in the urothelium, mainly umbrella cells, the interstitial cells of the suburothelium and the outer muscle, as well as in nerve fibres.n