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Few studies have addressed the functional impact after transanal total mesorectal excision.This study aimed to evaluate function and health-related quality of life among patients with rectal cancer treated with transanal total mesorectal excision.Consecutive patients treated between 2016 and 2018 were selected. Their function and quality of life were studied preoperatively and at 3 and 12 months after surgery.This is a prospective case series.Patients were eligible if they had primary anastomosis, their diverting stoma had been reversed, and they did not have anastomotic leakage. Forty-five patients were finally included. A total of 31 (68.8%) and 32 patients (71.1%) completed the 3- and 12-month surveys.Standard transanal total mesorectal excision was performed.The primary end point was functional and quality-of-life outcomes using validated questionnaires. Secondary end points included values obtained with endoanal ultrasounds, anorectal manometries, and rectal sensation testing.Wexner and Low Anterior Resection Syndrome scores significantly increased 3 months after surgery but returned to baseline values at 12 months. The rate of "major low anterior resection syndrome" at the end of follow-up was 25.0% (+11.7% compared with baseline, p = 0.314). Sexual and urinary functions remained stable throughout the study, although a meaningful clinical improvement was detected in male sexual interest. Among quality-of-life domains, all deteriorations returned to baseline values 12 months after surgery, except worsening of flatulence symptoms, and improvement in insomnia and constipation. At 12 months, an expected decrease in the mean width of the internal sphincter, the anal resting pressure, and the tenesmus threshold volume was found.This study was limited by its small sample size, the absence of a comparative group, and significant missing data in female sexual difficulty and in ultrasounds and manometries at 3 months.Patients undergoing transanal total mesorectal excision report acceptable quality-of-life and functional outcomes 12 months after surgery. See Video Abstract at http://links.lww.com/DCR/B541.ANTECEDENTES:Pocos estudios han abordado el impacto funcional después de la escisión mesorrectal total transanal.OBJETIVO:Evaluar la función y la calidad de vida relacionada con la salud en pacientes con cáncer de recto tratados con escisión mesorrectal total transanal.DISEÑO:Se seleccionaron pacientes consecutivos tratados entre 2016 y 2018. Se estudió su función y calidad de vida, en la etapa preoperatoria, a los tres y doce meses postoperatorios.METODO:Serie de casos prospectivos.PACIENTES:Los pacientes eran incluidos en presencia de anastomosis primaria, cierre del estoma de derivación y en ausencia de fuga anastomótica. Finalmente se incluyeron cuarenta y cinco pacientes. Un total de 31 (68,8%) y 32 pacientes (71,1%) completaron las encuestas de tres y doce meses, respectivamente.INTERVENCIONES:Escisión mesorrectal total transanal estándar.PRINCIPALES MEDIDAS DE RESULTADO:Los criterio de evaluación principal fueron los resultados funcionales y de calidad de vida mediante cuestionarios previamente validados. Los criterios de evaluación secundarios incluyeron los valores obtenidos con ecografía endoanal, manometría anorrectal y prueba de sensibilidad rectal.RESULTADOS:La escala de Wexner y el síndrome de resección anterior baja aumentaron significativamente tres meses después de la cirugía, pero volvieron a los valores iniciales a los doce meses. La tasa de "síndrome de resección anterior inferior grave" al final del seguimiento fue del 25,0% (+ 11,7% en comparación con el valor inicial, p = 0,314). La función sexual y urinaria se mantuvo estable durante todo el estudio, aunque se detectó una mejora clínica significativa en la libido masculina. Entre los criterios que evalúan la calidad de vida, todas las alteraciones en la misma volvieron a los valores iniciales, doce meses después de la cirugía, excepto el aumento de flatulencia, la mejoría del insomnio y el estreñimiento. A los doce meses, se encontró una disminución esperada en el grosor medio del esfínter interno, la presión anal en reposo y el volumen umbral para la presencia de tenesmo.LIMITACIONES:Tamaño de muestra limitado, ausencia de un grupo comparativo, falta significativa de datos para identificar la dificultad para la actividad sexual femenina y el efectuar ecografía y manometría a los tres meses.CONCLUSIONES:Los pacientes sometidos a escisión mesorrectal total transanal refieren una calidad de vida y resultados funcionales aceptables a los doce meses después de la cirugía. Consulte Video Resumen en http://links.lww.com/DCR/B541.

The aims of the study were to determine the time-course of urinary incontinence recovery after vaginal distension (VD), elucidate the mechanisms of injury from VD leading to external urethral sphincter (EUS) dysfunction, and assess if transcutaneous electrical stimulation (TENS) of the dorsal nerve of the clitoris facilitates recovery of urinary continence after VD. Rats underwent 4-h VD, 4-h sham VD (SH-VD), VD plus 1-h DNC TENS, and VD plus 1-h sham TENS (SH-TENS). TENS or SH-TENS were applied immediately and at days 2 and 4 post-VD. Micturition behavior, urethral histochemistry and histology, EUS and nerve electrophysiology, and cystometrograms were evaluated. VD induced urine leakage and significantly disrupted EUS fibers and nerve-conduction (VD vs SH-VD group;p p p > 0.05). TENS significantly decreased the frequency of urine leakage post-VD (days 5–7;p

To assess the efficacy and safety of intradetrusor botulinum toxin type A injections (IBTI) for idiopathic overactive bladder (iOAB) in non-neurological adults with an artificial urinary sphincter (AUS). We retrospectively selected, in the 11 French centers, members of a collaborative network (GENULF (Groupe d’etude de neuro-urologie de langue francaise)), the patients who had had an artificial urinary sphincter implantation and who had subsequently developed iOAB requiring IBTI. This study was approved by the French association of urology ethics committee (no 2018012). Between 2006 and 2020, 33 patients were included from 5 French centers. Mean follow-up after the first IBTI was 47 months. The average age of the studied population was 68 years, with 70% of females. A complete resolution of symptoms at optimal IBTI dose was experienced by 21 (64%) patients. Seven (21%) patients had partial improvement. Five non-responder patients (15%) had no improvement at all. Maximum cystometric bladder capacity was 240 ml pre-IBTI and 335 ml post IBTI. Discontinuation free survival at 60 months was 50%. Two erosions occurred during the 6 months following an IBTI both in male patients with a perineal implantation. There were four AUS balloon perforations that occurred during the 6 months following an IBTI, all of them in female patients. IBTI has a good efficacy for the treatment of iOAB in patients with an AUS. However, both patients and practicians must be aware of the risk of rare and usually mild complications.

To evaluate the effect of homogeneous spinal-shortening axial decompression procedure (HSAD) on bladder function in patients with spina bifida tethered syndrome. Patients with tethered spinal cord syndrome were collected prospectively, and all patients were treated with lumbar HSAD. Patients’ urodynamic evaluation mainly included detrusor function, sphincter function, sphincter coordination (Ig TLR, ratio of tension and loose of urethral sphincter), and bladder compliance. Meanwhile, all patients were followed up with ICI-Q-SF, SF-12, and Rantala scores. Twenty-four patients were included, with the average age of 27 ± 16 years. At the final follow-up, patients’ detrusor function, sphincter function, sphincter coordination, and bladder compliance, were all improved dramatically (all P

Fistula-in-ano due to cryptoglandular disease is a common condition. While a simple anal fistula can be treated successfully by a fistulotomy, the risk of potential damage to the anal sphincters and subsequent poor functional outcomes persist in a large portion of patients with complex fistulae. Several sphincter-preserving treatment procedures have been described for complex fistulae over the past 3 decades, with variable results and complication rates, and no procedure is proven to be superior to the others. We developed external sphincter-sparing anal fistulotomy (ESSAF), a reproducible simple modification of the ligation of intersphincteric fistula tract (LIFT) technique for the treatment of complex fistula-in-ano.. The aim of the present study was to describe the technique and our outcomes. This was a retrospective review of all patients who underwent ESSAF for a complex anal fistula at our institution from January 2014 to December 2019. The primary outcome measure of this study was the primary fistula healing rate. Secondary outcome measures included fecal and/or gas incontinence and postoperative complications. During the ESSAF procedure, the mucosa and skin overlying the fistula tract are incised to allow complete exposure of the sphincter complex. Then the internal sphincter muscle fibers overlying the tract are divided and the tract is meticulously curetted and debrided. Next, the internal opening of the tract traversing the external sphincter muscle is suture-ligated with absorbable sutures. Then, a minimal amount of mucosa is advanced and the incision is partially closed with absorbable sutures, while its external portion is left open for drainage. Fifty-nine patients [43 males, median age was 50 years (range 36–63 years)] underwent ESSAF for complex anal fistula during the study period. Mean follow-up was 12 ± 14.7 months. Of the 59 patients, 42 (71.2%) experienced fistula closure, with a median healing time of 8 weeks (IQR 4–16 weeks). None of the patients developed significant anal incontinence following the procedure. One patient (1.7%) suffered from soiling and another patient (1.7%) developed postoperative bleeding. There were no infectious complications. Of the 17 patients (28.8%) who failed to heal successfully, 9 (15.2%) did not heal primarily and 8 (16%) experienced recurrence after complete healing. Thirteen (76%) of these patients underwent reoperation with complete recovery after ESSAF (n = 4), fistulotomy (n = 8) or endorectal advancement flap (ERAF) (n = 1). Overall ESSAF initiated recovery in 93.2% of the patients. ESSAF is a feasible, safe, reproducible and effective sphincter-sparing procedure for the treatment of complex anal fistulae.

Objectives: Some studies have shown that rhabdosphincter reconstruction provides an earlier return to continence after radical prostatectomy. We aim to study the impact of this procedure in urinary continence along with comparing two specific surgical techniques for posterior reconstruction. Materials and methods: We studied a group of patients who were submitted to LRP with No Rhabdosphincter Reconstruction (NRR) and another group with Posterior Reconstruction of the Rhabdosphincter (PRR). The latter was further divided into two groups: "Rocco type stitch" group and "Bollens type stitch" group. We used three questionnaires (IIEF-5, ICIQ-SF and IPSS) to assess urinary continence and erectile function 90 days after surgery. Results: Patients of PRR group had a better full continence rate than patients of NRR group at 90 days (96.6% vs 33.3%, p < 0.001). Concerning urinary incontinence (p = 0.116), lower urinary tract symptoms (p = 0.543) and postoperative complication rates (p = 0.738), our results suggested that there were no differences between the techniques studied. Conclusions: Posterior reconstruction of the rhabdosphincter has significant benefits for urinary continence recovery on patients undergoing radical prostatectomy. No differences were observed in continence recovery between the two techniques analyzed. Additionally, reconstruction of the rhabdosphincter appears to be a safe procedure with no increased risk of postoperative complications.

Background. The aim of the study is to evaluate the effectiveness of non-invasive research methods in the diagnosis of urinary disorders in patients with type 1 diabetes mellitus (DM). Materials and methods. In this work, we have examined 184 female patients with type 1 DM complicated by urogenital form of diabetic autonomic neuropathy and urinary disorders using non-invasive methods. These methods include surface electromyography and ultrasound of the bladder. Results. It is established that the study of the contractile ability of the pelvic floor muscles and the sphincter apparatus of the urethra makes it possible to determine the clinical form of urinary disorders. The study of the contractile ability of the pelvic floor muscles and the urethral sphincter apparatus allows, in addition to the results of the questionnaire scale in diabetes, to determine the possible clinical form of urinary disorders in patients with type 1 DM. The parameters of surface electromyography vary depending on the clinical form of urination disorders. In urinary retention, there is an increase in the muscle tone of the urogenital zone as a consequence of the formation of the phenomenon of denervation hypersensitivity. Conclusions. Urinary incontinence is accompanied by diffuse demyelination of sensory and motor nerve trunks, with a coarse axonal component as a result of increased vegetative-trophic disturbances of the muscular apparatus of the urogenital zone. The amount of residual urine, which is determined by ultrasound, in patients with retention grows with an increase in the degree of impaired urination.

Female urethral diverticulum (UD) is a rare and benign condition that presents as an epithelium-lined outpouching of the urethra. It has various symptoms, of which incontinence in the form of postmicturition dribble is the most common. The gold standard for the diagnosis of UD is magnetic resonance imaging, and the treatment of choice is transvaginal diverticulectomy. Despite the high success rate of transvaginal diverticulectomy, postoperative complications such as de novo stress urinary incontinence (SUI), recurrence, urethrovaginal fistula, recurrent urinary tract infections, newly-onset urgency, and urethral stricture can occur. De novo SUI is thought to result from weakening of the anatomical support of the urethra and bladder neck or damage to the urethral sphincter mechanism during diverticulectomy. It can be managed conservatively or may require surgical treatment such as a pubovaginal sling, Burch colposuspension, or urethral bulking agent injection. Concomitant SUI can be managed by concurrent or staged anti-incontinence surgery. Recurrent UD may be a newly formed diverticulum or the result of a remnant diverticulum from the previous diverticulectomy. In cases of recurrent UD requiring surgical repair, placing a rectus fascia pubovaginal sling may be an effective method to improve the surgical outcome. Urethrovaginal fistula is a rare, but devastating complication after urethral diverticulectomy; applying a Martius flap during fistula repair may improve the likelihood of a successful result. Malignancies in UD are rarely reported, and anterior pelvic exenteration is the recommended management in such cases.

Background: The first application of Onabotulinum-A Toxin in urology was its injection into the urinary sphincter to treat neurogenic detrusor-sphincter dyssynergia in quadri-plegic men. Since that first report by Dyskatra et al., in 1988, the results of focal Onabotulinum-A Toxininjections into the sphincter, the bladder wall and lately into the prostate have raised the interest of the urology community in this promising new therapeutic modality. This is an evidence-based review of the current indications, techniques and outcomes of Ona-botulinum-A Toxin injections into the urethral sphincter. Aim of Study: We evaluated the effect of detrusor injection of onabotulinum-A toxin into the urethral urinary sphincter in children with bladder-external sphincter dyssynergia to decrease urethral resistance and improve voiding. Material and Methods: Prospective treatment was per-formed in 25 children 4 to 15 years old (mean age 7) with bladder-neck dyssynergia using onabotulinum-A toxin. Pre-operatively all children were evaluated by ultrasound, voiding cystourethrography, excretory urography, magnetic resonance imaging and urodynamic studies, including pressure flow, electromyography and uroflowmetry. Using a rigid pediatric endoscope and a 4Fr injection needle 50 to 100 IU onabotu-linum-A toxin was injected into the external sphincter at the 5 and 7 o'clock positions. Follow-up was 6 to 15 months. Repeat injections every 6 months were given according to the response with a maximum of 3 injections. Results: Immediately after onabotulinum-A toxin injection all except 1 patient were able to void without catheterization. No acute complications occurred. Postoperatively post-void residual urine decreased by 30%, detrusor leak point pressure decreased significantly by a mean ± SD of 66±18 vs 37±4cm H2O and uroflowmetry showed a marked increase in maximum urine flow of 7±2 vs 17.3±8ml per second. Conclusions: Urethral sphincter onabotulinum-A toxin injection could be considered a reliable treatment modality in children with nonneurogenic neurogenic bladder after the failure of conservative therapy.

Bladder extrophy - is a difficult malformation for the treatment. Aplasia of one of the cavernous bodies of the penis is an extremely rare pathology. In the available literature, we did not meet reports of correction of bladder extrophy in children with a single cavernous body of the penis.From 1990 to 2020, 545 children (364 boys) with extrophy have been repair. Two (0.5 %) boys only had a classic bladder extrophy combined with the aplasia of one cavernous body. The first patient with classical extrophy and multiple malformations (fingers of the right hand, fingers of the right foot, aplasia of the left kidney, left cavernous body, left testicle and hypoplasia of the left half of the scrotum) the penis with the single cavernous body on the right was somewhat thinner, but formed anatomically correctly with the presence of a urethra and closed prepuce. The primary closure of the bladder was performed with bilateral iliac osteotomy and the joint of pelvic bones at the age of 1 year. The patient had the anatomically properly formed bladder sphincter and urethra, penile correction was not required. After the operation, urinary continence had been achieved.The second boy was with classical extrophy and epispadia of the single cavernous body, he was given stage treatment. At the age of 5 days (2004) the primary closure of the bladder and the connection of the pelvic bones were performed. At the age of 4 years (2008) the formation of the urethra was carried out, the correction of the dorsal deformation of the single cavernous body by excision of the chord and the application of multiple superficial cross-cutting on the tunica albuginea. Bladder neck plastic by Kelly technique in combination with bilateral osteotomy of pelvic bones was performed at the age of 7 years in (2011). The boy of 15 years (2019) had a bladder volume of 350-400 ml. Dry 4-5 hours. Urinate freely with a wide stream. Then a two-stage plastic of the distal urethra was performed. We used the Bracka technique with augmentation of the glans penis and implantation a free graft of the mucous lip. We achieved a good result.Using modern penile correction technologies help to socially adapt patients with rare and difficult malformations.

AIMS: In vivo experiments were performed to establish and validate a rat model of urethral sphincter injury and to develop a method for leak point pressure (LPP) measurements performed repeatedly in the same animal.METHODS: Twenty-four Sprague-Dawley female rats underwent bladder and epidural catheter implantation. Five days later, cystometry was performed using continuous infusion. Anesthesia with isoflurane, ketamine-xylazine (KX) or fentanyl-fluanisone-midazolam (FFM) was used. After three micturition cycles, intrathecal bupivacaine was administered leading to the suppression of reflex bladder contractions. LPP measurements were performed using vertical tilt. After the initial LPP measurement, animals underwent partial resection of the striated urethral sphincter. The effect was evaluated 6 weeks after surgery, by repeating the LPP measurement in the same animal.RESULTS: Ten out of 19 animals showed full micturition cycles under isoflurane, and all 9 animals under KX anesthesia. No significant difference in micturition pressures (Mean ± SEM; 30.1 ± 2.3 vs. 26.8 ± 1.6 mmHg) and LPP (31.0 ± 2.4 vs. 28.0 ± 0.9 mmHg) was observed between isoflurane and KX groups, respectively. Reflex micturition was suppressed with FFM. Bupivacaine led to overflow incontinence in all cases. Sphincter injury caused fibrotic changes and a significant increase in LPP (26.4 ± 2.3 before vs. 46.9 ± 4.6 mmHg after injury, p CONCLUSIONS: KX anesthesia preserves bladder contractions. Intrathecal bupivacaine eliminates reflex micturition, allowing for repeated LPP measurements in the same animal. Resection of striated sphincter resulted in increased LPP 6 weeks post injury. The site of urethral sphincter resection healed with fibrosis.

Background A common side effect following radical prostatectomy is urinary incontinence. Here, we describe a novel surgical technique to reduce postoperative urinary incontinence and facilitate early return of continence. Objective To describe the novel “hood technique” for robotic-assisted radical prostatectomy (RARP). Design, setting, and participants This is an institutional review board–approved prospective study of 300 patients (median age 64 yr) with localized prostate cancer treated with the RARP hood technique at a major urban hospital between April 2018 and March 2019. The exclusion criteria were as follows: patients with anterior tumor location based on biopsy or multiparametric magnetic resonance imaging. All but one patient participated in follow-up over 12 mo after the procedure. Surgical procedure The RARP “hood technique” was performed to preserve the detrusor apron, puboprostatic ligament complex, arcus tendineus, endopelvic fascia, and pouch of Douglas. Measurements Clinical data collected included pre- and intraoperative variables, and postoperative functional and oncological outcomes and complications. Descriptive statistical analysis was performed. Results and limitations Continence rates at 1, 2, 4, 6 12, 24, and 48 wk after catheter removal were 21%, 36%, 83%, 88%, 91%, 94%, and 95%, respectively. Positive surgical margin rate was 6%. Thirty patients (9.7%) experienced complications after RARP: 17 (5.7%), 11 (3.6%), and one (0.4%) had Clavien-Dindo grade I, II, and III complications, respectively. This study was conducted within a single health system and may not be generalizable. The study lacked randomization and a comparative arm. Conclusions Results indicate that the hood technique spares musculofascial structures anterior to the urethral sphincter complex with early return of continence after surgery, without compromising positive surgical margin rates. Exclusion of anterior tumor location contributed to a reduction in positive surgical margins. Patient summary By better preservation of anatomical structures around the urethra, we were able to achieve early return of urinary continence without a negative impact on complications and cancer outcomes.

To compare transcorporal vs bulbar artificial urinary sphincter (AUS) implantation in men with fragile urethra and to investigate the risk factors of AUS explantation in this population. The charts of all male patients who had an AUS implantation between 2004 and 2020 in 16 centers were reviewed retrospectively. The primary endpoint was device explantation-free survival. Only patients with a fragile urethra were included in the present analysis. Fragile urethra was defined as a urethra carrying a high risk of cuff erosion because of prior radiotherapy and/or history of AUS explantation and/or history of urethral stricture surgery. The patients were divided in two groups according to the implantation site: bulbar vs transcorporal. 464 patients were included for analysis. 88 patients underwent a transcorporal AUS implantation and 376 underwent a bulbar AUS implantation. Explantation-free survival was similar in both groups (estimated 5-year explantation free survival rates 55.3% vs. 58.4%; p=0.98). In the subgroup of patients with a history of previous AUS explantation, transcorporal approach tended to bring longer explantation-free survival (2-year explantation-free survival: 61.9% vs. 58.2%; p=0.096). In multivariate analysis, the only risk factor of shorter explantation-free survival was the history of previous AUS explantation (HR=2.65; p=0.01). Transcorporal AUS implantation was not associated with longer explantation-free survival. History of previous AUS explantation was the only risk factor associated with shorter explantation-free survival and this subgroup of patients may be the only one to draw benefits of transcorporal AUS implantation.

The inspection of the urethra in patients with documented or suspected urethral stricture should be carried out with small caliber ureteroscope of 6/7.5Ch. Different from flexible cystoscope (16Ch) or resectoscope (26Ch), small caliber ureteroscope allows a comprehensive evaluation of the stricture, including its length and the status of the mucosa in its proximity, without injuring or overstretching the urethra. With a small caliber ureteroscope it is also possible to cross the stricture, allowing the evaluation of the proximal urethra, the external urethral sphincter, and the bladder. A 6/7.5Ch ureteroscope also allows estimation of the real caliber of the stricture, providing a useful landmark for further treatment decisions.

The International Continence Society (ICS) describes incontinence as an objectively demonstrable loss of urine which is not voluntary and that is a social and/or sanitary issue. The complaint of leakage of urine, which is not voluntary on an effort made, on exertion, on sneezing or while coughing is described as Stress urinary incontinence (SUI). The intra-abdominal increases as the effort or exertion increases, and the urethral sphincter is not capable to sustain a pressure greater than the pressure applied on the urinary bladder. Eventually, leakage of urine occurs during the daily activities like lifting, laughing, jumping, while sneezing or coughing. In women, stress urinary incontinence is most common category of incontinence of urine. Even though it isn’t a lethal illness. SUI has a number of negative effects on women's quality of life, including restricting social interaction and relationship and the personal relationships but also physical activity. Cystocele is the weakness of pubocervical fascia, which makes the urinary bladder to descend downwards and backwards against the anterior wall of the vagina. If this is a not taut then it will protrude. In more extreme cases a pouch of bladder sets up which holds on to the residual urine. The conservative treatment, a nonsurgical therapy, includes ameliorating the living standards, urinary bladder training, pelvic floor muscle exercises and strengthening. Kegel exercises are the most effective form of strengthening muscles of pelvic floor in addition are a noninvasive therapy and the use of vaginal weights or cones are not included. The rehabilitation and strengthening muscles of pelvic floor is facilitated and promote urine storage. The combination of Kegel’s exercise along with other interventions for a span of six weeks has shown a significant improvement in the symptoms.

PURPOSE OF REVIEW Posterior urethral obstruction (PUO) from prostate surgery for benign and malignant conditions poses a significant reconstructive challenge. Endoscopic management demonstrates only modest success and often definitive reconstructive solutions are necessary to limit morbidity and firmly establish posterior urethral continuity. This often demands a combined abdominoperineal approach, pubic bone resection, and even sacrifice of the external urinary sphincter and anterior urethral blood supply. Recently, a robotic-assisted approach has been described. Enhanced instrument dexterity, magnified visualization, and adjunctive measures to assess tissue quality may enable the reconstructive surgeon to engage posterior strictures deep within the confines of the narrow male pelvis and optimize functional outcomes. The purpose of this review is to review the literature regarding endoscopic, open, and robotic management outcomes for the treatment of PUO, and provide an updated treatment algorithm based upon location and complexity of the stricture. RECENT FINDINGS Contingent upon etiology, small case series suggest that robotic bladder neck reconstruction has durable reconstructive outcomes with acceptable rates of incontinence in carefully selected patients. SUMMARY Initial reports suggest that robotic bladder neck reconstruction for recalcitrant PUO may offer novel reconstructive solutions and durable function outcomes in select patients.

In recent years, the frequency of operations for genital prolapse and urinary incontinence has been steadily increasing. Neurogenic disorders of urination can be the first manifestations of the disease of extragenital pathology. Neurogenic bladder is bladder dysfunction (lethargy or spasticity) caused by neurogenic damage. Any disease in which the afferent or efferent innervation of the bladder is damaged can lead to a neurogenic bladder.Purpose. To study the features of urinary disorders in women with severe extragenital diseases and to improve the methods of rehabilitation of patients after reconstructive plastic surgery for various types of urinary incontinence.Materials and methods. 153 patients aged 50-70 years (mean age 55.1 ± 6.3 years) and duration of postmenopause from 2 to 5 years (7.6 ± 4.1 years) were examined at the outpatient department of the of Moscow Regional Research Institute of Obstetrics and Gynecology, Russian Federation, who applied for various manifestations of urination disorders. All patients were offered the method of biofeedback in combination with electrical stimulation of the pelvic floor muscles as a treatment. When overactive detrusor therapy was detected, therapy was combined with medicamentous (solifenacin 5 mg [Vesicar] or myrobegron 50 mg [Betmiga] in the morning) in combination with estriol (cream or suppositories) 0.5 mg intravaginally 2 times a week. In the presence of symptoms of climacteric syndrome in the absence of contraindications, menopausal hormonal therapy was prescribed.Results. Subjectively, 150 (98.1 %) patients noted an improvement in their condition, 3 (1.9 %) patients did not notice the effect of treatment. The results showed a significant improvement in all OABSS and bladder diary scores, including frequency of urination during the day and at night, urgency and number of urge incontinence episodes, and urine volume. Analysis of the -hour pad test showed that the volume of urine lost, which averaged 16.5 g before treatment, was negative after treatment in patients who noted the effect. In 2 patients who did not notice the effect, no changes were found. Investigation of the intraurethral pressure profile in 23 (17.6 %) women before treatment revealed insufficiency of the internal sphincter of the urethra, leading to urinary incontinence during stress. After treatment, in 19 (82.6 %) patients, the insufficiency of the internal sphincter was not determined. In 3 (13.0 %) patients, intraurethral pressure remained in the range of 60 to 80 cm of water column and did not lead to urinary incontinence during stress. In 1 (4.3 %) patient, the insufficiency of the urethral closure persisted, which required repeated surgery.Conclusions. In patients with severe extragenital diseases against the background of vulvovaginal atrophy, an overactive bladder and a mixed form of urinary incontinence prevail. Extragenital pathology of various origins, especially concerning various parts of the central nervous system, obesity and diabetes significantly worsens the course of urination disorders in both conservative and surgical and combined treatment and requires additional treatment methods: pelvic floor muscle training, biofeedback therapy in combination with electrical stimulation of the pelvic floor muscles, local hormonal therapy, the use of M-anticholinergics, B-adrenomimetics.

AIMS To establish the long-term efficacy and safety of bladder augmentation in spina bifida patients. MATERIAL AND METHODS Sixteen patients were operated on using the Bramble technique. Preoperative and postoperative evaluation included clinical history, blood tests, urine cultures, cystography, pyelography, ultrasound, and filling cystometry. In the final review a standardized quality of life questionnaire was applied. RESULTS Median follow-up was 20 years (15-26). Kidney function was stabilized except for one case that required a kidney transplant. Hydronephrosis disappeared or improved (p = 0.03). Vesicoureteral reflux grades I-II was cured without reimplantation and grades III-IV responded better with reimplantation than without (p = 0.03). Quality of life improved in all patients, with all stating they would undergo the procedure again. After surgery, 94% of the patients exhibited diurnal continence but 25% exhibited nocturnal incontinence. Pressure at capacity decreased and bladder capacity increased (p

History of introduction of duloxetine in medical practice, mechanism of action and using of duloxetine in concervative treatment women and men with stress urinary incontinence are shown. Modern structure of external urethral sphincter in women and men was shown with increasing of sphincter tone under duloxetine influence. Duloxetine recommended by International Continent Society for initial treatment women with stress urinary incontinence but this drug gives only improvement of urine continence and quality of life with side effects. Duloxetine with connection with pelvic floor muscle training gives better results than using separately duloxetine and pelvic floor muscle training. Nausuea is the most frequency side symptom after using duloxetine. Results of own investigations were shown and indications for using duloxetine in women with stress urinary incontinence were summed up. The most positive results were obtained after combination of duloxetine with pelvic floor muscle training and electrostimulation of urethral sphincter. Duloxetine for treatment men with stress urinary incontinence after radical prostatectomy is only clinical tested. Estimation of efficacy of duloxetine in treatment men with stress urinary incontinence after open prostatectomy due to benign prostatic hyperplasia is needed.

AIM To suggest new method of surgical correction of hypospadias in girls. MATERIALS AND METHODS For 50 years under our supervision there were 220 girls diagnosed with hypospadias of various forms. In the diagnosis used anamnesis, examination, catheterization and cystoscopy of the bladder, vaginoscopy, ultrasound and X-ray research methods. RESULTS AND DISCUSSION Of 220 girls with a diagnosis of hypospadias, vestibular (partial) hypospadias occurred in 201 girls, vestibulovaginal (subtotal) in 16, and vaginal (total) in 3. Of 201 girls with vestibular hypospadias, 37 suffered from urinary incontinence, 16 had vesicoureteral reflux, 21 had doubling, 5 had renal hypoplasia, and 12 had renal dystopia. The vulvovaginal form was manifested not only by the dystopia of the external opening of the urethra, but also combined with the underdevelopment of the sphincteral apparatus of the bladder. All children had daytime and nighttime urinary incontinence, vulvovaginitis. Cystoscopy revealed hyperemia of the urethra and bladder neck. X-ray urological examination revealed VUR in 6 children, ureterohydronephrosis - in 2. All children suffered from chronic pyelonephritis, 8 - day and night urinary incontinence. There were 3 girls (14-16 years old) with vaginal (total) hypospadias. All suffered from constant urinary incontinence, vulvovaginitis, cystitis, chronic pyelonephritis, all had VUR. The new operation for the vaginal (total) form of hypospadias, proposed by us, restores the closure function of the bladder sphincter by suturing the defect in the posterior wall of the bladder neck. CONCLUSION Hypospadias is rare in girls. There are vestibular, vestibulovaginal and vaginal forms of hypospadias. In most cases, the vestibular form does not require surgical treatment. With the vestibulovaginal and vaginal (total) form of hypospadias, surgical treatment is indicated.

Sidoruk Serhii. Blood supply of the anal canal in patients with chronic hemorrhoids. Journal of Education, Health and Sport. 2021;11(04): 217-221. eISSN 2391-8306. DOI http://dx.doi.org/10.12775/JEHS.2021.11.04.022 https://apcz.umk.pl/czasopisma/index.php/JEHS/article/view/JEHS.2021.11.04.022 https://zenodo.org/record/5153839 The journal has had 5 points in Ministry of Science and Higher Education parametric evaluation. § 8. 2) and § 12. 1. 2) 22.02.2019. © The Authors 2021; This article is published with open access at Licensee Open Journal Systems of Nicolaus Copernicus University in Torun, Poland Open Access. This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author (s) and source are credited. This is an open access article licensed under the terms of the Creative Commons Attribution Non commercial license Share alike. (http://creativecommons.org/licenses/by-nc-sa/4.0/) which permits unrestricted, non commercial use, distribution and reproduction in any medium, provided the work is properly cited. The authors declare that there is no conflict of interests regarding the publication of this paper. Received: 26.02.2021. Revised: 31.03.2021. Accepted: 30.04.2021. BLOOD SUPPLY OF THE ANAL CANAL IN PATIENTS WITH CHRONIC HEMORRHOIDS Serhii Sidoruk Ivano-Frankivsk National Medical University, Dpt. Surgery 1 Abstract The most important factors in the development of chronic haemorrhoids today are considered to be the combination of two factors (vascular and mechanical) that lead to the development of hemorrhoids. The underlying vascular factor is the vascular dysfunction, providing arterial blood flow through the arteries to the cavernous bodies and outflow through the cavernous veins, which leads to dilation of cavernous bodies and the formation of vascular malformations. There were performed clinical examination and treatment of 140 patients with chronic hemorrhoids of stage III-IV according to Goligher. The features of arterial blood supply of the anal canal were evaluated by transrectal ultrasound examination. It was found that there was no clear linear relationship between the number of anal arteries with increased blood flow and the number of hemorrhoidal nodes in the patient. Each node was supplied with blood from one or two arteries: the node placed at 11 o'clock had blood supply from the arteries visualized at 10 and 11 o'clock, the node at 3 o'clock - arteries at 3 and 5 o'clock, the node at 7 o'clock - arteries at 7 and 9 o'clock. The arteries were most frequently visualized at the first (89.4%), the third (93.3%), the seventh (88.8%) and the eleventh (93.4%) hours. With less frequency the hemodynamically significant arteries were visualized at the fifth (65.0%), the ninth (62.8%) and the tenth (66.7%) hours. The arteries that were suppliing blood hemorrhoidal vessels were located in the internal sphincter at a depth of 5 to 10 mm. In the area of 3, 7 and 11 hours, they overlapped with a mosaic pattern that corresponded to the localization of the cavernous body and resembled an arteriovenous fistula according to the СDS. Key words: chronic hemorrhoids; ultrasound examination; blood flow; anal canal.

Rectovaginal fistula is abnormal connections between the vagina and rectum. Via this connection, the passages of flatus or stool from rectum to vagina occur. Patient history and physical examination are usually enough to make diagnosis of fistula. Although there are so many defined surgical options including sphincteroplasty, advanced flap, muscle interposition, fibrin glue, plugs, and closure of fistulas remain a challenging condition with the high rate failure of surgical repair In this study, we aim to report the results of a new treatment approach with the injection of botulinum toxin into lateral internal sphincter on the management of rectovaginal fistula in conjunction with the surgical repair. Between 2013 and 2019, 8 patients with recurrent rectovaginal fistula underwent 10 surgical repairs in conjunction with 100 units botulinum toxin injection. Results of these patients were analyzed. We have treated 8 patients with recurrent rectovaginal fistula. The etiology of fistula in our patients included obstetrical trauna (3 patients), radiotherapy and rectal surgery (2 patients), vaginal reconstruction (2 patients) and Crohn’s disease (1 patient). The median number of their previous operations was 1.5 (range, 1–3). The sizes of fistulas range from 0.5 × 1 to 2 × 3 cm. In our surgical intervention, at the end, all of them were closed (100%) successfully. Botulinum toxin injection into lateral internal sphincter can be used successfully in combination with surgical intervention for the treatment of the rectovaginal fistulas.

Under healthy condition, more than one urethra-closing reflex, including both bladder afferent-independent and -dependent actions function during momentary elevation of intravesical (bladder) pressure to prevent urinary incontinence. In the current study, the effects of a novel selective 5-hydroxytryptamine type 2C (5-HT2C) receptor agonist, TAK-233, on evoked momentary urethra-closing functions were investigated in female rats and humans to elucidate 5-HT2C receptor functions. In anesthetized female rats, TAK-233 dose-dependently and significantly increased the urethral resistance during sneezing in rats with distended vaginas and bilaterally transected pelvic nerves. The drug also dose-dependently and significantly increased urethral resistance during momentary intravesical pressure elevation by electrical stimulation of abdominal muscles in rats with a transected spinal cord at the T8-9 level and intact pelvic nerves. The increased effects observed during electrical stimulation were abolished by either an intravenously administered selective 5-HT2C receptor antagonist, SB 242084, or bilateral transection of the pelvic nerves or somatic nerves innervating the external urethral sphincter and pelvic floor muscles. In the spinal cord-transected and pelvic nerve-intact rats, TAK-233 enlarged the urethra-closing responses induced by both passive and abrupt intravesical pressure elevation measured by a micro-tip transducer located in the middle urethra. Additionally, the effects of TAK-233 on the stimulus threshold of urethral contractile responses induced by transcranial magnetic stimulation were investigated in healthy female volunteers. The drug dose-dependently and significantly lowered this stimulus threshold, indicating an increased sensitivity of the response. These results demonstrate that 5-HT2C receptor stimulation enhances the evoked momentary urethra-closing functions in both female rats and humans. Significance Statement 5-hydroxytryptamine (serotonin) type 2C (5-HT2C) receptor stimulation by TAK-233 enhanced urethral resistance in rats during an evoked momentary event in which the bladder afferent-independent or -dependent reflex functions via striated muscle-mediated mechanisms. The increases in sensitivity of transcranial magnetic stimulation-evoked urethral contractile responses in healthy female subjects indicates that this mechanism also functions in humans. The evoked momentary conditions activating these reflexes provide a suitable model to demonstrate the exerting effects of 5-HT2C receptor stimulation.

Background Urinary continence recovery after radical prostatectomy is a major issue even in the robotic era. Surgical techniques aimed at improving earlier return to continence are continuously sought. Objective To describe our novel surgical technique of urethral fixation during robot-assisted radical prostatectomy (RARP) and to assess early urinary continence recovery and perioperative complications. Design, setting, and participants A prospective, single-center, single-surgeon cohort of 70 consecutive patients undergoing RARP between January and December 2019 was analyzed. A study group of 35 patients operated on with the urethral fixation technique was compared with a control group of 35 patients receiving standard vesicourethral anastomosis. Surgical procedure Urethral fixation versus standard vesicourethral anastomosis during RARP was evaluated. In the study group, the urethral stump was fixed to the dorsal median raphe posteriorly and to the medial portion of the levator ani muscle posterolaterally. The same posterior musculofascial reconstruction incorporating the vesicourethral anastomosis was performed in both groups. Measurements Urinary continence recovery, perioperative complications, operating room time, and estimated blood loss were recorded and compared between the two groups. Results and limitations The two groups were comparable with regard to all demographic, clinical, and pathological variables. Recovery of urinary continence at 3 mo after catheter removal was reported by 34 (97.1%) patients in the study and 28 (80%) patients in the control group (p = 0.02). Patients in the study group reported significantly higher rates of urinary continence even at 1 wk and 1 mo after catheter removal compared with the control group (68.6% vs 45.7%, p = 0.04, and 80% vs 54.3%, p = 0.04, respectively). No differences were observed in operating room time (p = 0.7) or estimated blood loss (p = 0.65). Ninety-day postoperative complications were observed in one (2.9%) patient in the study and in four (11.4%) in the control group (p = 0.3). The main limitation is the nonrandomized comparison of relatively small cohorts. Conclusions In our study, we observed a significant improvement in early urinary continence recovery, with no increase in operating room time or perioperative complications, using the novel urethral fixation technique compared with the standard vesicourethral anastomosis during RARP. Patient summary We describe our novel surgical technique of urethral fixation during robot-assisted radical prostatectomy. Compared with the standard technique, utilization of our technique was found to be associated with an improved early recovery of urinary continence, with no increase in operating room time or perioperative complications.

The aim was to compare pelvic floor muscle (PFM) elasticity between interstitial cystitis/bladder pain syndrome (IC/BPS) patients and healthy women using real-time tissue elastography. The subjects were 17 IC/BPS female patients (IC/BPS group; age 34–84 years), 10 healthy middle-aged women (middle-aged group; 50–80 years), and 17 healthy young adult women (young group; 23–37 years). The target sites of elastography were the striated urethral sphincter (SUS) and adipose tissue as the reference site; muscle elasticity was calculated as the strain ratio (SR) of the SUS to the reference site. Evaluations were performed at rest and during PFM contraction. The IC/BPS group completed lower urinary tract symptom and pain questionnaires. SUS SR was compared among the three groups. SUS SR at rest and during PFM contraction was compared among the three groups with the t-test and the Wilcoxon test. Associations between questionnaire results and SUS SR were evaluated by correlation analysis. There was no significant difference in age between the IC/BPS and middle-aged groups, but the young group was significantly younger than the other groups (p

Introduction: The 200 million people in the world experience urinary incontinence. In general, with increasing age, the capacity of the bladder decreases. The remaining urine in the bladder tends to increase and irregular contraction of the bladder muscles becomes more frequent. This situation often makes the elderly experience problems with the fulfillment of urine elimination needs, namely urinary incontinence. Efforts to overcome urinary incontinence in the form of bladder training programs are aimed at developing muscle tone and bladder sphincter so that it can function optimally. Objective: Knowing the profile of muscle strength and physical performance with the incidence of urinary incontinence in elderly women. Methods: This research was a retrospective descriptive study based on the results of filling out the questionnaire and evaluating it directly. Based on tabulated data, 38 elderly women were selected as the study sample. Results: There were (42.1%) urinary incontinence on elderly with very poor left hand muscle strength and (50%) urinary incontinence on elderly with very poor right hand muscle strength. In physical performance with urinary incontinence as many as (57.8%) were normal and (42.1%) were poor. Conclusions: Muscle strength and physical performance can be used as a measurement to early detection of the urinary incontinence. Keywords: urinary incontinence; muscle strength; physical performance; descriptive retrospective study

The aim was to analyze the long-term effects of muscle-derived stem cells (MDSCs) therapy in traumatized urethras of female rats regarding messenger ribonucleic acid (mRNA) expression of collagens 1 and 3, Ngf and Ki67; and the mRNA and protein expression of Myh11 and Myh2. Muscle-derived stem cells were injected into the tail vein of rats 3 days after trauma by vaginal distention. Urethras were analyzed from 30 animals divided into three groups: control without injury or treatment, trauma (30 days post-injury), and MDSC (30 days post-injury who received MDSC therapy). Real-time quantitative polymerase chain reaction (RT-qPCR) and immunohistochemistry were performed. The Kruskal–Wallis and ANOVA tests were used with p

The study aims to compare the urethral sphincter size and bladder neck position and mobility in women with different parities. Women referred to the urodynamics clinic for lower urinary tract and prolapse symptoms were included in the study. A detailed history was taken, and transperineal two- and three-dimensional ultrasound was performed on all the women. The women were divided into four groups according to the vaginal parity. Group 1 had no vaginal childbirths. Group 2 had one, group 3 had two and group 4 had three or more vaginal childbirths. The data was analysed and compared among the groups. One hundred fifty women were included in the study. There were 34, 22, 48 and 46 women in groups 1 to 4 respectively. The distribution of different urodynamic diagnoses was similar in all four groups. The urethral sphincter measurements were significantly larger in the vaginally nulliparous group than in all other groups. The measurements were not smaller in multiparous women than in primiparous women. The bladder neck was at a lower position at rest in parous women than nulliparous women. The bladder neck movement was not more in groups 2 to 4 than in group 1. The urethral sphincter was smaller and the bladder neck position was lower in parous women than nulliparous women. These differences were not progressive with increasing parity. Request for elective caesarean section during the second pregnancy to protect the urethra is not supported by this study.

Purpose: The aim of this study was to investigate the efficacy of autologous platelet-rich plasma (PRP) in the treatment of stress urinary incontinence (SUI) due to intrinsic sphincter deficiency (ISD) refractory to medical treatment.Methods: Thirty-five patients with SUI due to urodynamically proven ISD were prospectively enrolled. Five milliliters of PRP (2.5–5 times the platelet concentration in peripheral blood) was injected into the external sphincter at 5 sites; all patients received 4 injections at monthly intervals. The primary end-point was the change in SUI severity as assessed by a visual analogue scale (VAS of SUI). The secondary-endpoints were the Global Response Assessment score and changes in urodynamic parameters from baseline to 3 months after treatment.Results: The mean age of patients was 68.7±12 years; the median duration of SUI was 4 years. Five patients had neurogenic SUI, while 30 had nonneurogenic SUI (21 with postprostatectomy incontinence, 6 with previous radical cystectomy, and 3 with other etiologies). Complete dryness was achieved in 7 patients (20.0%) while moderate improvement was observed in 14 (40.0%). The mean VAS of SUI score decreased significantly from 6.57±1.89 to 3.77±2.41 after treatment. The abdominal leak point pressure (ALPP) increased significantly from 98.3±55.8 to 157.3±79.3 cm H2O. There was no increase of ALPP in neurogenic SUI and less increase of ALPP in patients with failed treatment outcomes. No perioperative adverse events or severe complications occurred.Conclusions: Urethral PRP injection is safe and effective in increasing urethral resistance and improving SUI. PRP could be an alternative treatment modality for male and female patients with moderate SUI due to nonneurogenic causes.

Objectives Both detrusor underactivity (DU) and bladder outlet obstruction are the common causes of chronic urinary retention. Some novel treatment approaches focus on modulating micturition reflex and external urethral sphincter (EUS) function. This study used electrophysiologic (EP) studies to investigate the micturition reflex and EUS conditions of chronic urinary retention patients. Methods Sixty patients with urodynamic DU and chronic urinary retention were studied using (1) bulbocavernous reflex (BCR) by electric stimulation, (2) electromyography (EMG) of the EUS, and (3) nerve conduction velocity (NCV) studies of the pudendal nerve. The EP findings were analyzed in DU patients with different etiologies. Results The BCR was positive in 41.7% of patients. In EMG studies, denervation, reinnervation, and reduced recruitment of the EUS were observed in 21.7%, 71.7%, and 88.3% patients, respectively. Decreased amplitude of pudendal nerve conduction in NCV studies was noted in 73.3% of patients. Patients with sacral neuropathy had a lower BCR positive rate (p = 0.001), a nonsignificant but higher denervation rate (p = 0.059) in EMG studies, and a higher rate of decreased amplitude in NCV (p = 0.011) than those without sacral neuropathy. Excluding patients with sacral neuropathy or diabetes mellitus, a high percentage of neurologic deficits was still detected in EP studies. Conclusions Chronic urinary retention patients with urodynamic DU not only have bladder dysfunction, but also potential neuropathy in the sacral reflexes, pudendal nerve, or urethral sphincter innervation. The neurologic deficits explored in EP studies may affect the decision-making around the therapy to restore the voiding function in DU.

Objective To understand the structures around the vesicourethral junction and to improve functional outcomes after nerve-sparing radical cystectomy with orthotopic urinary diversion for female patients, we histologically elucidated the fibromuscular construction and nerve distribution around the vesicourethral junction. Methods Pelvic specimens containing all the pelvic viscera were obtained from 33 donated female cadavers. Macroslices that included the urethra, the anterior wall of the vagina, and the inferomedial edge of the levator ani muscle were made and performed elastica Masson and immunohistochemical staining. The intraoperative findings were collected in 3 female patients undergoing nerve-sparing radical cystectomy. Results In 18 out of the 33 cadavers, smooth muscle mass occupied a space between the urethra and the inferomedial edge of the levator ani muscle and covered the inferior margin of the bladder detrusor. We termed this mass the hiatal smooth muscle. The detrusor nerves entered the bladder, and the cavernous and sphincter nerves ran between the hiatal smooth muscle and vesicourethral junction. The boundary between hiatal smooth muscle and urethral smooth muscle was easily distinguished intraoperatively during dissection of the vesicourethral junction. Conclusion We found that more than half of elderly women have hiatal smooth muscle between the urethra and inferior edge of the levator ani. Autonomic nerve fibers innervating the urethral sphincter, run between the hiatal smooth muscle and vesicourethral junction in female cadavers with hiatal smooth muscle. When performing female radical cystectomy before neobladder reconstruction, nerve sparing can be reliably performed using the hiatal smooth muscle as a landmark.

Aims Interstitial cystitis (IC) is a chronic pain syndrome that is characterized by suprapubic pain upon bladder filling. Bletilla striata, a well-known traditional Chinese herb with established efficacy in wound healing and anti-inflammation, was hypothesized to improve the symptoms of IC possibly though forming a physical barrier that could isolate the bladder tissue from irritants. This study was conducted to evaluate the beneficial effects of intravesical treatment with B. striata extract solution (BSES) on visceral pain and bladder function of rats with zymosan-induced IC. Methods Thirty female rats were randomly divided into control group, zymosan-induced cystitis rats treated with normal saline (Z + NS), and zymosan-induced cystitis rats treated with BSES (Z + BSES). All rats underwent evaluation for abdominal withdrawal reflex (AWR) scores to assess visceral hypersensitivity, cystometrography, and electromyogram (EMG) of both external urethral sphincter and bladder detrusor. Data were analyzed by one way analysis of variance. Results The Z + NS group had an increased visceral hypersensitivity as compared to control group. Rats treated with BSES (Z + BSES group) had decreased AWR scores and amplitude of bladder detrusor-EMG. Besides, BSES treatment improved overactive bladder with significant effects on the extend of micturition interval and increase of storage of urine. Conclusions Intravesical instillation of BSES can significantly alleviate zymosan-induced visceral hypersensitivity and bladder overactivity associated with IC. This study suggested that intravesical instillation with BSES might be a promising treatment for IC.

Pankaj Garg,1,2 Baljit Kaur,3 Konica Singla,2 Geetha R Menon,4 Vipul D Yagnik5 1Department of Colorectal Surgery, Indus International Hospital, Mohali, India; 2Department of Colorectal Surgery, Garg Fistula Research Institute (GFRI), Haryana, India; 3Department of Radiology, SSRD Imaging Centre, Chandigarh, India; 4Department of Biostatistics, Indian Council of Medical Research, New Delhi, India; 5Department of Surgical Gastroenterology, Nishtha Surgical Hospital and Research Centre, Patan, Gujarat, IndiaCorrespondence: Pankaj GargGarg Fistula Research Institute (GFRI), H.no- 1042, Sector-15, Panchkula, Haryana, 134113, IndiaFax +91 9501522000Email drgargpankaj@yahoo.comPurpose: In some anal fistulas, the internal/primary opening cannot be located even after examination and assessment on MRI or transrectal ultrasound. The efficacy of a simple new protocol to manage such therapeutically challenging fistulas was tested.Patients and Methods: All anal fistula patients operated consecutively over 7 years were included in the study. A simple two-step protocol was followed for fistulas in which the internal opening was not locatable after clinical examination and MRI assessment. First, the MRI was reassessed. The site where the fistula was closest to the internal sphincter was noted. It was assumed that the internal-opening was located at that position and the fistula was treated accordingly. Second, in horseshoe anal fistulas with no apparent internal opening, it was assumed that the internal opening was located in the midline. Low fistulas were treated by fistulotomy and high fistulas by a sphincter-sparing procedure. Incontinence was evaluated by objective incontinence scores (Vaizey scores).Results: A total of 757 patients were operated (median follow-up-33 months). Of these, 57 patients were excluded due to short or inadequate follow-up. In 154/700 (22%) patients, the internal opening could not be located while in 546/700 (78%), the internal opening was found. Both the groups were similar in all parameters. In the “internal-opening found” group, the fistula healed completely in 486/546 (89%) and in the ‘internal-opening not found group’, the fistula healed in 140/156 (90.9%) (p=1.01). The objective continence scores did not change significantly after surgery in both the groups.Conclusion: This new protocol seems effective as a high cure rate could be achieved in ‘internal-opening not found’ fistulas which was comparable to fistula healing in the ‘internal-opening found’ group.Keywords: anal fistula, internal opening, horseshoe, MRI, recurrence, fistula-in-ano

Individuals with spinal cord injury or neurological disorders have problems in voiding function due to the dyssynergic contraction of the urethral sphincter. Here, we introduce a closed-loop control of intraspinal microstimulation (ISMS) for efficient bladder voiding. The strategy is based on asynchronous two-electrode ISMS with combined pulse-amplitude and pulse-frequency modulation without requiring rhizotomy, neurotomy, or high-frequency blocking. Intermittent stimulation is alternately applied to the two electrodes that are implanted in the S2 lateral ventral horn and S1 dorsal gray commissure, to excite the bladder motoneurons and to inhibit the urethral sphincter motoneurons. Asynchronous stimulation would lead to reduce the net electric field and to maximize the selective stimulation. The proposed closed-loop system attains a highly voiding efficiency of 77.2–100%, with an average of 91.28 ± 8.4%. This work represents a promising approach to the development of a natural and robust motor neuroprosthesis device for restoring bladder functions.

Purpose To test the effect of anatomic variants of the prostatic apex overlapping the membranous urethra (Lee type classification), as well as median urethral sphincter length (USL) in preoperative multiparametric magnetic resonance imaging (mpMRI) on the very early continence in open (ORP) and robotic-assisted radical prostatectomy (RARP) patients. Methods In 128 consecutive patients (01/2018–12/2019), USL and the prostatic apex classified according to Lee types A–D in mpMRI prior to ORP or RARP were retrospectively analyzed. Uni- and multivariable logistic regression models were used to identify anatomic characteristics for very early continence rates, defined as urine loss of ≤ 1 g in the PAD-test. Results Of 128 patients with mpMRI prior to surgery, 76 (59.4%) underwent RARP vs. 52 (40.6%) ORP. In total, median USL was 15, 15 and 10 mm in the sagittal, coronal and axial dimensions. After stratification according to very early continence in the PAD-test (≤ 1 g vs. > 1 g), continent patients had significantly more frequently Lee type D (71.4 vs. 54.4%) and C (14.3 vs. 7.6%, p = 0.03). In multivariable logistic regression models, the sagittal median USL (odds ratio [OR] 1.03) and Lee type C (OR: 7.0) and D (OR: 4.9) were independent predictors for achieving very early continence in the PAD-test. Conclusion Patients’ individual anatomical characteristics in mpMRI prior to radical prostatectomy can be used to predict very early continence. Lee type C and D suggest being the most favorable anatomical characteristics. Moreover, longer sagittal median USL in mpMRI seems to improve very early continence rates.

Hypothesis/Aims of study. At present, there is no doubt about the importance of the problem of female stress urinary incontinence (SUI) and the search for the best way to eliminate it. Sling operations in SUI treatment are the most popular in world and domestic practice. However, they are not without certain complications. In this regard, it becomes relevant to determine the factors for predicting their effectiveness and safety. The aim of this study was to conduct a comparative study of the effectiveness of two anti-stress operations: TVT-Obturator® and urethrovesicopexy with vaginal flap, by using echography of the urethrovesical segment. Study design, materials and methods. During the period from 2011 to 2018, 105 incontinent patients were examined and operated on. Two groups were formed: Group 1 consisted of 52 patients who underwent TVT-Obturator® surgery, Group 2 included 52 patients who underwent urethrovesicopexy with vaginal flap. In all patients, the anatomical topographic position of the bladder and urethrovesical segment, the internal urethral sphincter status, as well as the angles α and β were determined, based on which the conclusion about the type of SUI was made and, accordingly, the adequate method of surgical intervention was determined. Results. Before the operation, the angle α averaged 37.2 ± 10.11, with 24.7 ± 4.64 a year after the operation and 26.8 ± 3.72 five years after the operation. Rotation of the angle α in the study groups >20° before surgery did not significantly affect the presence of long-term complications, urinary retention after a year and five years, and recurrence of urinary incontinence. After the operation, there was an increase in the angle β after a year ( p = 0.0032) and five years ( p = 0.0035) and in the total urethral length after a year ( p = 0.0022), but after five years, this parameter did not differ significantly from that before surgery ( p = 0.29). Conclusion. TVT-Obturator® and urethrovesicopexy with vaginal flap are equally effective ( p > 0.05) in the surgical treatment of female SUI in both the nearest postoperative period (96.2% and 94.3%, respectively) and the distant period (90.4% and 88.7%, respectively).

Background Urinary incontinence is a bothersome symptom. Although the relationship between stress urinary incontinence (SUI) and vaginal delivery is established, the pathology underlying SUI after vaginal birth remains to be elucidated. Objectives To determine whether levator ani muscle avulsion predisposes for SUI in women. Search strategy Pubmed and Embase were searched for terms and their variations “levator ani muscle avulsion” and “urinary incontinence”, from inception until 5 November 2019. Selection criteria Inclusion criterion: studies describing the relationship between urinary incontinence and levator ani muscle avulsion in women at least 1 year after delivery. Exclusion criterion: studies only analyzing the urethral sphincter or hiatus dimensions. Data collection and analysis Odds ratios were used and if not available, were calculated as means of data synthesis, adjusted odds ratios if presented by the study, random‐effects model to compute a pooled estimate. Results Seven studies were included, accounting for 2388 women. Comparing women with and without levator ani muscle avulsion, the overall odds ratio for SUI is 0.87 (95% confidence interval 0.56–1.34), and after adjustment for possible confounders was 0.72 (95% confidence interval 0.40–1.30). Conclusion There is no relationship between levator ani muscle avulsion and SUI in women., A systematic review and meta‐analysis was conducted to evaluate the relationship between levator ani muscle avulsion and stress urinary incontinence, which could not be supported.

Objective: To evaluate the efficacy and safety of Combined detrusor and external urethral sphincter BTX-A injections for detrusor overactivity (DO) and detrusor external sphincter dyssynergia (DESD) secondary to spinal cord injury. Study Design: Prospective study. Methods: The study was carried out in 18 SCI patients with detrusor overactivity (DO) and detrusor external sphincter dyssynergia (DESD) receiving Combined detrusor and external urethral sphincter BTX-A injections treatment. Contain 200 U botulinum toxin intradetrusor and 100 U external urethral sphincter injections. The effective outcomes included maximum detrusor pressure at first DO and DESD (PdetmaxDO-DESD), volume at first DO and DESD (VDO-DESD), maximum urethral closure pressure (MUCP), and Incontinence-Specific Quality-of-Life Instrument (I-QoL). Adverse events were recorded. Results: All patients experienced a significant mean reduction in PdetmaxDO-DESD (50.75%), maximum urethral closure pressure (26.34%) and a significant mean increase in VDO-DESD (63.00%) 12-weeks post-injection. Significant (p < 0.001) improvement in mean Incontinence-Specific Quality-of-Life Instrument was also found. No obvious adverse event and toxic effect was observed. Conclusion: Combined detrusor and external urethral sphincter BTX-A injections is a good choice for patients with DO and DESD secondary to spinal cord injury. It could not only protect the upper urinary tract but also improve quality of life.

An anal fissure is one of the most common diseases of the anal canal with the incident rate of 20–23 cases per 1000 citizens. Most of acute anal fissures are healed spontaneously but a few of them can become chronic process. Chronic anal fissures are characterized by any two of the criteria: pain after defecation lasts longer than 3 months, sentinel pile is present, fibers of internal sphincter at the base of the anoderm.The spasm of the internal sphincter is a guiding pathogenetic mechanism in the development of chronic anal fissures. It leads to circulatory disorder in the anoderm and non-healing wounds. Therefore, the treatment of anal fissures primarily must be focus on eliminating of internal sphincter spasms and then excising of fissures.Recently, botulinum toxin type A injection in treatment of chronic anal fissures has become popular as a noninvasive method of eliminating internal sphincter spasms.Botulinum toxin as a medical agent has been studied since the late 1960s. Botulinum toxin type A has been used to treat of various pathologies including coloproctology diseases for more than 40 years.The botulinum toxin injections make the internal sphincter relax, and as a result create optimal conditions for healing chronic anal fissures.Using of botulinum toxin type A does not cause dangerous complication. Fecal incontinence after using botulinum toxin is transitory.The review describes the use of botulinum toxin type A injections to treat chronic anal fissures.

Urethral sphincter mechanism incompetence (USMI) is a common cause of urinary incontinence in dogs. Although estrogen is often prescribed for the medical therapy of USMI for spayed female dogs, they are known to have limited effectiveness and potential adverse effects. In castrated male dogs with USMI, testosterone reagents have been attempted besides estrogen. In this study, the effect of testosterone drugs, mainly methyltestosterone, on spayed female dogs with USMI was retrospectively evaluated. Ten spayed female dogs with USMI were included. Diagnosis of USMI was based on the results of the dogs’ medical history, clinical signs, and no abnormalities in physical examinations, urinalysis, ultrasonography, X-ray imaging, and neurological examinations. Methyltestosterone was administered at doses of 0.32–1.27 mg/kg BW p.o. semel in die (sid.) to twice a week. Nine of the ten dogs had good or excellent responses 2 to 4 weeks after the start of treatment. The minimum effective dose was 0.32 mg/kg/day. Although no severe adverse symptoms occurred in any dog, a mild increase in alanine aminotransferase was temporally observed at doses of 1.0 and 1.1 mg/kg/day in the two dogs. After dose reduction or withdrawal, two of eight dogs had recurrence of urinary incontinence. Resumption of testosterone treatment clearly improved the symptoms in the two dogs. These results indicate that testosterone reagents might be an option for treating USMI in spayed female dogs as well.

The article presents an assessment and analysis of the most important medical and social risk factors for long-term postoperative urogenital disorders in women of reproductive age after radical surgical treatment for uterine fibroids. Radical operations for uterine fibroids cause an increase in the proportion of urogenital disorders, the clinical manifestations of which have a negative impact on the physical, psycho-emotional form and social significance of women in society. A survey of 80 women aged 40 to 50 years, the main group included 40 patients who underwent vaginal hysterectomy, the comparison group consisted of 40 patients with hysterectomy performed by abdominal access. Data on the assessment of pelvic floor condition and urogenital dysfunction using a standardized POP-Q system, both at the stage of preoperative observation and for 3 and 5 years after surgery. Сonducted surveys, filling diaries of pain, urination, physical examination and bimanual examination, determination of the pH of the vaginal contents, colposcopy, evaluated the index of the vaginal condition, the state of the microbiota of the mucous membranes, a comprehensive urodynamic examination, cystometry, ultrasound examination of the pelvic organs and assessment of ovarian structure.The most important risk factors are identified, which would allow to form groups of patients that require individualized approaches in the choice of surgical techniques and rehabilitation program. These included obstetric and gynecological history (birth of large fetuses, episiotomies, birth injuries, high birth parity); ovarian surgery, the use of gonadotropin-releasing hormone agonists. chronic diseases of the respiratory system and gastrointestinal tract, accompanied by increased intra-abdominal pressure; the presence of stigmas of undifferentiated connective tissue dysplasia; clinical manifestations of pelvic floor failure and functional disorders of the urethral sphincter. When choosing a method and access in case of surgical treatment for uterine fibroids, it is advisable to take into account the presence of pelvic prolapse and initial dysuric manifestations in women, the functional state of the sphincter apparatus and urethral hypermobility, obstetric and gynecological pathology and previous surgery on the organs of the uterus. the patient, her awareness of possible complications, the surgeon’s experience and his choice of surgical techniques.

Purpose: The aim of this study was to determine the significance of the membranous urethral length (MUL), including the thickness of the urethral sphincter, for recovery from postoperative stress urinary incontinence (SUI) following holmium laser enucleation of the prostate (HoLEP).Methods: We analyzed 78 patients who underwent HoLEP between June 2013 and September 2018, all of whom preoperatively received magnetic resonance imaging. MUL was measured using sagittal T2-weighted fast spin-echo images. The clinical and anatomical factors associated with MUL were evaluated. The recovery time of urinary incontinence was compared between patients with a long MUL (≥14 mm) and a short MUL (

Patients with neurogenic lower urinary tract dysfunction (NLUTD) experience urinary incontinence with or without difficult urination, which might promote recurrent urinary tract infection (UTI) and exacerbate upper urinary tract function. Nonetheless, appropriate bladder management has been shown to reduce urological complications and improve quality of life. In addition to pharmacological therapy and surgical intervention, botulinum toxin A (BoNT-A) has been widely utilized in NLUTD. The therapeutic efficacy of detrusor BoNT-A injections for neurogenic detrusor overactivity due to spinal cord injury (SCI), multiple sclerosis, or other central nervous system lesions, such as cerebrovascular accident, Parkinson disease, early dementia, and pediatric NLUTD due to myelomeningocele, has been well established, with repeated BoNT-A injections every 6 to 9 months being necessary to maintain its therapeutic effects. Urethral BoNT-A injection can decrease urethral sphincter resistance and facilitate efficient voiding in patients with NLUTD who wish to preserve self-voiding. Detrusor BoNT-A injection can also decrease the occurrence of autonomic dysreflexia in patients with SCI, even after failed augmentation enterocystoplasty, with additional benefits including reduced UTI episodes and preserved renal function with repeated injections. However, this treatment does have some side effects. Complete informed consent for BoNT-A injection therapy with full disclosure of its potential complications should therefore be obtained before this procedure is undertaken.

Purpose: This study aimed to assess the feasibility of a rapid diffusion tensor imaging (DTI) for evaluation of the female urinary sphincter function based on differentiation between rest and muscle contraction.Methods: Magnetic resonance imaging (MRI) of the lower pelvis was performed at 3 Tesla in 10 healthy female volunteers (21–36 years; body mass index, 20.8±3.6 kg/m2) between June and July 2019. High-resolution T1- and T2-weighted images were acquired for anatomical reference, and following DTI performed in 4 experiment phases: twice during rest (denoted rest-1, rest-2) and contraction (contraction-1, contraction-2). Manual segmentation of the urinary sphincter and the levator ani muscles were performed by 2 independent readers. Mean diffusivity (MD) and fractional anisotropy (FA) values derived from DTI volumes were compared in search for significant differences between the experiment phases. Interreader agreement was assessed by intraclass correlation coefficient (ICC).Results: Kruskal-Wallis test showed significant differences between MD values among all the experiment phases, by both independent readers (1st: X2 [3,76]=17.16, PX2 [3,76]=15.88, PPost hoc analysis revealed differences in MD values by both readers between: rest-1 vs. contraction-1 (least P

AIM The aim was to evaluate the physiological variation in rectoanal inhibitory reflex (RAIR) after laparoscopic intersphincteric resection (Lap-ISR) for ultralow rectal cancer. METHOD This was a retrospective study that included 56 patients who underwent Lap-ISR from a prospectively collected database. The RAIR was examined preoperatively and up to 12 months after ileostomy closure. The primary outcome included physiological variation in RAIR and its difference between partial, subtotal and total ISR. The secondary outcome was its correlation with functional outcome. RESULTS The reflex was present in 95% (53/56) of patients preoperatively, in 36% (20/56) before ileostomy closure, in 48% (27/56) at 3-6 months and in 61% (34/56) at 12 months after ileostomy closure. The elicited volume of RAIR was significantly increased at 12 months after ileostomy closure than at baseline (P = 0.005), but its duration and amplitude did not differ significantly. There was no significant difference in the reflex recovery between the ISR groups (partial vs. subtotal vs. total: 65% vs. 63% vs. 44%, P = 0.61). At 12 months after ileostomy closure, the RAIR-present group had favourable functional results and patient satisfaction (P

AIMS To report the long-term functional outcomes of artificial urinary sphincter (AUS) implantation in female patients with spinal dysraphism and stress urinary incontinence (SUI) related to intrinsic sphincter deficiency (ISD). METHODS The charts of all spina bifida female patients with SUI due to ISD who underwent AUS (AMS 800) implantation between 2005 and 2019 at three academic departments of urology were retrospectively reviewed. Reoperation was defined as either revision or explantation of the AUS device. Reoperation-free survival of the AUS device was estimated using the Kaplan-Meier method. Continence status as per patients' subjective assessment was categorized as follows: complete continence (no pads), improved continence, unchanged SUI or worsened SUI. RESULTS Twenty-three patients were included, 69.6% were self-catheterizing. The median follow-up was 14 years. Median time to first reoperation was 10 years. Survival rates without reoperation were 85.9%, 41.8%, 34.6%, and 20.9% at 5, 10, 15, 20 years, respectively. Survival rates without AUS explantation were 90.7%, 66.3%, 55.2%, and 41.4% at 5, 10, 15, 20 years, respectively. None of the patients who underwent device explantation had a new AUS implanted. The only predictive factor of reoperation-free survival was the type of spinal dysraphism (hazards ratio = 3.60 for closed vs. open dysraphism; p = .04). At last follow-up, 17 of the 23 patients were fully continent (73.9%). CONCLUSION AUS in female patients with spina bifida may be associated with satisfactory long-term functional outcomes and a high reoperation rate. The median time to first reoperation was similar to what is reported in the male AUS literature (10 years).

Objectives To investigate the therapy of stress urinary incontinence in a preclinical setting cells were injected into the urethrae of minipigs; however, cells injected by William's needle were frequently misplaced or lost; thus, we investigated if needle-free cell injections using a novel waterjet technology facilitates precise injections in the urethral sphincter complex. Materials and methods Porcine adipose tissue-derived stromal cells (pADSCs) were isolated from boars, expanded, labelled, and injected in the sphincter of female pigs by waterjet employing two different protocols. After incubation for 15 min or 3 days, the urethrae of the pigs were examined. Injected cells were visualised by imaging and fluorescence microscopy of tissue sections. DNA of injected male cells was verified by polymerase chain reaction (PCR) of the sex-determining region (SRY) gene. Cell injections by William's needle served as controls. Results The new waterjet technology delivered pADSCs faster and with better on-site precision than the needle injections. Bleeding during or after waterjet injection or other adverse effects, such as swelling or urinary retention, were not observed. Morphologically intact pADSCs were detected in the urethrae of all pigs treated by waterjet. SRY-PCR of chromosomal DNA and detection of recombinant green fluorescent protein verified the injection of viable cells. In contrast, three of four pigs injected by William's needle displayed no or misplaced cells. Conclusion Transurethral injection of viable pADSCs by waterjet is a simple, fast, precise, and yet gentle new technology. This is the first proof-of-principle concept study providing evidence that a waterjet injects intact cells exactly in the tissue targeted in a preclinical in vivo situation. To further explore the clinical potential of the waterjet technology longer follow-up, as well as incontinence models have to be studied.

In conus medullaris and cauda equina surgery, identification of the sacral nerve roots may be uncertain in spite of their anatomical/radiological landmarks. Mapping the sacral roots by recording the muscular responses to their stimulation may benefit from EMG recording of the External Anal sphincter (EAS) in addition to the main muscular groups of the lower limbs. In a consecutive series of 27 lumbosacral dorsal rhizotomy (DRh), authors carried out a prospective study on the reliability of the EMG recording of the EAS for identification of the S1 and S2 sacral roots. An EAS-response was recorded in all the 27 (bilaterally) explored individuals, testifying good sensitivity and selectivity of the method. EAS-responses were obtained in 96.3% of the 54 stimulated sides of the S2 root versus in only 16.66% for the S1 root, so that an absence of response would indicate S1 rather than S2 level. Furthermore, comparison between myotomal distribution of the S1 and S2 roots showed a significant difference (p

Hombre de 61 años de edad referido al servicio de neurocirugía de un segundo nivel de atención, por presentar alteraciones en la sensibilidad de la región abdominal y de miembros pélvicos, junto con una disminución en la fuerza de los mismos aunado a fallas ocasionales para el control de esfínter vesical, se realizaron estudios de diagnóstico, en las imágenes de resonancia magnética (RMN) se observa una lesión ocupante de espacio en la región torácica relacionada a un probable meningioma espinal en T6. Se efectuó laminoplastía y se resecó la lesión tumoral quitando la compresión medular, el resultado de patología confirmo un meningioma transicional, la sintomatología remitió, ha ido recuperando el déficit neurológico y la fuerza muscular.

A 14-year-old male neutered domestic shorthair cat presented with a 4-year history of urinary incontinence following prepubic urethrostomy. Physical examination confirmed peristomal dermatitis, urine scalding and constant urine leakage. Haematology, serum biochemistry and urinalysis were unremarkable. Ultrasonography revealed a non-distended urinary bladder. An artificial urethral sphincter mechanism, with subsequent incremental inflation of the cuff 6 weeks later, resulted in complete resolution of clinical signs, return to normal urinary function and excellent quality of life. The cat was still continent at 5-year follow-up. Further studies including additional cases are required to highlight effectiveness and harms of the procedure.