Aims: To determine the feasibility of intraurethral electrical stimulation to evoke increases in ... more Aims: To determine the feasibility of intraurethral electrical stimulation to evoke increases in urethral pressure and prevent urgency urinary incontinence (UUI) episodes in women. Methods: Women with UUI based on the LUTS questionnaire were recruited. Stimulation amplitude was varied at different locations along the urethra, different stimulation rates, and with the bladder empty and filled to first sensation while measuring evoked urethral pressures and noting sensation. Cystometry and micturition studies, with and without intraurethral stimulation were performed to determine if stimulation prevented incontinence episodes. Results: Eleven women (median age 70, range 27-85) with UUI participated in the study. Sensation thresholds were higher for proximal urethral stimulation and for stimulation at lower frequencies (1 Hz). Negligible increases in urethral pressure were observed despite large differences in tolerated stimulation amplitudes between subjects. A correlation between sen...
THE JOURNAL OF UROLOGY® CONCLUSIONS: The laparoscopic sacral colpopexy is a simple and effective ... more THE JOURNAL OF UROLOGY® CONCLUSIONS: The laparoscopic sacral colpopexy is a simple and effective minimally invasive technique for correction of genital prolapse.
, the author of the first illustrated textbook of surgery, Cerrahiyyetii'l Haniye (Royal Surgery)... more , the author of the first illustrated textbook of surgery, Cerrahiyyetii'l Haniye (Royal Surgery), in the body of Turkish medical literature, performed several urogenital procedures in Asia Minor 550 years ago. As a pioneer of surgery, Sabuncuoglu practiced on almost all kinds of surgery, including urologic procedures. METHODS: In this work, we present the surgical methods and the tools for several urogenital surgeries as practiced in the 14'h century in Asia Minor, based on the original copies of the book, Cerrahiyyetii 'l Haniyye. RESULTS: Cerrahiyyetii'l Haniyye, which consisted of approximately 190 chapters, included 136 drawings for operations, 164 drawings of surgical instruments, and illustrations for 14 types of incisions. In the book, urogenital surgery was covered in 10 chapters, which described the definition of the disorders, the types of the pathologies, diagnosis, and surgical techniques in detail. Surgical procedures and tools were presented with colorful miniatures drawn and painted by the author himself. Among the operations that were explained and drawn, were the treatment of hermaphroditism with clitoroplasty; varicocele repair; hydrocelectomy; hypospadias repair; treatments of meatal stenosis, imperforated urinary meatus, and urethral strictures; orchiectomy techniques; circumcision procedures; and the treatment of penile lesions. Sabuncuoglu mentioned the indications for treatment, the tips of the surgical techniques, and complications of the operations in each chapter. Some of the procedures, which were defined in the book, were as similar as today's, like varicocele repair with an inguinal approach. CONCLUSIONS: Cerrahiyyetii'l Haniyye is one of the most important surgical textbooks in the history of medicine, written 550 years ago in Asia Minor. It nourishes basic concepts with Sabuncuoglu' s original contributions regarding surgical procedures, postoperative care, and surgical instruments.
AimsIndividuals with spinal cord injury (SCI) exhibit neurogenic detrusor overactivity (NDO) caus... more AimsIndividuals with spinal cord injury (SCI) exhibit neurogenic detrusor overactivity (NDO) causing high intravesicle pressures and incontinence. The first aim was to measure changes in maximum cystometric capacity (MCC) evoked by electrical stimulation of the dorsal genital nerve (DGN) delivered either continuously or conditionally (only during bladder contractions) in persons with SCI. The second aim was to use the external anal sphincter electromyogram (EMGEAS) for real‐time control of conditional stimulation.MethodsSerial filling cystometries were performed in nine volunteers with complete or incomplete supra‐sacral SCI. Conditional stimulation was delivered automatically when detrusor pressure increased to 8–12 cmH2O above baseline. MCCs were measured for each treatment (continuous, conditional, and no stimulation) and compared using post‐ANOVA Tukey HSD paired comparisons. Additional treatments in two subjects used the EMGEAS for automatic control of conditional stimulation.R...
Purpose-Electrical stimulation of pudendal afferents can evoke reflex bladder contractions with r... more Purpose-Electrical stimulation of pudendal afferents can evoke reflex bladder contractions with relaxation of the external urethral sphincter in cats. This voiding reflex is mediated by pudendal sensory fibers innervating the penile and prostatic urethra that engage either a spinal or spinobulbospinal micturition pathway, respectively. However, the clinical translation of this potential therapy in persons with spinal cord injury (SCI) is limited by the lack of evidence demonstrating analogous reflex mechanisms in humans. Materials and Methods-We investigated the presence of excitatory pudendal-to-bladder reflexes in seven individuals with chronic SCI. The isovolumetric bladder pressure and perineal electromyogram (EMG) were recorded in response to intraurethral (IU) electrical stimulation at varying amplitudes and frequencies. Results-Selective electrical stimulation of the proximal and distal segments of the urethra evoked sustained reflex bladder contractions in different subsets of participants: 24.9 ± 13.9 cmH 2 O (n = 3) and 23.3 ± 16.1 cmH 2 O (n = 3), respectively. In contrast, the corresponding reflex perineal EMG exhibited a differential activation pattern between proximal and distal IU stimulation (normalized EMG, p < 0.05): 1.3 ± 0.2 and 0.3 ± 0.1, respectively. Conclusions-This study presents the first clinical evidence of two independent excitatory pudendal-to-bladder reflex pathways that can, in turn, differentially modulate efferent pudendal output. Both reflex mechanisms involve a complex interaction of multiple sensory inputs and may provide a neural substrate for restoring micturition following SCI.
American Journal of Obstetrics and Gynecology, Dec 1, 2000
The anatomic and functional success of suspension of the vaginal cuff to the proximal uterosacral... more The anatomic and functional success of suspension of the vaginal cuff to the proximal uterosacral ligaments is described. STUDY DESIGN: Forty-six women underwent vaginal site-specific repair of endopelvic fascia defects with suspension of the vaginal cuff to the proximal uterosacral ligaments for pelvic organ prolapse. Outcome measures included operative complications, pelvic organ prolapse quantitation, and assessment of pelvic floor symptoms. RESULTS: After a median follow-up of 15.5 months (range, 3.5 months-3.4 years), 90% of patients had both resolution of vaginal bulging or prolapse symptoms and improvement of the stage of prolapse. There were improvements in all pelvic organ prolapse quantitation measurements except for total vaginal length, for which the median decrease was 0.75 cm. Intraoperatively, ureteral occlusion was noted in 11% (5/46) of patients with universal cystoscopy. In 3 patients the uterosacral suspension sutures were removed and replaced with resolution of the occlusion and in 2 patients ureteral reimplantation was required. Symptomatic prolapse (2 apical segment, 1 anterior, and 1 posterior) developed in 4 patients (10%), and 3 of them underwent reoperation. There were significant improvements in symptoms of bulging and pressure, voiding dysfunction, and vaginal and perineal splinting. CONCLUSION: Suspension of the vaginal vault to the proximal uterosacral ligaments combined with sitespecific repair of endopelvic fascia defects provides excellent anatomic and functional correction of pelvic organ prolapse in most women. The risk of ureteral injury with this technique makes intraoperative cystoscopy essential. (
American Journal of Obstetrics and Gynecology, Dec 1, 2007
We previously described an endoscopic-assisted transvaginal mesh excision technique. This study c... more We previously described an endoscopic-assisted transvaginal mesh excision technique. This study compares surgical outcomes after transvaginal mesh excision vs endoscopic-assisted transvaginal mesh excision. In addition, we reviewed our postoperative outcomes with excision via laparotomy. This was an inclusive retrospective analysis of patients presenting to our institution from 1997 to 2006 for surgical management of vaginal erosion of permanent mesh after sacrocolpopexy. Three techniques were utilized: transvaginal, endoscopic-assisted transvaginal, and laparotomy. For the patients undergoing transvaginal excision, data recorded included number and type of excisions performed, number of prior excisions performed at outside facilities, intraoperative and postoperative complications (including blood transfusions, pelvic abscess, or bowel complications), use of postoperative antibiotics, persistent symptoms of vaginal bleeding and discharge at follow-up, and demographic characteristics. The intraoperative and postoperative complications and the postoperative symptoms were recorded for the laparotomy cases. Thirty-one patients underwent transvaginal mesh excision during this time period: 17 endoscopic-assisted transvaginal and 14 transvaginal without endoscope assistance. In addition, a total of 7 patients underwent abdominal excision via laparotomy. Comparison of the 2 vaginal methods revealed no difference in the demographics or success rate, with success defined as no symptoms at follow-up. Endoscopic-assisted transvaginal excision was successful in 7 of 17 patients and transvaginal without endoscopic assistance in 9 of 13 patients (1 patient excluded for lack of follow-up data) for a total vaginal success rate of 53.3%. No intraoperative and only minor postoperative complications occurred with either vaginal method. Three patients underwent 3 vaginal attempts to achieve complete symptom resolution. The average follow-up time for the entire vaginal group was 14 months. Seven patients ultimately required abdominal excision and all had symptom resolution, however, not without complications. Two patients had bowel injury during lysis of adhesions requiring bowel resection in 1 case and repair in another, 1 had a postoperative wound infection with breakdown, 1 was readmitted for postoperative fever requiring antibiotics, and 1 had an acute coronary syndrome requiring transfer to the cardiology service. Transvaginal excision of mesh with or without endoscopy appears to be a safe and less invasive method for excision of eroded vaginal mesh after prior abdominal sacrocolpopexy. Up to 3 vaginal excision attempts may be necessary to achieve symptom resolution, and complete removal of mesh will likely improve outcomes with the transvaginal technique. Although abdominal excision can be considered the gold standard for excision of eroded mesh, it is not without potentially increased morbidity.
Int Urogynecol J 2012; 23: 1591-1597. Introduction and Hypothesis: Posterior tibial nerve stimula... more Int Urogynecol J 2012; 23: 1591-1597. Introduction and Hypothesis: Posterior tibial nerve stimulation (PTNS) is a percutaneous method of peripheral, sacral neuromodulation. Its current use is limited; however, published data suggest PTNS may be an effective treatment for overactive bladder (OAB). Methods: We systematically reviewed the literature on PTNS for treatment of idiopathic OAB in women from January 2000 to August 2010 published in English in MEDLINE/PubMed, Embase, and Cochrane databases. We included random- ized controlled trials or observational studies reporting objective outcome measures with the use of either the Urgent PC or Stoller Afferent Nerve Stimulator (SANS) for PTNS. Studies were considered "good quality" if results from objective measures were provided for 20 women, results distinguished between type of OAB symptom, and data were reported separately for female subjects. Results: Of the 136 identified articles, 17 met inclusion criteria for data abstraction; 4 of the 17 studies met our criteria for good quality and reported success rates of 54 -93 %. Recurrent limitations in the literature were pooling of results for male and female subjects and lack of differentiation in the data on specific symptoms of OAB treated. Short-term follow-up and infrequent use of a control arm were also noted shortcomings of reviewed studies. Conclusions: Limited high quality data exist on PTNS for OAB in women. Although initial studies have demonstrated promise, more comprehensive evaluation of PTNS is needed to support its universal use for the treatment of OAB in women.
Introduction and hypothesis Posterior tibial nerve stimulation (PTNS) is a percutaneous method of... more Introduction and hypothesis Posterior tibial nerve stimulation (PTNS) is a percutaneous method of peripheral, sacral neuromodulation. Its current use is limited; however, published data suggest PTNS may be an effective treatment for overactive bladder (OAB). Methods We systematically reviewed the literature on PTNS for treatment of idiopathic OAB in women from January 2000 to August 2010 published in English in MED-LINE/PubMed, Embase, and Cochrane databases. We included randomized controlled trials or observational studies reporting objective outcome measures with the use of either the Urgent PC or Stoller Afferent Nerve Stimulator (SANS) for PTNS. Studies were considered "good quality" if results from objective measures were provided for ≥20 women, results distinguished between type of OAB symptom, and data were reported separately for female subjects. Results Of the 136 identified articles, 17 met inclusion criteria for data abstraction; 4 of the 17 studies met our criteria for good quality and reported success rates of 54-93 %. Recurrent limitations in the literature were pooling of results for male and female subjects and lack of differentiation in the data on specific symptoms of OAB treated. Short-term follow-up and infrequent use of a control arm were also noted shortcomings of reviewed studies. Conclusions Limited high quality data exist on PTNS for OAB in women. Although initial studies have demonstrated promise, more comprehensive evaluation of PTNS is needed to support its universal use for the treatment of OAB in women.
Aims: The purpose of this study was to determine whether a percutaneous needle electrode (PNE) te... more Aims: The purpose of this study was to determine whether a percutaneous needle electrode (PNE) technique or a surgical ¢rst stage lead placement (FSLP) better predicted whether a patient would progress to implantation of a pulse generator (IPG) in older urge incontinent women. Methods: Thirty subjects 55 years with refractory urge incontinence who had been selected to undergo a test stimulation procedure were randomized to either PNE or FSLP. Thirteen underwent PNE placement and seventeen underwent FSLP placement. If during the test stimulation period subjects had greater than 50% improvement in their incontinence parameters they quali¢ed for permanent lead and/or IPG implantation of the Interstim 1 device. Results: Twenty-one subjects (70%) responded to the test stimulation and underwent implantation, 15/17 (88%) in the FSLP group and 6/ 13 (46%) in the PNE group. Subjects who were randomized to the FSLP group were signi¢cantly more likely to proceed to implantation of the IPG (P ¼ 0.02) than those in the PNE group. There was no signi¢cant di¡erence in demographics, pre-test stimulation incontinence parameters or poststimulation visual analog pain scores between the randomized groups or between test stimulation responders and non-responders. When comparing FSLP and PNE responders, there was no signi¢cant di¡erence in the percent improvement in 24-hr pad weight, daily pad usage, or daily incontinence. Conclusion: FSLP better predicted progression to implantation of the IPG than a test stimulation with a PNE in an older urge incontinent cohort. Neurourol. Urodynam. 26: 14^18, 2007.
American Journal of Obstetrics and Gynecology, Dec 1, 2007
The purpose of this pilot study was to compare the efficacy of 2 techniques for evaluating bladde... more The purpose of this pilot study was to compare the efficacy of 2 techniques for evaluating bladder function after transvaginal surgery. Subjects scheduled for transvaginal, outpatient surgery were consecutively enrolled and randomized to backfill-assisted voiding trial or a trial of spontaneous voiding after surgery. Sixty subjects were enrolled. The mean time in the perioperative anesthesia care unit for the backfill group was 199.5 minutes vs 226.6 minutes in the spontaneous voiding group (P = .08). Subjects randomized to backfill were more likely to adequately empty their bladders and be discharged home without catheter drainage than subjects in the spontaneous voiding group (61.5% vs 32.1%, respectively, P = .02). Multiple logistic regression further demonstrated that the backfill-assisted technique predicted successful bladder emptying after vaginal surgery (P = .02). Women undergoing transvaginal outpatient surgery are more likely to empty their bladder effectively before discharge if they are evaluated with a backfill-assisted voiding trial.
Female pelvic medicine & reconstructive surgery, 2021
Objective The standard backfill void trial (VT) performed after urogynecologic surgery is time-co... more Objective The standard backfill void trial (VT) performed after urogynecologic surgery is time-consuming. We adopted a new VT protocol in which the bladder is backfilled in the operating room (OR). We hypothesized that this protocol would result in (1) shorter postoperative care unit (PACU) stay and (2) lower rates of postoperative catheterization compared with standard VT. Methods We performed a retrospective cohort study of women who underwent same-day urogynecologic surgery between August 2018 and March 2019. Basic demographic and procedure information was collected. Patients were divided into 2 groups based on VT performed. Continuous and categorical variables were compared using Student t tests and χ2 tests, respectively. A linear regression model for PACU length of stay was used to control for confounders. Results Two hundred twenty-five women were included. One hundred eleven (49.3%) had the OR backfill VT and 114 (50.7%) had the standard VT. There were no statistically significant between-group differences in demographics or procedures performed. The average time in PACU was 15 minutes shorter in the OR backfill compared with the standard VT group (154.8 ± 60.6 vs 169.8 ± 83.2, P = 0.12). After adjusting for confounders, having the OR backfill VT resulted in a 23-minute reduction in PACU time (β = −23.7; 95% confidence interval, −41.3 to −6.1; P = 0.009). The overall VT failure rate was 21.3% and was not significantly different between groups (24.3% vs 18.4%, P = 0.28). Conclusions The OR backfill VT resulted in a shorter stay in PACU without increasing the incidence of postoperative catheterization. With the transition to enhanced recovery after surgery protocols, streamlining PACU activities is a priority.
Clinical obstetrics, gynecology and reproductive medicine, 2015
Aim: To identify risk factors for positive preoperative urine cultures in asymptomatic women unde... more Aim: To identify risk factors for positive preoperative urine cultures in asymptomatic women undergoing urogynecologic surgery. We also sought to identify risk factors for mixed flora clean catch urine cultures. Methods: This is a cross-sectional study. Demographic data and screening preoperative urine cultures were extracted on all women who underwent urogynecologic surgery between 9/2011 and 9/2013. Urine culture results were defined as: negative (no growth), positive (≥100K organisms), and contaminated (mixed flora). Women with <100K colony-forming units of a single organism were excluded. Logistic regression models were constructed to evaluate for differences between groups. Results: 490 women were included. When comparing positive to negative cultures, the positive culture group was more likely to have a history of recurrent urinary tract infections (UTIs) (20% vs. 5%, p=0.001). In a logistic regression model,a history of recurrent UTIs remained a risk factor for a positive preoperative urine culture (OR 6.9, 95% CI 2.3-20.8), whereas vaginal estrogen usage decreased the risk of a positive preoperative culture (OR 0.3, 95% CI 0.1-0.9). When comparing contaminated to negative cultures, the contaminated culture group was more likely to be obese (45% vs. 28%, p=0.001). In a logistic regression model, obesity remained a risk factor for contaminated preoperative urine cultures (OR 2.0, 95% CI 1.3-3.2). Conclusion: A history of recurrent UTIs was a risk factor for a positive preoperative urine culture in asymptomatic women undergoing urogynecologic surgery. Vaginal estrogen therapy was associated with fewer positive preoperative urine cultures. Obesity was an independent risk factor for contaminated (mixed flora) clean catch urine culture results.
Female Pelvic Medicine & Reconstructive Surgery, 2020
Objective Polycarbonate urethane (PCU) is a new biomaterial, and its mechanical properties can be... more Objective Polycarbonate urethane (PCU) is a new biomaterial, and its mechanical properties can be tailored to match that of vaginal tissue. We aimed to determine whether vaginal host immune and extracellular matrix responses differ after PCU versus lightweight polypropylene (PP) mesh implantation. Methods Hysterectomy and ovariectomy were performed on 24 Sprague-Dawley rats. Animals were divided into 3 groups: (1) PCU vaginal mesh, (2) PP vaginal mesh, and (3) sham controls. Vagina-mesh complexes or vaginas (controls) were excised 90 days after surgery. We quantified responses by comparing: (1) histomorphologic scoring of hematoxylin and eosin– and Masson trichrome–stained slides, (2) macrophage subsets (immunolabeling), (3) pro-inflammatory and anti-inflammatory cytokines (Luminex panel), (4) matrix metalloproteinase (MMP)-2 and -9 using an enzyme-linked immunosorbent assay, and (5) type I/III collagen using picrosirius red staining. Results There was no difference in histomorpholo...
Female Pelvic Medicine & Reconstructive Surgery, 2020
Objectives We sought to determine whether vaginal host immune cellular and extracellular matrix r... more Objectives We sought to determine whether vaginal host immune cellular and extracellular matrix responses are altered in a rat sacrocolpopexy model when lightweight polypropylene mesh is attached on tension versus without tension. Methods We performed hysterectomy and ovariectomy in 32 Sprague-Dawley rats. Animals were assigned to 4 groups (n = 8/group): (1) controls with sham operation only (control), (2) mesh sutured only on the vagina (vaginal mesh), (3) sacrocolpopexy without tension, and (4) sacrocolpopexy with tension. Ninety days later, we excised vagina-mesh complexes. A histomorphologic scoring system of hematoxylin/eosin and Masson trichrome stained slides was used to assess host inflammatory responses. The cellular inflammatory response was further quantified using (1) identification of M1 and M2 macrophage subsets and (2) quantification of proinflammatory and anti-inflammatory cytokines. The extracellular matrix response was evaluated by measuring (1) matrix metalloprote...
Aims: To determine the feasibility of intraurethral electrical stimulation to evoke increases in ... more Aims: To determine the feasibility of intraurethral electrical stimulation to evoke increases in urethral pressure and prevent urgency urinary incontinence (UUI) episodes in women. Methods: Women with UUI based on the LUTS questionnaire were recruited. Stimulation amplitude was varied at different locations along the urethra, different stimulation rates, and with the bladder empty and filled to first sensation while measuring evoked urethral pressures and noting sensation. Cystometry and micturition studies, with and without intraurethral stimulation were performed to determine if stimulation prevented incontinence episodes. Results: Eleven women (median age 70, range 27-85) with UUI participated in the study. Sensation thresholds were higher for proximal urethral stimulation and for stimulation at lower frequencies (1 Hz). Negligible increases in urethral pressure were observed despite large differences in tolerated stimulation amplitudes between subjects. A correlation between sen...
THE JOURNAL OF UROLOGY® CONCLUSIONS: The laparoscopic sacral colpopexy is a simple and effective ... more THE JOURNAL OF UROLOGY® CONCLUSIONS: The laparoscopic sacral colpopexy is a simple and effective minimally invasive technique for correction of genital prolapse.
, the author of the first illustrated textbook of surgery, Cerrahiyyetii'l Haniye (Royal Surgery)... more , the author of the first illustrated textbook of surgery, Cerrahiyyetii'l Haniye (Royal Surgery), in the body of Turkish medical literature, performed several urogenital procedures in Asia Minor 550 years ago. As a pioneer of surgery, Sabuncuoglu practiced on almost all kinds of surgery, including urologic procedures. METHODS: In this work, we present the surgical methods and the tools for several urogenital surgeries as practiced in the 14'h century in Asia Minor, based on the original copies of the book, Cerrahiyyetii 'l Haniyye. RESULTS: Cerrahiyyetii'l Haniyye, which consisted of approximately 190 chapters, included 136 drawings for operations, 164 drawings of surgical instruments, and illustrations for 14 types of incisions. In the book, urogenital surgery was covered in 10 chapters, which described the definition of the disorders, the types of the pathologies, diagnosis, and surgical techniques in detail. Surgical procedures and tools were presented with colorful miniatures drawn and painted by the author himself. Among the operations that were explained and drawn, were the treatment of hermaphroditism with clitoroplasty; varicocele repair; hydrocelectomy; hypospadias repair; treatments of meatal stenosis, imperforated urinary meatus, and urethral strictures; orchiectomy techniques; circumcision procedures; and the treatment of penile lesions. Sabuncuoglu mentioned the indications for treatment, the tips of the surgical techniques, and complications of the operations in each chapter. Some of the procedures, which were defined in the book, were as similar as today's, like varicocele repair with an inguinal approach. CONCLUSIONS: Cerrahiyyetii'l Haniyye is one of the most important surgical textbooks in the history of medicine, written 550 years ago in Asia Minor. It nourishes basic concepts with Sabuncuoglu' s original contributions regarding surgical procedures, postoperative care, and surgical instruments.
AimsIndividuals with spinal cord injury (SCI) exhibit neurogenic detrusor overactivity (NDO) caus... more AimsIndividuals with spinal cord injury (SCI) exhibit neurogenic detrusor overactivity (NDO) causing high intravesicle pressures and incontinence. The first aim was to measure changes in maximum cystometric capacity (MCC) evoked by electrical stimulation of the dorsal genital nerve (DGN) delivered either continuously or conditionally (only during bladder contractions) in persons with SCI. The second aim was to use the external anal sphincter electromyogram (EMGEAS) for real‐time control of conditional stimulation.MethodsSerial filling cystometries were performed in nine volunteers with complete or incomplete supra‐sacral SCI. Conditional stimulation was delivered automatically when detrusor pressure increased to 8–12 cmH2O above baseline. MCCs were measured for each treatment (continuous, conditional, and no stimulation) and compared using post‐ANOVA Tukey HSD paired comparisons. Additional treatments in two subjects used the EMGEAS for automatic control of conditional stimulation.R...
Purpose-Electrical stimulation of pudendal afferents can evoke reflex bladder contractions with r... more Purpose-Electrical stimulation of pudendal afferents can evoke reflex bladder contractions with relaxation of the external urethral sphincter in cats. This voiding reflex is mediated by pudendal sensory fibers innervating the penile and prostatic urethra that engage either a spinal or spinobulbospinal micturition pathway, respectively. However, the clinical translation of this potential therapy in persons with spinal cord injury (SCI) is limited by the lack of evidence demonstrating analogous reflex mechanisms in humans. Materials and Methods-We investigated the presence of excitatory pudendal-to-bladder reflexes in seven individuals with chronic SCI. The isovolumetric bladder pressure and perineal electromyogram (EMG) were recorded in response to intraurethral (IU) electrical stimulation at varying amplitudes and frequencies. Results-Selective electrical stimulation of the proximal and distal segments of the urethra evoked sustained reflex bladder contractions in different subsets of participants: 24.9 ± 13.9 cmH 2 O (n = 3) and 23.3 ± 16.1 cmH 2 O (n = 3), respectively. In contrast, the corresponding reflex perineal EMG exhibited a differential activation pattern between proximal and distal IU stimulation (normalized EMG, p < 0.05): 1.3 ± 0.2 and 0.3 ± 0.1, respectively. Conclusions-This study presents the first clinical evidence of two independent excitatory pudendal-to-bladder reflex pathways that can, in turn, differentially modulate efferent pudendal output. Both reflex mechanisms involve a complex interaction of multiple sensory inputs and may provide a neural substrate for restoring micturition following SCI.
American Journal of Obstetrics and Gynecology, Dec 1, 2000
The anatomic and functional success of suspension of the vaginal cuff to the proximal uterosacral... more The anatomic and functional success of suspension of the vaginal cuff to the proximal uterosacral ligaments is described. STUDY DESIGN: Forty-six women underwent vaginal site-specific repair of endopelvic fascia defects with suspension of the vaginal cuff to the proximal uterosacral ligaments for pelvic organ prolapse. Outcome measures included operative complications, pelvic organ prolapse quantitation, and assessment of pelvic floor symptoms. RESULTS: After a median follow-up of 15.5 months (range, 3.5 months-3.4 years), 90% of patients had both resolution of vaginal bulging or prolapse symptoms and improvement of the stage of prolapse. There were improvements in all pelvic organ prolapse quantitation measurements except for total vaginal length, for which the median decrease was 0.75 cm. Intraoperatively, ureteral occlusion was noted in 11% (5/46) of patients with universal cystoscopy. In 3 patients the uterosacral suspension sutures were removed and replaced with resolution of the occlusion and in 2 patients ureteral reimplantation was required. Symptomatic prolapse (2 apical segment, 1 anterior, and 1 posterior) developed in 4 patients (10%), and 3 of them underwent reoperation. There were significant improvements in symptoms of bulging and pressure, voiding dysfunction, and vaginal and perineal splinting. CONCLUSION: Suspension of the vaginal vault to the proximal uterosacral ligaments combined with sitespecific repair of endopelvic fascia defects provides excellent anatomic and functional correction of pelvic organ prolapse in most women. The risk of ureteral injury with this technique makes intraoperative cystoscopy essential. (
American Journal of Obstetrics and Gynecology, Dec 1, 2007
We previously described an endoscopic-assisted transvaginal mesh excision technique. This study c... more We previously described an endoscopic-assisted transvaginal mesh excision technique. This study compares surgical outcomes after transvaginal mesh excision vs endoscopic-assisted transvaginal mesh excision. In addition, we reviewed our postoperative outcomes with excision via laparotomy. This was an inclusive retrospective analysis of patients presenting to our institution from 1997 to 2006 for surgical management of vaginal erosion of permanent mesh after sacrocolpopexy. Three techniques were utilized: transvaginal, endoscopic-assisted transvaginal, and laparotomy. For the patients undergoing transvaginal excision, data recorded included number and type of excisions performed, number of prior excisions performed at outside facilities, intraoperative and postoperative complications (including blood transfusions, pelvic abscess, or bowel complications), use of postoperative antibiotics, persistent symptoms of vaginal bleeding and discharge at follow-up, and demographic characteristics. The intraoperative and postoperative complications and the postoperative symptoms were recorded for the laparotomy cases. Thirty-one patients underwent transvaginal mesh excision during this time period: 17 endoscopic-assisted transvaginal and 14 transvaginal without endoscope assistance. In addition, a total of 7 patients underwent abdominal excision via laparotomy. Comparison of the 2 vaginal methods revealed no difference in the demographics or success rate, with success defined as no symptoms at follow-up. Endoscopic-assisted transvaginal excision was successful in 7 of 17 patients and transvaginal without endoscopic assistance in 9 of 13 patients (1 patient excluded for lack of follow-up data) for a total vaginal success rate of 53.3%. No intraoperative and only minor postoperative complications occurred with either vaginal method. Three patients underwent 3 vaginal attempts to achieve complete symptom resolution. The average follow-up time for the entire vaginal group was 14 months. Seven patients ultimately required abdominal excision and all had symptom resolution, however, not without complications. Two patients had bowel injury during lysis of adhesions requiring bowel resection in 1 case and repair in another, 1 had a postoperative wound infection with breakdown, 1 was readmitted for postoperative fever requiring antibiotics, and 1 had an acute coronary syndrome requiring transfer to the cardiology service. Transvaginal excision of mesh with or without endoscopy appears to be a safe and less invasive method for excision of eroded vaginal mesh after prior abdominal sacrocolpopexy. Up to 3 vaginal excision attempts may be necessary to achieve symptom resolution, and complete removal of mesh will likely improve outcomes with the transvaginal technique. Although abdominal excision can be considered the gold standard for excision of eroded mesh, it is not without potentially increased morbidity.
Int Urogynecol J 2012; 23: 1591-1597. Introduction and Hypothesis: Posterior tibial nerve stimula... more Int Urogynecol J 2012; 23: 1591-1597. Introduction and Hypothesis: Posterior tibial nerve stimulation (PTNS) is a percutaneous method of peripheral, sacral neuromodulation. Its current use is limited; however, published data suggest PTNS may be an effective treatment for overactive bladder (OAB). Methods: We systematically reviewed the literature on PTNS for treatment of idiopathic OAB in women from January 2000 to August 2010 published in English in MEDLINE/PubMed, Embase, and Cochrane databases. We included random- ized controlled trials or observational studies reporting objective outcome measures with the use of either the Urgent PC or Stoller Afferent Nerve Stimulator (SANS) for PTNS. Studies were considered "good quality" if results from objective measures were provided for 20 women, results distinguished between type of OAB symptom, and data were reported separately for female subjects. Results: Of the 136 identified articles, 17 met inclusion criteria for data abstraction; 4 of the 17 studies met our criteria for good quality and reported success rates of 54 -93 %. Recurrent limitations in the literature were pooling of results for male and female subjects and lack of differentiation in the data on specific symptoms of OAB treated. Short-term follow-up and infrequent use of a control arm were also noted shortcomings of reviewed studies. Conclusions: Limited high quality data exist on PTNS for OAB in women. Although initial studies have demonstrated promise, more comprehensive evaluation of PTNS is needed to support its universal use for the treatment of OAB in women.
Introduction and hypothesis Posterior tibial nerve stimulation (PTNS) is a percutaneous method of... more Introduction and hypothesis Posterior tibial nerve stimulation (PTNS) is a percutaneous method of peripheral, sacral neuromodulation. Its current use is limited; however, published data suggest PTNS may be an effective treatment for overactive bladder (OAB). Methods We systematically reviewed the literature on PTNS for treatment of idiopathic OAB in women from January 2000 to August 2010 published in English in MED-LINE/PubMed, Embase, and Cochrane databases. We included randomized controlled trials or observational studies reporting objective outcome measures with the use of either the Urgent PC or Stoller Afferent Nerve Stimulator (SANS) for PTNS. Studies were considered "good quality" if results from objective measures were provided for ≥20 women, results distinguished between type of OAB symptom, and data were reported separately for female subjects. Results Of the 136 identified articles, 17 met inclusion criteria for data abstraction; 4 of the 17 studies met our criteria for good quality and reported success rates of 54-93 %. Recurrent limitations in the literature were pooling of results for male and female subjects and lack of differentiation in the data on specific symptoms of OAB treated. Short-term follow-up and infrequent use of a control arm were also noted shortcomings of reviewed studies. Conclusions Limited high quality data exist on PTNS for OAB in women. Although initial studies have demonstrated promise, more comprehensive evaluation of PTNS is needed to support its universal use for the treatment of OAB in women.
Aims: The purpose of this study was to determine whether a percutaneous needle electrode (PNE) te... more Aims: The purpose of this study was to determine whether a percutaneous needle electrode (PNE) technique or a surgical ¢rst stage lead placement (FSLP) better predicted whether a patient would progress to implantation of a pulse generator (IPG) in older urge incontinent women. Methods: Thirty subjects 55 years with refractory urge incontinence who had been selected to undergo a test stimulation procedure were randomized to either PNE or FSLP. Thirteen underwent PNE placement and seventeen underwent FSLP placement. If during the test stimulation period subjects had greater than 50% improvement in their incontinence parameters they quali¢ed for permanent lead and/or IPG implantation of the Interstim 1 device. Results: Twenty-one subjects (70%) responded to the test stimulation and underwent implantation, 15/17 (88%) in the FSLP group and 6/ 13 (46%) in the PNE group. Subjects who were randomized to the FSLP group were signi¢cantly more likely to proceed to implantation of the IPG (P ¼ 0.02) than those in the PNE group. There was no signi¢cant di¡erence in demographics, pre-test stimulation incontinence parameters or poststimulation visual analog pain scores between the randomized groups or between test stimulation responders and non-responders. When comparing FSLP and PNE responders, there was no signi¢cant di¡erence in the percent improvement in 24-hr pad weight, daily pad usage, or daily incontinence. Conclusion: FSLP better predicted progression to implantation of the IPG than a test stimulation with a PNE in an older urge incontinent cohort. Neurourol. Urodynam. 26: 14^18, 2007.
American Journal of Obstetrics and Gynecology, Dec 1, 2007
The purpose of this pilot study was to compare the efficacy of 2 techniques for evaluating bladde... more The purpose of this pilot study was to compare the efficacy of 2 techniques for evaluating bladder function after transvaginal surgery. Subjects scheduled for transvaginal, outpatient surgery were consecutively enrolled and randomized to backfill-assisted voiding trial or a trial of spontaneous voiding after surgery. Sixty subjects were enrolled. The mean time in the perioperative anesthesia care unit for the backfill group was 199.5 minutes vs 226.6 minutes in the spontaneous voiding group (P = .08). Subjects randomized to backfill were more likely to adequately empty their bladders and be discharged home without catheter drainage than subjects in the spontaneous voiding group (61.5% vs 32.1%, respectively, P = .02). Multiple logistic regression further demonstrated that the backfill-assisted technique predicted successful bladder emptying after vaginal surgery (P = .02). Women undergoing transvaginal outpatient surgery are more likely to empty their bladder effectively before discharge if they are evaluated with a backfill-assisted voiding trial.
Female pelvic medicine & reconstructive surgery, 2021
Objective The standard backfill void trial (VT) performed after urogynecologic surgery is time-co... more Objective The standard backfill void trial (VT) performed after urogynecologic surgery is time-consuming. We adopted a new VT protocol in which the bladder is backfilled in the operating room (OR). We hypothesized that this protocol would result in (1) shorter postoperative care unit (PACU) stay and (2) lower rates of postoperative catheterization compared with standard VT. Methods We performed a retrospective cohort study of women who underwent same-day urogynecologic surgery between August 2018 and March 2019. Basic demographic and procedure information was collected. Patients were divided into 2 groups based on VT performed. Continuous and categorical variables were compared using Student t tests and χ2 tests, respectively. A linear regression model for PACU length of stay was used to control for confounders. Results Two hundred twenty-five women were included. One hundred eleven (49.3%) had the OR backfill VT and 114 (50.7%) had the standard VT. There were no statistically significant between-group differences in demographics or procedures performed. The average time in PACU was 15 minutes shorter in the OR backfill compared with the standard VT group (154.8 ± 60.6 vs 169.8 ± 83.2, P = 0.12). After adjusting for confounders, having the OR backfill VT resulted in a 23-minute reduction in PACU time (β = −23.7; 95% confidence interval, −41.3 to −6.1; P = 0.009). The overall VT failure rate was 21.3% and was not significantly different between groups (24.3% vs 18.4%, P = 0.28). Conclusions The OR backfill VT resulted in a shorter stay in PACU without increasing the incidence of postoperative catheterization. With the transition to enhanced recovery after surgery protocols, streamlining PACU activities is a priority.
Clinical obstetrics, gynecology and reproductive medicine, 2015
Aim: To identify risk factors for positive preoperative urine cultures in asymptomatic women unde... more Aim: To identify risk factors for positive preoperative urine cultures in asymptomatic women undergoing urogynecologic surgery. We also sought to identify risk factors for mixed flora clean catch urine cultures. Methods: This is a cross-sectional study. Demographic data and screening preoperative urine cultures were extracted on all women who underwent urogynecologic surgery between 9/2011 and 9/2013. Urine culture results were defined as: negative (no growth), positive (≥100K organisms), and contaminated (mixed flora). Women with <100K colony-forming units of a single organism were excluded. Logistic regression models were constructed to evaluate for differences between groups. Results: 490 women were included. When comparing positive to negative cultures, the positive culture group was more likely to have a history of recurrent urinary tract infections (UTIs) (20% vs. 5%, p=0.001). In a logistic regression model,a history of recurrent UTIs remained a risk factor for a positive preoperative urine culture (OR 6.9, 95% CI 2.3-20.8), whereas vaginal estrogen usage decreased the risk of a positive preoperative culture (OR 0.3, 95% CI 0.1-0.9). When comparing contaminated to negative cultures, the contaminated culture group was more likely to be obese (45% vs. 28%, p=0.001). In a logistic regression model, obesity remained a risk factor for contaminated preoperative urine cultures (OR 2.0, 95% CI 1.3-3.2). Conclusion: A history of recurrent UTIs was a risk factor for a positive preoperative urine culture in asymptomatic women undergoing urogynecologic surgery. Vaginal estrogen therapy was associated with fewer positive preoperative urine cultures. Obesity was an independent risk factor for contaminated (mixed flora) clean catch urine culture results.
Female Pelvic Medicine & Reconstructive Surgery, 2020
Objective Polycarbonate urethane (PCU) is a new biomaterial, and its mechanical properties can be... more Objective Polycarbonate urethane (PCU) is a new biomaterial, and its mechanical properties can be tailored to match that of vaginal tissue. We aimed to determine whether vaginal host immune and extracellular matrix responses differ after PCU versus lightweight polypropylene (PP) mesh implantation. Methods Hysterectomy and ovariectomy were performed on 24 Sprague-Dawley rats. Animals were divided into 3 groups: (1) PCU vaginal mesh, (2) PP vaginal mesh, and (3) sham controls. Vagina-mesh complexes or vaginas (controls) were excised 90 days after surgery. We quantified responses by comparing: (1) histomorphologic scoring of hematoxylin and eosin– and Masson trichrome–stained slides, (2) macrophage subsets (immunolabeling), (3) pro-inflammatory and anti-inflammatory cytokines (Luminex panel), (4) matrix metalloproteinase (MMP)-2 and -9 using an enzyme-linked immunosorbent assay, and (5) type I/III collagen using picrosirius red staining. Results There was no difference in histomorpholo...
Female Pelvic Medicine & Reconstructive Surgery, 2020
Objectives We sought to determine whether vaginal host immune cellular and extracellular matrix r... more Objectives We sought to determine whether vaginal host immune cellular and extracellular matrix responses are altered in a rat sacrocolpopexy model when lightweight polypropylene mesh is attached on tension versus without tension. Methods We performed hysterectomy and ovariectomy in 32 Sprague-Dawley rats. Animals were assigned to 4 groups (n = 8/group): (1) controls with sham operation only (control), (2) mesh sutured only on the vagina (vaginal mesh), (3) sacrocolpopexy without tension, and (4) sacrocolpopexy with tension. Ninety days later, we excised vagina-mesh complexes. A histomorphologic scoring system of hematoxylin/eosin and Masson trichrome stained slides was used to assess host inflammatory responses. The cellular inflammatory response was further quantified using (1) identification of M1 and M2 macrophage subsets and (2) quantification of proinflammatory and anti-inflammatory cytokines. The extracellular matrix response was evaluated by measuring (1) matrix metalloprote...
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Papers by Cindy Amundsen