Rehabilitation of People With Chronic Spinal Cord Injury Using a Laparoscopically Implanted Neurostimulator: Impact on Mobility and Urinary, Anorectal, and Sexual Functions

OBJECTIVES

This study aimed to assess the impact of the laparoscopic implantation of neuromodulation electrodes (Possover-LION procedure) on mobility and on sexual, urinary, and anorectal functions of people with chronic spinal cord injury (SCI).

MATERIAL AND METHODS

Longitudinal analysis of 30 patients with chronic SCI (21 ASIA impairment scale (AIS) A, eight AIS B, and one AIS C) submitted to the Possover-LION procedure for bilateral neuromodulation of femoral, sciatic, and pudendal nerves. Assessments were performed before the surgical procedure and at 3, 6, and 12 months postoperatively. The primary outcome was evolution in walking, measured by the Walking Index for Spinal Cord Injury score, preoperatively and at 12 months. Secondary outcomes were changes in overall mobility (Mobility Assessment Tool for Evaluation of Rehabilitation score), urinary function and quality of life (Qualiveen questionnaire), and bowel (time for bowel emptying proceedings and Wexner's Fecal Incontinence Severity Index [FISI]) and sexual functions (International Index of Erectile Function for men and Female Sexual Function Index for women). Surgical time, intraoperative bleeding, and perioperative complications were also recorded.

RESULTS

Qualitatively, 18 of 25 (72%) patients with thoracic injury and 3 of 5 (60%) patients with cervical injury managed to establish a walker-assisted gait at one-year follow-up (p < 0.0001). A total of 11 (47.8%) have improved in their urinary incontinence (p < 0.0001), and seven (30.4%) improved their enuresis (p = 0.0156). The FISI improved from a median of 9 points preoperatively to 5.5 at 12 months (p = 0.0056). Of note, 20 of 28 (71.4%) patients reported an improvement on genital sensitivity at 12 months postoperatively (p < 0.0001), but this was not reflected in sexual quality-of-life questionnaires.

CONCLUSIONS

Patients experienced improved mobility and genital sensitivity and a reduction in the number of urinary and fecal incontinence episodes. By demonstrating reproducible outcomes and safety, this study helps establish the Possover-LION procedure as an addition to the therapeutic armamentarium for the rehabilitation of patients with chronic SCI.

CLINICAL TRIAL REGISTRATION

This study was registered at the WHO Clinical Trials Database through the Brazilian Registry of Clinical Trials-REBEC (Universal Tracking Number: U1111-1261-4428).

CO2 Laser and radiofrequency compared to a sham control group in treatment of stress urinary incontinence (LARF study arm 3). A randomized controlled trial

INTRODUCTION AND HYPOTHESIS

Female stress urinary incontinence (SUI) is a prevalent condition, and conservative treatment options are needed. Were evaluated CO₂ laser and radiofrequency as treatment for SUI.

METHODS

One hundred thirty-nine women with SUI were eligible and randomized in a three-arm double-blind randomized controlled trial into radiofrequency (RF), laser (LS) and sham control (SCT) groups, with 3-monthly outpatient treatment sessions. One hundred fourteen women were included, 38 in each group, during a 12-month follow-up. The primary outcomes were: subjective improvement of SUI, evaluated on a Likert scale, and objective cure, which was a composite outcome defined according to negative stress tests, voiding diary and pad test. Questionnaires were also applied. The sample size was calculated to provide 80% power to identify a 20% difference between groups, p < 0.05.

RESULTS

Subjective improvement and objective cure of SUI were identified respectively in 72.6% and 45.2% in LS and in 61.7% and 44.7% in RF, both significantly higher than the 30.0% and 14.0% in SCT. Considering only mild cases (pad test < 10 g), objective cure was achieved in 66.7% in LS, 63.6% in RF and 22.2% in SCT. Significant reduction in the number of episodes of urinary incontinence was found according to voiding diaries (p = 0.029) and pad weight (p = 0.021). A significant reduction in urgency and urinary loss during sexual intercourse was observed only with LS and RF. Improvement in quality of life was also verified by the I-QoL and ICIQ-SF in favor of the energy-treated groups.

CONCLUSIONS

CO₂ laser and radiofrequency are outpatient options for SUI treatment, with no major complications. They had similar results and presented better results than in the sham control group.

Treatment for vaginal agenesis: A prospective and comparative study between vaginal dilation and surgical neovaginoplasty

OBJECTIVE

To compare, in terms of anatomical, functional, and sexual aspects, two types of treatment for women with vaginal agenesis: progressive dilation or surgical neovaginoplasty.

METHODS

Women with vaginal agenesis underwent either dilation treatment using the Frank method or surgical treatment using the modified Abbé-McIndoe technique with oxidized cellulose. Patients were evaluated 3-6 months after treatment for a follow-up including medical history, physical examination, general satisfaction, clinical aspect of the vagina, Female Sexual Function Index, and three-dimensional pelvic floor ultrasound.

RESULTS

In total, 20 women with vaginal agenesis were included in the present study; nine in the dilation group and 11 in the surgical group. A comparison between the groups (vaginal dilation and surgical neovaginoplasty) showed efficacy in neovagina formation after both treatments, with a statistically significant difference between the pre- and post-treatment periods (P value pre- × post-dilation group <0.0001 and P value pre- × post-surgical group <0.0001). There were no statistical differences in total vaginal length measurements (P value post-dilation × post-surgical = 0.09) or Female Sexual Function Index scores (P = 0.72) after both treatments.

CONCLUSION

Both treatments had satisfactory efficacy and positive outcomes for patients with vaginal agenesis concerning anatomical, functional, and sexual aspects, with minimum complications in the surgical group. Dilation treatment can remain the first-line therapy.

Lumbosacral plexus MR tractography: A novel diagnostic tool for extraspinal sciatica and pudendal neuralgia?

BACKGROUND

Diagnosing extraspinal sciatica and pudendal neuralgia remains a clinical challenge. MRI and MR Neurography (MRN) are currently the standard techniques used to support the diagnosis of extraspinal lumbosacral plexus entrapments; however, for the intrapelvic portions of the lumbosacral plexus their accuracy is still limited. MR Tractography (MRT) feasibility to image the lumbosacral plexus has been demosntrated, but its clinical applications have yet to be determined.

PURPOSE

To correlate MRT with intraoperative findings in patients undergoing laparoscopic treatment of intrapelvic entrapments of the lumbosacral plexus and compare its accuracy with Neuropelveological clinical assessment and MRN.

MATERIALS AND METHODS

This is a retrospective analysis of MRT reconstructions of diffusion tensor imaging (DTI) sequences acquired for the MRN collected from a cohort of 13 patients undergoing laparoscopic detrapment of the lumbosacral plexus. The primary outcome of this study was the correlation of MRT reconstruction with intraoperative findings. Secondary outcomes included the correlation of MRN, preoperative Neuropelveological clinical diagnoses and the diffusion-weighted imaging (DWI) fractional anisotropy (FA) and Apparent Diffusion Coefficient (ADC) in patients undergoing pelvic MRI and MRN for the investigation of intrapelvic nerve entrapments.

RESULTS

MRT correlated with intraoperative findings in 11 of 13 patients (85%). Neuropelveological clinical assessment was able to accurately diagnose a pelvic nerve entrapment in 12/13 patients (92%) and MRN agreed with surgical findings in only 2/13 (15%) patients. MRT was significantly superior to MRN (p < 0.001). FA and ADC did not correlate with the identification of a nerve entrapment, likely due to limitations regarding the placement of the seedpoints.

CONCLUSIONS

This initial, retrospective analysis, suggests that MRT is superior to MRN at diagnosing intrapelvic entrapments of the lumbosacral plexus. A prospective, double-blinded study is underway to validate this data, but these initial findings show great potential for MRT as a diagnostic tool for extraspinal sciatica and pudendal neuralgia. Clinical Trials Registry: U1111-1261-4910 (REBEC - Brazilian Registry for Clinical Trials).

Progesterone's role in deep infiltrating endometriosis: Progesterone receptor and estrogen metabolism enzymes expression and physiological changes in primary endometrial stromal cell culture

To study progesterone signaling activation, we measured changes in extracellular pH as a reflection of Na+/H+ exchange (NHE) using a cytosensor microphysiometer and assessed progesterone receptor (PR) and estrogen metabolism enzymes mRNA expression in cultured endometrial cells from women with deep infiltrating endometriosis and healthy controls using real-time quantitative PCR. This study was conducted at a University hospital and included patients with and without deep infiltrating endometriosis (DIE). Primary endometrial stromal cells (ECs) from women with DIE and controls were treated with 17β-estradiol and progesterone prior to microphysiometer measurements and qPCR evaluations. Decreased progesterone responsiveness and decreased total nuclear PR and HSD17B1 mRNA expression were observed in cultured ECs from women with deep infiltrating endometriosis relative to those from control samples before and after hormone treatment. These cells also showed increased 17β-hydroxysteroid dehydrogenases types 2 (HSD17B2) relative to control group and increased expression of aromatase (CYP19) after exposure to progesterone. These physiological and expression patterns observed in ECs cultures from women with DIE reinforces previous findings in the literature supporting the progesterone resistance hypothesis in the pathogenesis of endometriosis.

Superior gluteal vein syndrome: an intrapelvic cause of sciatica

The role of malformed or dilated branches of iliac vessels in causing pelvic pain is not well understood. Such vessels may entrap nerves of the lumbosacral (LS) plexus against the pelvic sidewalls, producing symptoms not typically encountered in gynecological practice, including sciatica and refractory urinary and/or anorectal dysfunction. We describe cases of sciatica in which laparoscopy revealed compression of the LS plexus by variant superior gluteal veins (SGVs). In demonstrating an improvement in patient symptoms after decompression, we identify this neurovascular conflict as a potential intrapelvic cause of sciatica. This study is a retrospective case series (Canadian Task Force Classification II-3). Nerve decompression laparoscopies were performed in São Paulo, Brazil. Thirteen female patients undergoing laparoscopy for sciatica with no clear spinal or musculoskeletal causes were included in this study. In all cases, we identified LS entrapment by aberrant SGVs, and performed decompression by vessel ligation. The average preoperative visual analog scale score of 9.62 ± 0.77 decreased significantly to 2.54 ± 2.88 post-operatively (P < 0.001). The success rate (defined as ≥ 50% improvement in visual analog scale score) was 92.3%, over a follow-up of 13.2 ± 10.6 months. Our case series demonstrates a high success rate and significant decrease in pain scores after laparoscopic intrapelvic decompression, thereby identifying pelvic nerve entrapment by aberrant SGVs as a potential yet previously unrecognized cause of sciatica. This intrapelvic neurovascular conflict—the SGV syndrome—should be considered in cases of sciatica with no identifiable spinal or musculoskeletal etiology.

Pelvic floor muscle training is better than hypopressive exercises in pelvic organ prolapse treatment: An assessor-blinded randomized controlled trial

AIMS

To verify if hypopressive exercises (HEs) can improve pelvic organ prolapse (POP) symptoms equally or better than pelvic floor muscle training (PFMT).

METHODS

Randomized controlled trial. Symptomatic women with untreated stage II POP according to the Pelvic Organ Prolapse Quantification System (POP-Q) having the ability to contract their pelvic floor muscles were invited. The outcome measures were POP symptoms as measured by specific questions and Prolapse Quality of Life (P-QoL); POP severity as measured by POP-Q; and PFM function. Intervention consisted by 12 weeks of PFMT or an HE home exercise program with bimonthly sessions with a physiotherapist. The protocol consisted of three initial sessions to learn how to perform the exercises correctly, followed by 3 months of exercise with monthly progression. Volunteers filled out exercise diaries to record their compliance.

RESULTS

PFMT presented better results in terms of the following symptoms: a bulge/lump from or in the vagina, heaviness or dragging on the lower abdomen, and stress incontinence. PFMT also presented better results regarding the Prolapse impact and role, social and personal limitations of P-QoL. Regarding the total number of symptoms at the end, the PFMT group presented a mean of 1.7 (±1.2), and the HE group presented a mean of 2.8 (±1,1); the effect size was 1.01 in favor of the PFMT group (95%CI = 1.002-1.021).

CONCLUSION

Both groups exhibited improvements in POP symptoms, quality of life, prolapse severity, and PFM function. PFMT was superior to HE for all outcomes.

Pelvic Floor 3D Ultrasound of Women with a TVT, TVT-O, or TVT-S for Stress Urinary Incontinence at the Three-year Follow-up

Objective Using three-dimensional ultrasound (3D-US), we aimed to compare the tape position and the angle formed by the sling arms in different techniques of mid-urethral sling insertion for the surgical treatment of stress urinary incontinence, three years after surgery. In addition, we examined the correlations between the US findings and the clinical late postoperative results. Methods A prospective cross-sectional cohort study of 170 patients who underwent a sling procedure between May 2009 and December 2011 was performed. The final sample, with US images of sufficient quality, included 26 retropubic slings (tension-free vaginal tape, TVT), 42 transobturator slings (tension-free vaginal tape-obturator, TVT-O), and 37 single-incision slings (tension-free vaginal tape-Secur, TVT-S). The images (at rest, during the Valsalva maneuver, and during pelvic floor contraction) were analyzed offline by 2 different observers blinded against the surgical and urinary continence status. Group comparisons were performed using the Student t-test, the chi-squared and the Kruskal-Wallis tests, and analyses of variance with Tukey multiple comparisons. Results Differences among the groups were found in the mean angle of the tape arms (TVT = 119.94°, TVT-O = 141.93°, TVT-S = 121.06°; p < 0.001) and in the distance between the bladder neck and the tape at rest (TVT = 1.65 cm, TVT-O = 1.93 cm, TVT-S = 1.95 cm; p = 0.010). The global objective cure rate was of 87.8% (TVT = 88.5%, TVT-O = 90.5%, TVT-S = 83.8%; p = 0.701). The overall subjective cure rate was of 83.8% (TVT = 88.5%, TVT-O = 88.5% and TVT-S = 78.4%; p = 0.514). The slings were located in the mid-urethra in 85.7% of the patients (TVT = 100%, TVT-O = 73.8%, TVT-S = 89.2%; p = 0.001), with a more distal location associated with obesity (distal: 66.7% obese; mid-urethra: 34% obese; p = 0.003). Urgency-related symptoms were observed in 23.8% of the patients (TVT = 30.8%, TVT-O = 21.4%, TVT-S = 21.6%; p = 0.630). Conclusions The angle formed by the arms of the sling tape was more obtuse for the transobturator slings compared with the angles for the retropubic or single-incision slings. Retropubic slings were more frequently located in the mid-urethra compared with the other slings, regardless of obesity. However, the analyzed sonographic measures did not correlate with the urinary symptoms three years after the surgery.

Laparoscopic implantation of electrodes for bilateral neuromodulation of the pudendal nerves and S3 nerve roots for treating pelvic pain and voiding dysfunction

INTRODUCTION AND HYPOTHESIS

The objective of this video is to describe the technique for laparoscopic implantation of electrodes for bilateral neuromodulation of S3 and pudendal nerves. We report a successful case of a 48-year-old woman with spina bifida occulta referred with a 14-year history of intense acyclic pelvic pain, urinary hesitancy, and intermittent flow refractory to various conservative measures.

METHODS

The procedure began with the removal of two previously placed InterStims. A quadripolar electrode was then laparoscopically inserted into Alcock's canal and attached to the pelvic pectineal line. Another lead was placed juxtaneurally to S3. Lead contacts were then exteriorized, and the peritoneum closed. The same procedure was then performed on the contralateral side. The leads were connected to a 16-pole rechargeable pulse generator. Postoperatively, the patient developed an acute dissection and partial thrombosis of the external iliac artery, which was treated endovascularly.

RESULTS

Complete pain resolution was observed with simultaneous S3 and pudendal stimulation, with pudendal stimulation turned off for voiding.

CONCLUSIONS

We conclude that laparoscopic implantation of neuromodulation electrodes allows simultaneous stimulation of S3 and pudendal nerves, providing more programming options and possibly increasing success rates in complex pelvic floor dysfunction cases.

Plasma kallikrein enhances platelet aggregation response by subthreshold doses of ADP

Human plasma kallikrein (huPK) potentiates platelet responses to subthreshold doses of ADP, although huPK itself, does not induce platelet aggregation. In the present investigation, we observe that huPK pretreatment of platelets potentiates ADP-induced platelet activation by prior proteolysis of the G-protein-coupled receptor PAR-1. The potentiation of ADP-induced platelet activation by huPK is mediated by the integrin α_IIbβ₃ through interactions with the KGD/KGE sequence motif in huPK. Integrin α_IIbβ₃ is a cofactor for huPK binding to platelets to support PAR-1 hydrolysis that contributes to activation of the ADP signaling pathway. This activation pathway leads to phosphorylation of Src, AktS⁴⁷³, ERK1/2, and p38 MAPK, and to Ca²⁺ release. The effect of huPK is blocked by specific antagonists of PAR-1 (SCH 19197) and α_IIbβ₃ (abciximab) and by synthetic peptides comprising the KGD and KGE sequence motifs of huPK. Further, recombinant plasma kallikrein inhibitor, rBbKI, also blocks this entire mechanism. These results suggest a new function for huPK. Formation of plasma kallikrein lowers the threshold for ADP-induced platelet activation. The present observations are consistent with the notion that plasma kallikrein promotes vascular disease and thrombosis in the intravascular compartment and its inhibition may ameliorate cardiovascular disease and thrombosis.

Primary Human Uterine Leiomyoma Cell Culture Quality Control: Some Properties of Myometrial Cells Cultured under Serum Deprivation Conditions in the Presence of Ovarian Steroids

Cell culture is considered the standard media used in research to emulate the in vivo cell environment. Crucial in vivo experiments cannot be conducted in humans and depend on in vitro methodologies such as cell culture systems. However, some procedures involving the quality control of cells in culture have been gradually neglected by failing to acknowledge that primary cells and cell lines change over time in culture. Thus, we report methods based on our experience for monitoring primary cell culture of human myometrial cells derived from uterine leiomyoma. We standardized the best procedure of tissue dissociation required for the study of multiple genetic marker systems that include species-specific antigens, expression of myofibroblast or myoblast markers, growth curve, serum deprivation, starvation by cell cycle synchronization, culture on collagen coated plates, and 17 β-estradiol (E₂) and progesterone (P₄) effects. The results showed that primary myometrial cells from patients with uterine leiomyoma displayed myoblast phenotypes before and after in vitro cultivation, and leiomyoma cells differentiated into mature myocyte cells under the appropriate differentiation-inducing conditions (serum deprivation). These cells grew well on collagen coated plates and responded to E₂ and P₄, which may drive myometrial and leiomyoma cells to proliferate and adhere into a focal adhesion complex involvement in a paracrine manner. The establishment of these techniques as routine procedures will improve the understanding of the myometrial physiology and pathogenesis of myometrium-derived diseases such as leiomyoma. Mimicking the in vivo environment of fibrotic conditions can prevent false results and enhance results that are based on cell culture integrity.

Cathepsin K induces platelet dysfunction and affects cell signaling in breast cancer - molecularly distinct behavior of cathepsin K in breast cancer

Background

Breast cancer comprises clinically and molecularly distinct tumor subgroups that differ in cell histology and biology and show divergent clinical phenotypes that impede phase III trials, such as those utilizing cathepsin K inhibitors. Here we correlate the epithelial-mesenchymal-like transition breast cancer cells and cathepsin K secretion with activation and aggregation of platelets. Cathepsin K is up-regulated in cancer cells that proteolyze extracellular matrix and contributes to invasiveness. Although proteolytically activated receptors (PARs) are activated by proteases, the direct interaction of cysteine cathepsins with PARs is poorly understood. In human platelets, PAR-1 and −4 are highly expressed, but PAR-3 shows low expression and unclear functions.

Methods

Platelet aggregation was monitored by measuring changes in turbidity. Platelets were immunoblotted with anti-phospho and total p38, Src-Tyr-416, FAK-Tyr-397, and TGFβ monoclonal antibody. Activation was measured in a flow cytometer and calcium mobilization in a confocal microscope. Mammary epithelial cells were prepared from the primary breast cancer samples of 15 women with Luminal-B subtype to produce primary cells.

Results

We demonstrate that platelets are aggregated by cathepsin K in a dose-dependent manner, but not by other cysteine cathepsins. PARs-3 and −4 were confirmed as the cathepsin K target by immunodetection and specific antagonists using a fibroblast cell line derived from PARs deficient mice. Moreover, through co-culture experiments, we show that platelets activated by cathepsin K mediated the up-regulation of SHH, PTHrP, OPN, and TGFβ in epithelial-mesenchymal-like cells from patients with Luminal B breast cancer.

Conclusions

Cathepsin K induces platelet dysfunction and affects signaling in breast cancer cells.

Electronic supplementary material

The online version of this article (doi:10.1186/s12885-016-2203-7) contains supplementary material, which is available to authorized users.

Vascular entrapment of the sciatic plexus causing catamenial sciatica and urinary symptoms

AIM OF THE VIDEO / INTRODUCTION

Pelvic congestion syndrome is a well-known cause of cyclic pelvic pain (Ganeshan et al., Cardiovasc Intervent Radiol 30(6):1105-11, 2007). What is much less well known is that dilated or malformed branches of the internal or external iliac vessels can entrap the nerves of the sacral plexus against the pelvic sidewalls, producing symptoms that are not commonly seen in gynecological practice, such as sciatica, or refractory urinary and anorectal dysfunction (Possover et al., Fertil Steril 95(2):756-8. 2011). The objective of this video is to explain and describe the symptoms suggestive of vascular entrapment of the sacral plexus, as well as the technique for the laparoscopic decompression of these nerves.

METHOD

Two anecdotal cases of intrapelvic vascular entrapment are used to review the anatomy of the lumbosacral plexus and demonstrate the laparoscopic surgical technique for decompression at two different sites, one on the sciatic nerve and one on the sacral nerve roots.

RESULT

After surgery, the patient with the sciatic entrapment showed full recovery of the sciatica and partial recovery of the myofascial pain. The patient with sacral nerve root entrapment showed full recovery with resolution of symptoms.

CONCLUSION

The symptoms suggestive of intrapelvic nerve entrapment are: perineal pain or pain irradiating to the lower limbs in the absence of a spinal disorder, and lower urinary tract symptoms in the absence of prolapse of a bladder lesion. In the presence of such symptoms, the radiologist should provide specific MRI sequences of the intrapelvic portion of the sacral plexus and a team and equipment to expose and decompress the sacral nerves should be prepared.

Laparoscopic implantation of neuromodulators for treating urinary dysfunctions and improving locomotion in multiple sclerosis patients

INTRODUCTION AND HYPOTHESIS

The laparoscopic implantation of neuromodulation electrodes--the LION procedure--was first described as a rescue procedure in patients with local complications of a Brindley procedure. The objective of this video article is to demonstrate the technique for the laparoscopic implantation of electrodes for bilateral neuromodulation of femoral, sciatic and pudendal nerves and describe our initial experience with two multiple sclerosis (MS) patients.

METHOD

This is a retrospective analysis of two patients with MS and neurogenic detrusor overactivity. A quadripolar electrode was implanted with two poles into the Alcock's canal and the two other laying over the lumbosacral trunk. The other two electrodes were implanted posteriorly to the femoral nerves.

RESULTS

At the neuromodulation trial, both patients presented a full recovery of urinary symptoms. One of them found it easier to stand up for transfers and daily activities and the other managed to advance from the wheelchair to the walker and both patients received the permanent implant. At 1-year follow up, urinary results were maintained and 1 patient presented a disease relapse, demanding multiple reprogramming sessions.

CONCLUSION

Our initial observations are encouraging and indicate that the LION procedure seems to produce in MS patients similar results to those observed in patients with spinal cord injury. Patients, however, should be advised that MS is a progressive disease and that the positive effects of neuromodulation can potentially fade with time and that multiple reprogramming sessions might be necessary.

Transobturator sling compared with single-incision mini-sling for the treatment of stress urinary incontinence: a randomized controlled trial

OBJECTIVE

To determine the efficacy and safety of a single-incision mini-sling compared with a transobturator midurethral sling for stress urinary incontinence (SUI) treatment.

METHODS

This prospective single-center randomized controlled trial involved 130 women with a diagnosis of SUI. Primary outcomes were the objective and subjective cure rates, defined as negative cough stress and pad tests, and satisfaction rates. Quality of life assessed by the Incontinence Quality of Life Questionnaire and the Urogenital Distress Inventory Short Form, operation time, complications, and reoperation rates were also recorded. The efficacy was analyzed using a noninferiority test with a margin of 15%. For the noninferiority test, a P value >.05 rejects the noninferiority hypothesis of the mini-sling.

RESULTS

Sixty-four patients in the mini-sling group and 56 in the transobturator group completed the 12-month follow-up. The objective cure rates for the mini-sling and the transobturator sling were 68.1% and 81.9% (absolute difference 13.8; 90% confidence interval [CI] 1.5-26.1; P=.439) and the subjective cure rates were 81.1% and 88.5% (absolute difference 7.4%; 90% CI 2.8-17.6; P=.110), respectively. There was a significant improvement in quality of life in both groups. Thigh pain was greater after the transobturator sling, four patients (7.1%) compared with zero (P=.045). The mean operation time was 5 minutes shorter for the mini-sling procedure (P=.000). Five patients (7.8%) in the mini-sling group and one patient (1.8%) in the transobturator group underwent surgical reintervention for persistent SUI (P=.213).

CONCLUSION

The noninferiority of the mini-sling could not be demonstrated in this study at the 12-month follow-up. The mini-sling was associated with shorter operative time and less postoperative thigh pain.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, www.clinicaltrials.gov, NCT01094353.

17β-Estradiol and steady-state concentrations of H2O2: antiapoptotic effect in endometrial cells from patients with endometriosis

Increased levels of hydrogen peroxide (H2O2) can initiate protective responses to limit or repair oxidative damage. However, H2O2 signals also fine-tune responses to growth factors and cytokines controlling cell division, differentiation, and proliferation. Because 17β-estradiol (E2) also plays important roles in these processes, and is considered a major risk factor in the development and progression of endometriosis, this study evaluated whether E2 has an antiapoptotic effect on oxidative stress in endometrial cells in combination with steady-state H2O2 levels ([H2O2]ss). Endometrial stromal cells were prepared from the eutopic endometrium of 18 women with and without endometriosis to produce primary cells. These cells were stimulated with E2 for 20h, exposed to [H2O2]ss, and examined for cell viability, proliferation, and apoptosis. The endometrial cells from women with endometriosis maintained the steady state for 120min at high H2O2 concentrations. When they were pretreated with E2 and exposed to [H2O2]ss, a decrease in apoptosis level was observed compared to the control cells (p<0.01). The endometrial cells from patients with endometriosis subjected to both E2 and [H2O2]ss showed increased ERK phosphorylation. These findings suggested that H2O2 is a signaling molecule that downregulates apoptosis in endometrial cells, supporting the fact that endometriosis, albeit a benign disease, shares some features with cancer such as decreased catalase levels. These results link the E2 effects on [H2O2]ss to resistance to apoptosis and progression of endometriosis.

Expression of genes encoding smooth muscle contractile proteins in vaginal tissue of women with and without pelvic organ prolapse

AIMS

We hypothesize that the expression of genes encoding vaginal smooth muscle (SM) contractile proteins is altered in patients with pelvic organ prolapse (POP) and is influenced by age and menopausal status. We aim to analyze the expression of SM-myosin heavy chain (MHY11), caldesmon (CALD1), SM gamma-actin (ACTG2), and tropomyosin (TPM1), in premenopausal and postmenopausal women with advanced POP and asymptomatic controls.

METHODS

During total hysterectomy we collected anterior vaginal wall biopsy samples from 55 women, 37 premenopausal (23 patients and 14 controls), and 18 postmenopausal women (13 patients and 5 controls). Total mRNA from the tissues was quantified by real-time RT-PCR.

RESULTS

MHY11 gene expression was down-regulated in premenopausal POP patients compared to premenopausal controls (fivefold, P = 0.002). In the postmenopausal groups, we observed a sixfold increase in the CALD1 gene expression in POP patients compared to asymptomatic controls (P = 0.03). The gene expression of CALD1, ACTG2, and TPM1 was significantly down-regulated in vaginal tissue of healthy women after menopause (P < 0.05).

CONCLUSION

Dysregulation of the vaginal SM content in POP patients involves alteration of different cellular pathways according to age and menopausal status.

Expression of Bone Morphogenetic Protein-1 in vaginal tissue of women with severe pelvic organ prolapse

OBJECTIVES

To analyze the differential gene and protein expression of Bone Morphogenetic Protein-1 in vaginal tissue of women with advanced pelvic organ prolapse and controls.

STUDY DESIGN

We sampled the anterior vaginal wall of 39 premenopausal (23 patients and 16 controls), and 18 postmenopausal women (13 patients and 5 controls) during hysterectomy. Total mRNAs and proteins were quantified by real-time RT-PCR and immunoblotting.

RESULTS

Bone Morphogenetic Protein-1 gene expression was decreased in pre- and postmenopausal pelvic organ prolapse patients compared with asymptomatic women (P = .01). The expression of 130 kDa, 92.5 kDa, and 82.5 kDa isoforms of Bone Morphogenetic Protein-1 were down-regulated in postmenopausal patients (P = .01), whereas the 130 kDa isoform expression was up-regulated in premenopausal patients (P = .009), when compared with respective controls.

CONCLUSION

The Bone Morphogenetic Protein-1 expression in human vagina was altered in patients with severe pelvic organ prolapse and influenced by menopausal status. Dysregulation of Bone Morphogenetic Protein-1 may contribute for a deficient vaginal connective tissue and support.

Pregnancy after uterine arterial embolization

OBJECTIVE

To evaluate pregnancy outcomes, complications and neonatal outcomes in women who had previously undergone uterine arterial embolization.

METHODS

A retrospective study of 187 patients treated with uterine arterial embolization for symptomatic uterine fibroids between 2005-2008 was performed. Uterine arterial embolization was performed using polyvinyl alcohol particles (500-900 mm in diameter). Pregnancies were identified using screening questionnaires and the study database.

RESULTS

There were 15 spontaneous pregnancies. Of these, 12.5% were miscarriages (n = 2), and 87.5% were successful live births (n = 14). The gestation time for the pregnancies with successful live births ranged from 36 to 39.2 weeks. The mean time between embolization and conception was 23.8 months (range, 5-54). One of the pregnancies resulted in twins. The newborn weights (n = 14) ranged from 2.260 to 3.605 kg (mean, 3.072 kg). One (7.1%) was considered to have a low birth weight (2.260 kg). There were two cases of placenta accreta (12.5%, treated with hysterectomy in one case [6.3%]), one case of premature rupture of the membranes (PRM) (6.3%), and one case of preeclampsia (6.3%). All of the patients were delivered via Cesarean section.

CONCLUSION

In this study, there was an increased risk of Cesarean delivery. There were no other major obstetric risks, suggesting that pregnancy after uterine arterial embolization is possible without significant morbidity or mortality.

Outcome of arterial embolization of uterine leiomyoma: case report

OBJECTIVE

To describe the outcomes after uterine artery embolization treatment of leiomyoma.

DESIGN

Case report.

SETTING

Department of Gynecology - Federal University of São Paulo.

PATIENT

a 34-year-old woman with a diagnosis of leiomyoma for two years.

INTERVENTION

embolization of uterine arteries with 500 to 700-microm diameter polyvinyl alcohol particles.

MAIN OUTCOME MEASURE

pregnancy and delivery.

RESULTS

After embolization, the follow-up revealed a good clinical response with significant reduction in uterus and leiomyoma volume. Also, the patient became spontaneously pregnant, but the delivery was cesarean section due to placenta accreta..

CONCLUSION

Regardless of arterial embolization results for controlling uterine bleeding, this procedure might have some consequences on pregnancy outcome.

Fas/CD95 promoter polymorphism gene and its relationship with cervical carcinoma

OBJECTIVE

Apoptosis is an important fail-safe control in human papillomavirus (HPV)-associated carcinogenesis. We tested the hypothesis that the A/G polymorphism at -670 of Fas promoter is associated with an increased risk for cervical cancer, using a matched case-control setting.

METHODS

The material in this case-control study consisted of 91 patients with cervical carcinoma and 176 population-based control subjects, recruited between 2002 and 2004; all the ethnic Brazilian women had histologically confirmed cervical carcinoma. Control subjects were age-matched; healthy women who were selected following a negative cervical cytology and normal colposcopy. Fas genotyping was performed using a PCR-RFLP technique.

RESULTS

No significant difference existed in the distribution of the Fas polymorphisms (wild, heterozygous, mutant) between the cases and controls. The heterozygous (OR: 4.85, 95% CI: 1.1-22.6) genotypes among the younger (< 48 yrs) cancer patients were almost 5-fold increased, as compared with the wild type. No such increase was observed among the patients older than 48 years.

CONCLUSIONS

Our data suggest that 670A/G polymorphism in the promoter region of the death receptor Fas is associated with an increased risk of cervical cancer among Brazilian women under 48 years. The mechanisms would be the inhibition of apoptosis by Fas -670G allele-mediated down-regulation of Fas transcription.

Single-blind, randomized, controlled trial of pelvic floor muscle training, electrical stimulation, vaginal cones, and no active treatment in the management of stress urinary incontinence

PURPOSE

To compare the effectiveness of pelvic floor exercises, electrical stimulation, vaginal cones, and no active treatment in women with urodynamic stress urinary incontinence.

PATIENTS AND METHODS

One hundred eighteen subjects were randomly selected to receive pelvic floor exercises (n=31), ES (n=30), vaginal cones (n=27), or no treatment (untreated control) (n=30). Women were evaluated before and after completion of six months of treatment by the pad test, quality of life questionnaire (I-QOL), urodynamic test, voiding diary, and subjective response.

RESULTS

In the objective evaluation, we observed a statistically significant reduction in the pad test (p=0.003), in the number of stress urinary episodes (p<0.001), and a significant improvement in the quality of life (p<0.001) in subjects who used pelvic floor exercises, electrical stimulation, and vaginal cones compared to the control group. No significant difference was found between groups in the urodynamic parameters. In the subjective evaluation, 58%, 55%, and 54% of women who had used pelvic floor exercises, electrical stimulation, and vaginal cones, respectively, reported being satisfied after treatment. In the control group, only 21% patients were satisfied with the treatment.

CONCLUSION

Based on this study, pelvic floor exercises, electrical stimulation, and vaginal cones are equally effective treatments and are far superior to no treatment in women with urodynamic stress urinary incontinence.

Intron 1 and exon 1 alpha estrogen receptor gene polymorphisms in women with endometriosis

OBJECTIVE

To evaluate the association of intron 1 and exon 1 polymorphisms in the estrogen receptor alpha gene (ER-alpha) with endometriosis in women.

DESIGN

Association study.

SETTING

Endometriosis Unit, Federal University of São Paulo.

PATIENT(S)

The control group consisted of volunteers older than 45 years who had no evidence of endometriosis antecedents. Two groups with the disease were evaluated: the first group had stage I or II endometriosis and the second group stage III or IV.

INTERVENTION(S)

Polymerase chain reaction (PCR) followed by digestion with HaeIII and MspI endonucleases (RFLP) were applied to detect intron 1 and exon 1 polymorphisms, respectively, in a total of 125 controls and 105 affected women.

MAIN OUTCOME MEASURE(S)

Frequency and distribution of HaeIII and MspI polymorphisms in ER-alpha.

RESULT(S)

No significant differences in the frequency of polymorphisms either in intron 1 or exon 1 of ER-alpha were found when endometriosis patients were compared with control subjects. Furthermore, the frequency of ER-alpha polymorphisms within the two different groups of patients with disease was statistically similar. The odds ratio between presence of intron 1 single-nucleotide polymorphisms (SNP) and endometriosis was 0.904, and the odds ratio between exon 1 SNP and endometriosis was 0.976.

CONCLUSION(S)

The evaluated polymorphisms were not associated with endometriosis.

Ultrasonographic and Doppler velocimetric evaluation of the levator ani muscle in premenopausal women with and without urinary stress incontinence

OBJECTIVES

The objective was to evaluate the cross-sectional area (CSA) and the Doppler velocimetric parameters of the levator ani muscle vessels in premenopausal women with and without urinary stress incontinence.

STUDY DESIGN

Sixty-three premenopausal women constituted three groups: GI (nulliparous), GII (continent multiparous), and GIII (incontinent multiparous). The patients had undergone transperineal ultrasound in which the CSA was measured and Doppler velocimetry was performed. The examination was repeated by a second observer using the same procedure.

RESULTS

There was a statistically significant correlation between the measurements of the observers I and II regarding all the parameters studied, except for the A/B ratio in GIII. The CSA was significantly greater in GI and GII than in GIII. As far as Doppler velocimetry is concerned there were no differences in the Doppler velocimetric indices among the three groups. Concerning the absent end diastolic shift, it was observed that there was a significantly greater incidence of such findings in GI+GII (continent women) towards GIII (incontinent women).

CONCLUSIONS

The CSA evaluation and the Doppler velocimetry of the levator ani muscle vessels were highly reproducible. The CSA was higher in continent women and the frequency of the absent end diastolic shift was higher in incontinent women.

Impact of pregnancy and childbirth on female rats’ urethral nerve fibers

This study aims to evaluate the urethral nerve fibers of adult female rats during pregnancy and after vaginal birth, cesarean section or simulated birth trauma. For immunohistochemical analysis of nerve fibers, 70 female rats were distributed in seven groups of ten female rats: group 1, control; group 2, pregnant; group 3, cesarean section; group 4, vaginal birth; group 5, virgin female rats with simulated birth trauma; group 6, cesarean section followed by simulation of birth trauma; and group 7, vaginal birth followed by simulation of birth trauma. The number of nerve fibers in groups 1, 2, and 3 were significantly higher than the other groups. Pregnancy and cesarean section did not cause alterations in the nerve fibers number. Vaginal birth and simulated birth trauma significantly decreased the number of nerve fibers in the female rats' middle urethra.

Hormonal influence on periurethral vessels in postmenopausal incontinent women using Doppler velocimetry analysis

The lack of estrogen affects the urinary tract mainly by diminishing vascular, muscular and epithelial trophism, resulting in negative effects on continence in postmenopausal women.

OBJECTIVE

Study the effect of hormone therapy (estrogen and progesterone) in periurethral vessels detected by Doppler velocimetric analysis using, as parameters, the number of vessels, resistance and pulsatility indexes, as well as the minimum diastolic value.

METHODS

Thirty-eight postmenopausal women with stress urinary incontinence were randomized into two groups. The first consisted of women receiving 3 months of estrogen therapy previous to 3 months of continuous estrogen and progesterone combined therapy. The second comprised of women receiving 3 months of continuous estrogen and progesterone therapy. Periurethral Doppler velocimetric analysis was done before hormone administration and during treatment in both groups.

RESULTS

We observed a statistically significant increased number of periurethral vessels during treatment in both groups. There was an increase in value of the mean minimum diastolic value during estrogen and progesterone therapy in Group 2. The resistance indexes diminished in both groups. However, they were not statistically significant.

CONCLUSION

Hormonal therapy of short duration (3-6 months) had a positive effect on the urethral continence mechanism increasing the number of periurethral vessels either with estrogen alone or combined therapy (estrogen and progesterone).

Genetic polymorphisms of cytochrome P450cl7alpha (CYP17) and progesterone receptor genes (PROGINS) in the assessment of endometriosis risk

We designed the present study in order to evaluate the eventual role of polymorphisms in the genes encoding cytochrome P450c17alpha (CYP17) and the progesterone receptor (PROGINS) as risk factors for endometriosis development. Eligible cases consisted of 121 women with surgically confirmed endometriosis who underwent treatment in a hospital in São Paulo, Brazil during the period from September 2003 to September 2005. The 281 controls were participants with normal gynecological as well as pelvic ultrasound evaluation, who did not have any gynecological conditions during their reproductive lives such as pelvic pain and/or dyspareunia nor infertility history. Genomic DNA was obtained from buccal cells and processed for DNA extraction using the GFX DNA extraction kit (GE Healthcare). The CYP17 (-34T-->C) polymerase chain reaction-restriction fragment length polymorphism assay has been described previously, as has the progesterone receptor polymorphism (PROGINS) detection assay. PROGINS heterozygosis genotype frequencies were shown to be statistically higher in endometriosis cases compared with controls. On the other hand, differences in the CYP17 polymorphism (-34T-->C) frequencies were not even close to significance (p = 0.278) according to our findings.

Estrogen receptor alpha polymorphism and susceptibility to uterine leiomyoma

Uterine leiomyoma is the most frequent pelvic tumor found in female genital tract. Some studies have suggested an association between single nucleotide polymorphisms (SNPs) in estrogen receptors genes with susceptibility in developing uterine leiomyoma. In this work, we estimated the frequency of two SNPs: one located in the intron 1 (rs9322331) and other in the exon 1 (rs17847075) of the estrogen receptor alpha (ESR1) gene in 125 women with uterine leiomyoma and 125 healthy women. To do this we used a PCR-RFLP method with MspI and HaeIII restriction enzymes to respectively detect C/T SNPs in the intron 1 and in the exon 1 of ESR1. To our knowledge this is the first study aimed to investigate the association of ESR1 SNPs with the risk of developing uterine leiomyoma in Brazilian women. Our results showed that the allele frequencies of the exon 1 and the intron 1 of the ESR1 gene did not differ between cases and controls (P = 0.325 and 0.175, respectively). Furthermore, our findings provided little support for the association of these SNPs on ESR1 with leiomyoma. However, we found that the SNP in the intron 1 of the ESR1 gene was underrepresented in the Brazilian female population.

The impact of pregnancy and childbirth in the urethra of female rats

The aim of this study was to evaluate the modifications in the amount of collagen, muscular, and elastic fibers in the mid-urethra of adult female rats during the pregnancy and after the natural childbirth, cesarean, and after simulated trauma of childbirth. The authors evaluated the histomorphometric aspects (collagen, muscular, and elastic fibers) in the mid-urethra of 70 animals distributed in seven groups: group 1 (n = 10)--control, group 2 (n = 10)--pregnant female rats, group 3 (n = 10)--female rats submitted to cesarean, group 4 (n = 10)--female rats with natural childbirth, group 5 (n = 10)--virgin female rats with simulated trauma of childbirth, group 6 (n = 10)--female rats submitted to cesarean followed by simulation of childbirth trauma, and group 7 (n = 10)--female rats with natural childbirth followed by simulation of childbirth trauma. The average concentration of collagen and elastic fibers and the collagen/muscular fiber correlation in groups 1, 2, and 3 were similar and significantly inferior to groups 4, 5, 6, and 7. The average of muscular fibers was similar in groups 1, 2, and 3 and significantly superior to groups 4, 5, 6, and 7. Pregnancy and cesarean did not induce alterations in collagen, muscular, and elastic fibers. However, the vaginal delivery and simulation of childbirth trauma determined the decrease in muscular fibers and the increase in collagen and elastic fibers and the correlation collagen/muscular fiber.

Polymorphisms in exons 1B and 1C of the type I interleukin-1 receptor gene in patients with endometriosis

To study possible correlation between the prevalence of polymorphisms in the type I interleukin-1 receptor gene and pelvic endometriosis. Genotypes of 223 women were analyzed: 109 women with surgically and histologically confirmed endometriosis and 114 healthy women. Distributions of two single-base polymorphisms of the human interleukin-1 receptor type I (IL-1RI) gene were evaluated: PstI, due to a C-->T transition in exon 1B and BsrBI a C-->A transition at position 52 in exon 1C. Polymorphisms were detected by polymerase chain reaction (PCR) followed by restriction fragment length polymorphism analysis (RFLP) resolved on 3% agarose gels stained with ethidium bromide. Genotypes for PstI polymorphisms did not differ significantly among control and endometriosis (P = 0.058). However, in relation to BsrBI polymorphism, protective risk was observed for the development of endometriosis [OR 0.39-IC 95% (0.2-0.9)]. BsrBI heterozygote genotype (C/A) showed protective effect against endometriosis development.

Expression of vascular endothelial growth factor in the lower urinary tract in rats after castration and estrogen administration

OBJECTIVE

To evaluate quantitatively, by means of immune histochemistry, the expression of the vascular endothelial growth factor (VEGF) in the bladder, vesicourethral junction, and urethra in normal, castrated adult rats and under estrogen administration.

DESIGN

Sixty adult virgin rats (Rattus norvergicus albinus, Rodentia, Mammalia) from the CEDEME-UNIFESP Animal House were used. Rats were divided into three groups. Group I comprised noncastrated rats, group II comprised oophorectomized rats, and group III comprised castrated rats administered 17beta-estradiol in the form of subcutaneous implants at the dose of 0.18 mg/implant for 30 days. After performing standard immunohistochemistry procedures, the intensity of the dark-brown color was used as the cytoplasmic protein expression of VEGF. Cells without this coloration or weakly stained were considered negative. percentile of VEGF expression was obtained by counting 1,000 cells per slide and establishing the ratio between positive and total cells.

RESULTS

The VEGF expression was uniform and similar along the urinary tract in group I. After castration, protein expression was almost absent in the bladder and was low in the vesicourethral junction and urethra. With estrogen replacement, very little of the expression was recovered in the bladder, and the reaction became evident in the vesicourethral junction and urethral sections.

CONCLUSIONS

The present study implies a potential relationship between VEGF and urinary tract physiology. The results suggest that there are quantitative differences in VEGF expression in these tissues depending on steroid hormone status.

Effect of tibolone on cytochrome c oxidase I, beta-2-microglobulin and vascular endothelial growth factor gene expression in the lower urinary tract of castrated rats

INTRODUCTION

The objective of this study was to evaluate the effect of tibolone on cytochrome oxidase I (COX I), beta-2-microglobulin (B2M) and vascular endothelial growth factor (VEGF) gene expression in the lower urinary tract of castrated rats. These genes are related to cell energy, cellular immunity and vascularization processes.

METHODS

Fifty adult castrated rats remained at rest for 28 days. Thereafter they were randomly divided into two groups of 25 animals each. The lower urinary tract (bladder and urethra) was extracted in animals of one group and the other group received tibolone at a dose of 0.25 microg/animal/day for another 28 days followed by removal of the lower urinary tract. Total RNA was extracted from animals of both groups, forming two pools. After RT-PCR (reverse transcriptase polymerase chain reaction), expression of COX I, B2M and VEGF genes was evaluated by agarose gel electrophoresis, visualized by UV illumination.

RESULTS

Expression of the three genes (COX I, B2M and VEGF) was greater in the group treated with tibolone.

CONCLUSION

The use of tibolone increases the expression of COX, B2M and VEGF genes in the lower urinary tract as compared with that in castrated rats.

The effects of bethanechol and cisapride on urodynamic parameters in patients undergoing radical hysterectomy for cervical cancer. A randomized, double-blind, placebo-controlled study

To evaluate the effects of bethanechol and cisapride on urodynamic parameters in patients undergoing radical hysterectomy for cervical cancer. In this double-blind, placebo-controlled study, 79 patients with cervical cancer were randomized to receive bethanechol (30 mg/day), cisapride (30 mg/day), bethanechol combined with cisapride (same doses) and placebo. Urodynamic study was performed, including flowmetry, cystometry, pressure-flow study and urethral pressure profile before radical hysterectomy. Medication was administered postoperatively during 30 days. At the end of this period, urodynamic evaluation was repeated. There was an increase in both the maximum cystometric capacity and bladder capacity at first desire to void in the placebo group compared to the other groups. The rate of detrusor instability was higher in the group that used bethanechol combined with cisapride. Detrusor pressure at maximum flow was significantly higher when cisapride was used. There was a significant increase in postvoid residual volume in the placebo group. In patients undergoing radical hysterectomy, bethanechol and cisapride determined lower cystometric capacity and decreased bladder capacity at first desire to void, a higher maximum flow rate and higher detrusor pressure at maximum flow, with lower postvoid residual volumes. The early use of bethanechol and cisapride after radical hysterectomies positively modified urodynamic parameters, determining a more efficient detrusor function.

Effects of tamoxifen on Doppler velocimetry parameters of periurethral vessels in postmenopausal women

The purpose of the present study was to assess the effect of tamoxifen on periurethral vessels by Doppler velocimetry examination. Increase in the number of these vessels as well as decrease in resistance and pulsatility indices by tamoxifen were observed.

Sulfated glycosaminoglycans of the vagina and perineal skin in pre- and postmenopausal women, according to genital prolapse stage

The aim of this study was to analyze the amount and types of sulfated glycosaminoglycans (GAGs) of the extracellular matrix (ECM) in the posterior vaginal wall and perineal skin in menacme and postmenopausal women, according to genital prolapse stage. Samples of vaginal tissue and perineal skin were obtained from 40 women who underwent vaginal surgery. Sulfated glycosaminoglycans were extracted by extensive tissue maxatase digestion, submitted to electrophoresis on agarose gel, and their concentrations were determined by densitometry. Dermatan sulphate (DS) was the predominant GAG, followed by chondroitin sulfate (CS) and heparan sulfate (HS). In the vagina there was a significant decrease in total GAGs, CS, DS and HS in postmenopausal women with prolapse stage 2 and 3 compared to the premenopausal group, independent of the stage. In stage 2 and 3 postmenopausal patients there was a significant decrease of DS and HS compared to the stage 1 postmenopausal group. In perineal skin there was no significant difference between total GAG amount, DS and HS. However, the amount of CS in premenopausal stage 1 patients was significantly than that in postmenopausal patients stage 1 and stages 2 and 3. In conclusions, there are quantitative and qualitative differences in GAGs of the ECM in vaginal wall and perineal skin between women in menacme and the postmenopause, according to genital prolapse stage.

Glycosaminoglycan profile in bladder and urethra of castrated rats treated with estrogen, progestogen, and raloxifene

OBJECTIVE

This study was undertaken to evaluate the action of conjugated equine estrogens alone, medroxyprogesterone, the combination of these estrogens with progestogens, and of raloxifene on the glycosaminoglycan profile in the bladder and urethra of adult oophorectomized rats in comparison with noncastrated rats.

STUDY DESIGN

Sixty adult rats, of which 50 were submitted to bilateral oophorectomy, were studied. After 4 days, the latter were assigned to five groups of 10 animals each. For 30 consecutive days the following treatments were given: group 1, conjugated equine estrogens; group 2, conjugated equine estrogens combined with medroxyprogesterone acetate; group 3, medroxyprogesterone; group 4, raloxifene; and group 5, placebo. Thereafter the bladders and urethras of the animals were removed, processed to yield a dry powder of which the sulfated glycosaminoglycan content was determined by densitometry after agarose gel electrophoresis and that of hyaluronic acid by a fluorimetric assay.

RESULTS

Glycosaminoglycans found in the bladder and urethra were dermatan sulfate, heparan sulfate, and hyaluronic acid. In the bladder, hypoestrogenism or replacement with estrogens led to a lower sulfated glycosaminoglycan content. Replacement with estrogens and/or medroxyprogesterone reverted this effect. Hypoestrogenism decreased the dermatan sulfate/heparan sulfate ratio and reduced hyaluronic acid content. Estrogen therapy reverted this alteration and medroxyprogesterone addition annulled the estrogenic effect. In the urethra, castration did not alter hyaluronic acid content and sulfated glycosaminoglycan content, but raloxifene decreased the latter.

CONCLUSION

Castrated rats had a decrease in sulfated glycosaminoglycans and hyaluronic acid content in the bladder. Hormonal replacement altered the quantity and quality of glycosaminoglycans. In the urethra, raloxifene reduced sulfated glycosaminoglycans.

Bladder neck mobility and functional evaluation of the pelvic floor in primiparae according to the type of delivery

In this study, 91 primiparous women were selected, with a period of post-delivery variable from 45 to 60 days. These patients were divided according to the type of delivery into three groups: I--consisting of 32 patients who had vaginal delivery; II--comprised 29 patients who were subjected to forceps; III--formed by 30 women who were subjected to cesarean section. Patients with a previous pregnancy were not included, so that the possible previous alterations of the pelvic floor did not interfere with the present evaluation. Patients with a pre-term pregnancy, fetus below 2,500 g or above 4,000 g, anomalous presentations, twin pregnancy, diabetes mellitus, systhemic arterial hypertension, hypertensive disease specific of pregnancy, endocrinopathies and neuropathies were also excluded. After 45 to 60 days from delivery the patients were subjected to anamnesis, gynecological examination, functional evaluation of the pelvic floor (FEAF), Q-Tip test and ultrasound of the bladder neck. As for the functional evaluation of the pelvic floor, it was observed that the patients with cesarean section presented better indexes compared to those who were subjected to forceps. The Q-Tip test showed that in both the patients from group I and group II bladder neck mobility was greater than in those from group III. Concerning bladder neck topography in relation to public symphysis and its mobility, which were evaluated by ultrasound, it was observed that at rest all the groups had the neck in a supra-pubic position, with no differences among them. Yet, during the required strain, the bladder neck stayed in the infra-pubic position with major frequency in group I. Bladder neck mobility was greater in the vaginal delivery group in relation to the other groups. It was also noticed that the group undergoing cesarean section showed less mobility. The obtained results lead us to conclude that despite the fact that vaginal delivery may cause displacement of the urethro-vesical junction during strain, and consequently greater bladder neck mobility, it is the attending physician's role to minimize the damage to the pelvic floor, thus avoiding the emergence of a predisposing factor to future stress urinary incontinence.

Does electrical stimulation of the pelvic floor make any change in urodynamic parameters? When to expect a cure and improvement in women with stress urinary incontinence?

OBJECTIVE

Our study aimed at determining the effects of pelvic floor electrical stimulation assessed by the number of leakages per day recorded in a voiding diary over 90 days of treatment and urodynamic parameters.

STUDY DESIGN

This prospective study was carried out with 34 patients presenting stress urinary incontinence who were treated and evaluated by voiding diaries and urodynamic tests. The primary outcome measure was the number of leakages during the 90 days of treatment. Urodynamic tests were performed before and after treatment.

RESULTS

In our series, average and maximum flow rates and residual urine volume were within normal range in all subjects before and after treatment. Maximum urethral closure pressure and functional profile length on urethral pressure profiles did not change after treatment. In the cystometry, bladder capacities at the first (p < 0.0082) and maximum sensations (p < 0.01) improved significantly after treatment. During the 90 days of treatment, we observed a gradual drop in the number of leakages. This decrease began around day 22. It dropped in half around day 45, tending to zero close to day 90 of treatment (p < 0.01).

CONCLUSIONS

The number of incontinent leakage dropped to half around the 8th week, and on average, there was a tendency of the patients to be cured after the 12th week of treatment. At urodynamic studies we observed a significant increase in bladder capacity at the first desire to void and in the maximum cystometric capacity.

Urodynamic alterations after pelvic floor exercises for treatment of stress urinary incontinence in women

The following study improves the effectiveness of pelvic floor exercise in women with stress urinary incontinence. A group of 27 women with stress urinary incontinence performed specific pelvic floor exercises twice a week for 45 minutes under a therapist's supervision for a period of 12 weeks. This group had urodynamic and urethral pressure profile studies and filled in a daily diary. The patients self-evaluated their symptoms. After the therapy, the urodynamic and urethreal pressure profile studies were repeated and the results were: 66.7% patients were self-evaluated as cured; 14.8% improved and 18.5% unchanged. The urodynamic results showed that 48.2 % of the patients did not have urinary loss, however, 51,8% of the patients that had a loss showed an increase in vesicle volume, and only 7.3% remained unchanged. The results show that pelvic floor exercises are an effective and low cost treatment for stress urinary incontinence rehabilitation.

Urodynamic and clinical evaluation of postmenopausal women with stress urinary incontinence before and after cyclic estrogen therapy

OBJECTIVE

The purpose [corrected] of this study was to evaluate the effects of isolated cyclic estrogen therapy in menopausal women with stress urinary incontinence, and thus without the effects of progesterone.

METHODS

Nineteen menopausal patients with stress urinary incontinence were selected and submitted to anamnesis and physical, gynecological and urodynamic examinations. The group was homogeneous in relation to parity, body mass index and degree of urogenital prolapse. All the patients received conjugated equine estrogens orally, at a dose of 0.625 mg, for 21 days each month. After three months the clinical and urodynamic evaluations in relation to urine loss, were performed again.

RESULTS

Of the patients 57.9% were satisfied with the treatment. The urodynamic parameters remained unaltered in 36.85% of the patients.

CONCLUSION

Our results show that estrogen is important for stress urinary incontinence in postmenopause, specially in patients without cystocele or with cystocele of degree I or II.

Histomorphometric study of the inferior urinary tract of adult female rats during the interval between castration and hormonal replacement

OBJECTIVE

To evaluate the epithelial thickness, number of vessels, amount of collagen and muscular fibers of the bladder and urethra of castrated adult female rats during the time between castration and the beginning of the administration of synthetic conjugated estrogen.

METHOD

118 adult female rats were divided into four groups: Group I (n = 30): noncastrated female rats; group II (n = 30): female rats treated with synthetic conjugated estrogen in the dose of 50 microg/animal/day for 28 days, beginning immediately after castration; group III (n = 28): female rats treated with synthetic conjugated estrogen, 50 microg/animal/day for 28 days, beginning 30 days after castration: group IV (n = 30): female rats sacrificed after 30 days of castration. The histology of the bladder wall and the medium-third of the urethra wall were evaluated after flushing with hematoxylin-eosin and picrosirius for morphometric analysis.

RESULTS

It was verified that the epithelial thickness in groups II and III were similar whereas in groups I, II and III the thickness of the bladder and also the urethra were larger than in group IV. Concerning the bladder groups I and II were similar. In group I the urethra was superior than in groups II and III. In relation to the number of vessels and muscular fibers, groups I, II and III were similar to each other and superior to group IV in the bladder and urethra. The amount of collagen was similar in groups I, II and III and inferior in group IV in the bladder and in the urethra.

CONCLUSION

Independent of the time of estrogen administration (immediate or within 30 days) after castration, the thickness of the epithelium, the number of vessels, amount of collagen and muscular fibers were similar. The female rats with estrogen replacement presented significantly larger thickness of the epithelium, number of vessels and muscular fibers, and a smaller amount of collagen in the bladder and urethra in relation to the castrated group. Finally, estrogen therapy (immediate and 30 days after castration) reverted the effects of the estrogen deficiency in the vessels, collagen and muscular fibers, the bladder and of the urethra when compared to the group of castrated female rats, thus becoming similar to noncastrated animals.

Clinical and urodynamic evaluation of women with detrusor instability before and after functional pelvic floor electrostimulation

Detrusor instability is the second most frequent cause of female urinary incontinence. There are many therapeutic options, including non-invasive and surgical procedures. In this study, we evaluated the effects of pelvic floor vaginal electrostimulation using equipment designed in our institution, over three consecutive months, for treatment of 29 women with detrusor instability. After treatment 22 patients (76%) considered themselves cured or symptomatically improved; seven patients (24%) had no change in symptoms after therapy. There was objective cure and improvement in ten (34.5%) and in eight (27.5%) patients, respectively, and the urodynamic parameters did not change in 11 patients (38%). Electrical stimulation resulted in a gradual decrease in the number of urinary leakage episodes and increase in maximum cystometric capacity in first desire to void and in urinary volume.

Vaginal hysterectomy allied with Kelly-Kennedy surgery and perineal repair for the treatment of patients with a prolapsed uterus and urinary stress incontinence

PURPOSE

To evaluate patients with uterine prolapse, before and after surgical treatment, using urodynamic and bladder neck ultrasound.

MATERIAL AND METHODS

33 postmenopausal patients with uterine prolapse were submitted to vaginal hysterectomy (Mayo-Ward technique) allied with Kelly-Kennedy surgery and perineal repair. The women were divided into three groups depending on the degree of prolapse. A urodynamic examination was performed before, after 30 days and in the third month after the operation. A bladder neck ultrasound was performed before and in the third month after the operation.

RESULTS

In 23 women who lost urine preoperatively, 14 continued to show objective loss 90 days after the surgery. Ultrasound identified a significant elevation in the bladder neck during rest in groups I and II, but not in group III. There was a significant reduction in its mobility in all three groups.

CONCLUSION

Kelly-Kennedy surgery does not have any indication, even in patients with urinary stress incontinence and a prolapsed uterus who are submitted to vaginal hysterectomy.

Analysis of collagen in parametrium and vaginal apex of women with and without uterine prolapse

Our objective was to compare the amount of collagen in parametrium and vaginal apex between women with uterine prolapse at pre- and postmenopause, and in women without prolapse. The study included 22 premenopausal women without prolapse (group A), 10 premenopausal women with prolapse (group B), and 23 postmenopausal women with prolapse (group C) (total 55). Patients in group A underwent abdominal hysterectomy for uterine leiomyoma, and patients in groups B and C underwent vaginal hysterectomy. During the surgical procedure we obtained biopsies from the lateral parametrium and vaginal apex. The tissue was stained for histological analysis with picrosirius. We observed a lower amount of collagen in the parametrium of women with uterine prolapse, both in menacme and in postmenopause, than in the parametrium of women without prolapse. We observed no statistically significant difference in vaginal apex between the groups.