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Biomedical subjects

L Brubaker

Publications and source records attributed to L Brubaker.

At least 19 recordsLinked to original sources
PubMed1998

Pudendal denervation affects the structure and function of the striated, urethral sphincter in female rats.

Our aim was to examine the effects of denervation on urethral anatomy and urine voiding pattern. Rats usually void at one end of their cage, which gives a behavioral index of continence. The voiding preference for denervated rats was decreased to 88.8 + 4.7%, n = 32, P < 0.001, compared to improvements with time for unoperated (117 +/- 10%, n = 16) or sham-operated rats (105 +/- 8%, n = 5). The volume of urine or the frequency of voidings between denervated, unoperated or sham-operated rats did not differ significantly. Urethral sections were analyzed immunochemically and quantified morphometrically. Smooth muscle volume remained constant but skeletal muscle volume decreased after denervation, from 43 +/- 2% to 36 +/- 3% (P < 0.05, n = 5). Fiber diameter decreased from 14.3 +/- 1.4 microm to 8.5 +/- 0.7 microm (P < 0.005). We concluded that pudendal nerve transection in female rats causes behavioral alterations in voiding and muscular atrophy of the striated sphincter.

Animals↗
PubMed1998

Effect of preoperative voiding mechanism on success rate of autologous rectus fascia suburethral sling procedure.

OBJECTIVE: To evaluate the efficacy of the rectus fascia suburethral sling procedure and to determine whether preoperative voiding caused by the Valsalva maneuver is a risk factor for short-term objective failure. METHODS: This study is a retrospective chart review of 50 patients who underwent the suburethral sling procedure with rectus fascia at our institution between March 1994 and August 1996. All patients had genuine stress incontinence with intrinsic sphincteric deficiency or urethral hypomobility. Preoperative multichannel urodynamics were measured in all patients, and postoperative urodynamic testing was done at 3 months in 48 patients. RESULTS: Ninety-four percent of patients were cured subjectively of stress urinary incontinence at 3 months. Objective cure was found by urodynamic measurements in 73% of the 48 patients who underwent postoperative testing. There was an increased risk of objective failure in patients whose voiding preoperatively was caused by the Valsalva maneuver. Objective failure was found at 3 months in 54% of the 13 patients in the Valsalva group, compared with 17% of the 35 in the non-Valsalva group (P=.011). Patients in the Valsalva group also tended to have longer durations of postoperative catheterization than did patients in the non-Valsalva group (P=.049). CONCLUSION: The rectus fascia suburethral sling procedure appears to be an effective operation for the treatment of genuine stress incontinence in carefully selected patients. However, patients who are identified preoperatively as voiding because of the Valsalva maneuver have a higher failure rate for this procedure.

Adult↗
PubMed1997

The use of mesh in gynecologic surgery.

The aim of this review was to compare properties of the most commonly used synthetic meshes and describe their use in gynecologic procedures. An Ovid search of the English literature from 1966 to the present was carried out, together with a hand search of Index Medicus from 1950 to 1965. Articles involving the use of mesh in surgical procedures or comparative studies of the different mechanical properties of mesh are included. Overviews from urogynecologic texts and surgical texts are also included. All studies in this review consisted of retrospective case series (21 suburethral sling articles, 15 sacrocolpopexy articles, and five pelvic sling articles). No randomized prospective trials were available. Outcome variables, including cure rates and mesh-related complications, are reviewed and compared. Conclusions show that long-term success of the suburethral sling with synthetic mesh ranges from 61% to 100%, and the success rate of the abdominal sacrocolpopexies using mesh ranges from 68% to 100%. Mesh-related complications rates are frequent, with up to a 35% removal rate and 10% sinus tract formation for suburethral slings and 9% erosion rate for sacrocolpopexy. The ideal synthetic mesh material for pelvic surgery, one that induces minimal foreign-body reaction with minimal risk of infection, rejection and erosion, has yet to be developed.

Female↗
PubMed1997

Vaginal topography does not correlate well with visceral position in women with pelvic organ prolapse.

The objective was to determine whether vaginal topography accurately predicts the location of the pelvic viscera on fluoroscopy in women with pelvic organ prolapse. Eighty-nine women undergoing preoperative evaluation for reconstructive pelvic surgery at a tertiary care referral practice formed the study population. Each woman completed a comprehensive urogynecologic history and physical examination, which included a quantified (POP-Q) assessment of her vaginal topography, as described by Bump et al. In addition each woman underwent pelvic floor fluoroscopy (PFF). Visceral sites were selected which corresponded clinically to the vaginal sites measured by the POP-Q. The most dependent portion of the bladder, small intestine, rectum and urethrovesical junction was measured. Twenty-five (28%) women had stage II prolapse, 34 (38%) had stage III prolapse, and 28 (32%) had stage IV prolapse. The remaining 2 women were symptomatic, with stage I prolapse. For the entire study population there was no correlation between the fluoroscopic position of the small bowel and/or rectum and any apical or posterior wall POP-Q site (C, Ap or Bp). There was no correlation with the fluoroscopic position of the UVJ at rest or with straining and the corresponding POP-Q site (Aa). The fluoroscopic position of the most dependent portion of the bladder correlated only modestly with the upper (Ba, rho = 0.51) and lower Aa, rho = 0.68) anterior vaginal wall POP-Q sites. In women without prior surgery (n = 33) there was only modest correlation between the fluoroscopic position of the bladder and the corresponding POP-Q site (Aa, rho = 0.71). In this unoperated subpopulation there was no correlation with PFF and any other POP-Q site. In women who had undergone prior hysterectomy (n = 25) or hysterectomy with anterior and/or posterior colporrhaphy (n = 17), there was only a modest correlation of the most dependent portion of the bladder and the upper anterior vaginal wall site (Bb, rho = 0.67 and rho = 0.55, respectively). It was concluded that vaginal topography does not reliably predict the position of the associated viscera on PFF in women with primary or recurrent pelvic organ prolapse.

Female↗
PubMed1997

An alternative statistical approach for predicting prolonged catheterization after Burch colposuspension during reconstructive pelvic surgery.

Our objective was to use an alternative statistical approach to identify clinical and urodynamic predictors of prolonged catheterization following Burch colposuspension. Seventy women with genuine stress incontinence underwent Burch colposuspension with suprapubic catheter placement at Rush Presbyterian-St. Luke's Medical Center from 1 July 1992 to 1 October 1993. Patient charts were retrospectively reviewed to extract pertinent variables from their history, examination and preoperative urodynamic evaluation. The day of suprapubic catheter removal was considered the end-point 'event' for the purposes of survival analysis. This statistical model allowed us to identify preoperative clinical parameters important in determining the percentage of patients requiring catheters as a function of time. The need for defining prolonged postoperative catheterization was eliminated. Aging (P=0.01), increasing maximal urethral pressures (P=0.02) and menopausal status (P=0.02) were important in determining the percentage of patients requiring catheters as a function of time. Data from our preoperative voiding studies were not predictive of prolonged catheterization following Burch colposuspension.

Adult↗
PubMed1997

Transvaginal electrical stimulation for female urinary incontinence.

OBJECTIVE: Our purpose was to determine the objective and subjective efficacy of transvaginal electrical stimulation for treatment of common forms of urinary incontinence in women. STUDY DESIGN: A prospective, double-blind, randomized clinical trial included 121 women with either urinary incontinence caused by detrusor instability or genuine stress incontinence, or both (mixed incontinence). Participants used the assigned device for 8 weeks. Identical preintervention and postintervention assessment included multichannel urodynamic testing, quality-of-life scale, and urinary diaries. RESULTS: A total of 121 women completed this study at four North American urogynecology centers. Detrusor instability was cured (stable on provocative cystometry) in 49% of women with detrusor instability who used an active electrical device (p = 0.0004, McNemar's test), whereas there was no statistically significant change in the percentage with detrusor instability in the sham device group. There was no statistically significant difference between the preintervention and postintervention rates of genuine stress incontinence for either the active device group or the sham device group. CONCLUSION: This form of transvaginal electrical stimulation may be effective for treatment of detrusor overactivity, with or without genuine stress incontinence.

Adult↗
PubMed1996

Levator ani muscle in women with genitourinary prolapse: indirect assessment by muscle histopathology.

The objective of this study was to assess the state of innervation in levator ani muscle sites using muscle histopathology. Asymptomatic women and patients with genitourinary prolapse were included. Histopathologic analysis allows indirect assessment of a muscle's innervation. Therefore, levator ani muscle was collected in a standardized fashion during abdominal surgery and frozen in the operating room using isopentane slush cooled by liquid nitrogen. Serial sections of levator ani muscle in cross-section were studied with standard histochemical and immunohistochemical techniques. The staining patterns from these histochemical techniques allowed quantitative determination of the ratios of fiber types I, IIA, and IIB and their fiber diameters. Objective assessment of fiber type grouping was performed. The distribution of both fiber type percentage and diameter were non-parametric. Therefore, the Mann-Whitney U-test was used to analyze the data for statistical differences between the means for these variables. There was no statistical difference in levator ani muscle fiber type percentage and diameter in patients with prolapse and/or urinary incontinence when compared to asymptomatic women. Levator ani muscles have a higher proportion of slow fibers (66%) than found in other human female muscle (48%). There was no evidence for denervation/reinnervation in any of the biopsy specimens. In this study, levator ani muscle biopsies from incontinent and/or prolapse patients were neither denervated nor reinnervated.

Adult↗
PubMed1996

Clinical correlates in patients not completing a voiding diary.

Our objective was to determine whether voiding diary non-compliance was an important clinical predictor for the absence of urinary symptoms. History questionnaires and voiding diaries are mailed to all patients before initial visits. The study included 349 patients capable of filling out the history questionnaire and voiding diary prior to their initial visit. The control group (n = 261) consisted of patients who filled out both forms. The study group (n = 88) consisted of patients who filled out their history questionnaire yet left their voiding diary blank. Study variables were extracted by chart review to determine the clinical significance of non-compliance with voiding diary completion. Non-Caucasian patients were less likely to complete their diary (P = 0.008). Patients presenting for treatment of pelvic organ prolapse (no urinary symptoms) were also less likely to complete their diary (P = 0.01, OR 0.41, 0.20-0.85). These patients should be counseled about the importance of the voiding diary in validating urinary symptoms. Urodynamic diagnosis were similar in patients considering surgical correction of pelvic organ prolapse, independent of diary non-compliance.

Case-Control Studies↗
PubMed1996

Rectocele.

Rectocele formation is a complex anatomical and functional abnormality. Traditional diagnostic techniques may be augmented by quantitative physical examination and fluoroscopic assessment during defecation. Few studies of surgical outcomes have been published, but these studies suggest that anatomic correction of the rectocele does not reliably correct symptoms that have been attributed to it. A 'gold standard' for diagnosis is sorely needed.

Female↗
PubMed1995

Suburethral sling release.

BACKGROUND: The suburethral sling is an effective surgical procedure for curing genuine stress incontinence. However, a well-known complication is urinary retention. This report describes a method of modifying sling placement 6 weeks after the initial surgery to ameliorate the complication of urinary retention. CASE: A 68-year-old woman had undergone suburethral sling placement as part of her pelvic reconstructive surgery. Preoperatively, she had objective, urodynamic evidence of severe genuine stress incontinence, consistent with intrinsic sphincter deficiency. She was unable to void for 6 weeks postoperatively, at which time this procedure was offered. After an uneventful suburethral sling release, the patient had immediate return of voiding function, and symptoms resolved over the next 2 weeks. CONCLUSION: This procedure may be a useful alternative to sling removal in cases of persistent urinary retention after placement of a suburethral sling.

Aged↗
PubMed1994

Pharmacokinetics of intravaginal metronidazole gel.

The pharmacokinetics of a single 500 mg oral dose of metronidazole and 5 g of 0.75% metronidazole intravaginal gel (37.5 mg metronidazole) were compared in 12 adult volunteers in a randomized crossover manner. Serial serum samples were collected over a 48-hour period and analyzed for metronidazole and hydroxymetronidazole. Metronidazole serum concentrations after intravaginal administration were only 2% of concentrations seen with the standard 500-mg oral dose. The dose-adjusted maximum serum concentration (898 +/- 121 ng/mL vs. 237 +/- 69 ng/mL) and area under the serum concentration-time curve (9362 +/- 2873 ng * hr/mL vs. 4977 +/- 2671 ng * hr/mL) were significantly greater for the oral versus intravaginal dose of metronidazole. The time to reach maximum concentration (1.4 +/- 0.6 hr vs. 8.4 +/- 2.2 hr) was significantly shorter for the oral compared with the intravaginal dose. The mean bioavailability for the intravaginal gel was 56%. Our results show that the 0.75% gel formulation may offer the advantage of fewer systemic adverse effects compared with other formulations for the treatment of bacterial vaginosis.

Absorption↗
PubMed1993

Kegel or cut? Variations on his theme.

Pelvic floor muscle training has long been recognized as a beneficial treatment for urinary incontinence. This paper discusses the concepts of muscle grading facilitation and training. Individually designed programs, suitable for the patient's current status, are critical to success. It may be tempting to operate, but it takes a dedicated health care provider to manage incontinence nonsurgically.

Biofeedback, Psychology↗
PubMed1993

Pelvic floor evaluation with dynamic fluoroscopy.

OBJECTIVE: To evaluate dynamic fluoroscopy of the pelvic floor for the study of women with pelvic floor disorders. METHODS: In a prospective, observational study in a tertiary care referral center, 30 women with prolapse beyond the introitus underwent comprehensive fluoroscopic imaging of the pelvic floor. RESULTS: Dynamic fluoroscopy of the pelvic floor was technically possible in all patients. Whereas the physical examinations appeared relatively similar in these patients, the fluoroscopic examination revealed distinct differences. Of the 30 women, 25 had a cystocele, 25 had a rectocele, and 26 had an enterocele. Eleven patients had their surgical plan modified accordingly. Pelvic floor fluoroscopy is not a test for urinary or fecal incontinence. However, incontinence was demonstrated objectively in ten women (eight with fecal incontinence, two with urinary incontinence). CONCLUSION: Dynamic fluoroscopy of the pelvic floor is a useful adjunct in the clinical evaluation of women with prolapse. This imaging can be used to individualize the operative approach to prolapse. It is superior to clinical examination for the detection of enterocele formation. In addition, it provides information regarding the emptying function of the rectocele, which is not obtainable on physical examination.

Adult↗
PubMed1990

Cystometry, urethrocystometry, and videocystourethrography.

A number of techniques are available to detect detrusor overactivity. The test best suited to an individual investigator is a function of expertise, frequency of use, cost, availability, and ability to interpret the testing method. Even the simplest methods may be used effectively when the examiner understands the test and its limitations. Many investigators will find it useful to use more than one of these techniques. It is in the patient's best interest for her physician to maintain a reasonable index of suspicion and continue testing rather than submit her to inappropriate therapy based on an inadequate evaluation.

Cystoscopy↗
PubMed1990

Nonsurgical treatment of detrusor overactivity in postmenopausal women.

Detrusor overactivity with subsequent urge incontinence becomes increasingly more prevalent as women age. Because of that, most women treated for detrusor instability and hyperreflexia are postmenopausal and are not always good candidates for the same treatments given to their younger counterparts. Nonsurgical treatments of detrusor overactivity are available to postmenopausal women.

Aged↗
PubMed1988

The effect of retropubic urethropexy on detrusor stability.

A group of 86 women with genuine stress incontinence who underwent retropubic urethropexy were evaluated with both pre- and postoperative urodynamics. Twenty of these 86 women (23.3%) also had unstable detrusors preoperatively. Eleven of these 20 women (55%) had stable detrusors after retropubic urethropexy. Five of the 66 patients (7.6%) who had stable detrusors preoperatively were found to have unstable detrusors on postoperative urethrocystometry. The overall cure rate for women with detrusor instability and genuine stress incontinence was only 30%. Analysis of symptoms, previous anti-incontinence procedures, age, parity, and cystometric parameters revealed no differences between those women who had stable detrusors after retropubic urethropexy and those who remained unstable. Similarly, patients whose bladders became unstable after retropubic urethropexy could not be distinguished from those who remained stable. Patients undergoing retropubic urethropexy should understand the possibility that the operation may cause urinary incontinence due to detrusor instability even if it cures their genuine stress incontinence, and that if they have both genuine stress incontinence and detrusor instability, their chances for an operative cure of both conditions are low.

Adult↗