The Relationship of the In-Situ Advancing Vaginal Wall Sling to Vaginal Epithelial Inclusion Cyst

Epithelial inclusion cyst is an under recognized complication of the in-situ advancing vaginal wall sling. A 63-year-old woman with stage I pelvic organ prolapse and mixed incontinence underwent in-situ sling placement in November 1997. In February 1998 she presented with a painful recurrent inflammatory anterior vaginal wall mass. The mass was cystic and drained spontaneously four times over the period of conservative management. The patient underwent resection of a clinical and pathological vaginal epithelial inclusion cyst in September 1998. At 6-month follow-up the patient remains continent and the cyst has not reformed. The vaginal surgeon should be aware of the potential for epithelial inclusion cyst formation after in-situ sling placement, and actively search for them at postoperative examination.     

带金属网架小肠移植替代气管的实验研究

用带金属网架游离小肠移植进行犬气管替代。方法采用游离小肠段，外置金属网架，内置硅橡胶管，通过小血管吻合建立血运，替代６ｃｍ长气管。结果气管替代后动物呼吸和活动状况良好，肠管与气管吻合口愈合坚实，病理学检查示肠粘膜层萎缩变薄，吻合口处气管上皮与肠腺上皮连接，未见上度化生及爬行替代现象。结论用带金属网架的游离小肠移植为一可考虑的替代气管方法。     

Epithelial (true) splenic cysts. Pathogenesis of the mesothelial and so-called epidermoid cyst of the spleen

Nonparasitic cysts of the spleen are classified as primary or epithelial cysts if their inner surface has a cellular lining. Depending upon the pattern of the inner surface cell layer, the primary splenic cysts are divided into mesothelial or epidermoid subtypes. In order to study their pathogenesis, five epithelial splenic cysts (two with mesothelial lining, and three with foci of stratified squamous epithelium) were investigated by scanning and transmission electron microscopy and by immunohistochemistry. In places, the squamous epithelium was continuous with a flattened mesothelial layer. Furthermore, within the stratified epithelium, a continuous spectrum of cytodifferentiation from mesothelial to squamous cells was found. Thus, the epidermoid splenic cyst seems to be a variant of the mesothelial cyst with focal squamous metaplasia. Rupture of the splenic capsule with hemosiderin deposits and infoliation of the mesothelium was seen in one case, implying a traumatic genesis. In addition, stoma-like channels providing connections between the lumen of the cyst and the sinus of the adjacent splenic tissue were detected by scanning electron microscopy. As with other cystic lesions, the influx of blood cells and proteinaceous fluid from these stomata may contribute to the growth of the cysts, which are usually of considerable size when surgically removed.     

Management of vaginal erosion of polypropylene mesh slings

PURPOSE: The SPARC (American Medical Systems, Minneapolis, Minnesota) polypropylene sling has recently been introduced as an alternative delivery system to TVT (Ethicon, New Brunswick, New Jersey) tension-free vaginal tape for placement of a tension-free mid urethral sling. Erosion must always be considered a risk of synthetic materials. We present 4 cases of vaginal erosion of polypropylene mesh placed with this system and the successful conservative management done. MATERIALS AND METHODS: A total of 90 patients received a SPARC polypropylene pubovaginal sling at our institution between October 1, 2001 and October 1, 2002. During followup 3 of our patients and 1 patient with tension-free vaginal tape who was referred from elsewhere presented with vaginal exposure of the mesh. RESULTS: Two patients described persistent vaginal discharge 6 weeks postoperatively, including 1 who complained primarily of partner discomfort during sexual intercourse. Two patients were completely asymptomatic and mesh erosion was discovered at routine physical examination 6 weeks postoperatively. Pelvic examination demonstrated vaginal exposure of the mesh in all cases. Each patient was observed conservatively and 3 months postoperatively all 4 had complete spontaneous epithelialization over the mesh. None had stress incontinence, urgency or urge incontinence, all emptied the bladder to completion and all patients were completely satisfied with the procedure. CONCLUSIONS: The recent literature suggests that polypropylene mesh erosion should be treated with complete removal of the sling material. We present 4 cases of vaginal erosion of polypropylene slings that were managed conservatively with observation and resulted in complete spontaneous healing. Sling preservation with continued patient continence and satisfaction is a feasible option in those with vaginal exposure of polypropylene mesh.     

Integrity of airway epithelium is essential against obliterative airway disease in transplanted rat tracheas.

BACKGROUND: The pathogenesis of obliterative bronchiolitis after lung transplantation requires further elucidation. In this study we used rat trachea transplantation to examine the role of epithelium in the progression of obliterative airway disease. METHODS: Normal and denuded (i.e., epithelium removed) trachea grafts from Lewis (LEW) and Brown Norway (BN) rats were transplanted sub-cutaneously into LEW rats. Viable trachea epithelial cells (to recover epithelium) were seeded into the lumen of some of the denuded tracheas. Grafts were removed at different time-points between 2 days and 8 weeks after transplantation. Histologic analysis was performed to evaluate cellular infiltration of inflammatory cells, loss of epithelium, and obliteration of trachea lumen. RESULTS: Obliteration was found to occur in trachea transplants after loss of epithelium, caused by rejection in allografts or by enzymatic denudation in isografts. In these situations, fibroblasts started to proliferate and migrate into the lumen in the second week after transplantation. Obliteration could be prevented when epithelial integrity was restored by seeding epithelial cells; no obliteration occurred when denuded trachea isografts were seeded with epithelial cells, whereas non-seeded denuded tracheas were obliterated at Day 6 after transplantation. CONCLUSIONS: We conclude that integrity of airway epithelium is essential for rat trachea transplants to be safeguarded from obliterative airway disease. For clinical lung transplantation the results of our study suggest that protection of the integrity of airway epithelium may be important in preventing the development of obliterative bronchiolitis.     

Assessment of tissue-engineered stomach derived from isolated epithelium organoid units

OBJECTIVE: Isolated stomach epithelial organoid units developed on biodegradable polymers were transplanted to assess the feasibility of a tissue-engineered stomach. BACKGROUND: Despite recent advances in reconstruction techniques, total gastrectomy is still accompanied by various complications. An alternative treatment would be a tissue-engineered stomach, which replaces the mechanical and metabolic functions of a normal stomach. METHODS: Stomach epithelial organoid units isolated from neonatal rats were seeded onto biodegradable polymers. The constructs implanted into the omenta of adult rats were harvested for examination at designated times. Nine rats underwent a second operation for anastomosis. RESULTS: The constructs resulted in cyst-like formations showing vascularized tissue with neomucosa lining the lumen. The surface morphology as assessed using scanning electron microscopy was similar to that of a native stomach. Immunohistochemical staining for alpha-actin smooth muscle and gastric mucin indicated the presence of a smooth muscle layer and a well-developed gastric epithelium, respectively. The luminal surface of the anastomosed tissue-engineered stomach was well-covered with epithelium. CONCLUSIONS: Epithelium-derived stomach organoid units seeded on biodegradable polymers and transplanted into donor rats were shown to vascularize, survive, and regenerate into complex tissue resembling native stomach. Anastomosis between the units and native small intestine may have the potential to stimulate epithelial growth. This research may provide insight into new approaches to alleviate complications following total gastrectomy.     

Vaginoplasty using deepithelialized vulvar transposition flaps: the Grünberger method

BACKGROUND: One of the most important criteria indicative of the longterm success of vaginal enlargement is the absence of postoperative contracture. Numerous procedures have been developed for reconstruction of an inadequate vagina. Some are technically complex techniques (myo- and fasciocutaneous flaps) with few postoperative complications of vaginal contracture, and others implement autografts with a greater tendency of tissue contraction. STUDY DESIGN: We report here a method of vaginoplasty using deepithelialized vulvar transposition flaps to enlarge the width of narrow vaginas found mainly in cases of congenital adrenogenital syndrome-associated vaginal atresia, but also in cases of acquired vaginal atresia (surgery and radiotherapy-induced). We used deepithelialized dermis from the labia majora to construct an enlarged vaginal entrance and cavity, a technique that is easy to learn and perform. RESULTS: The healing phase of this operation is free of tissue rejection, most likely because of the close embryologic relationship of the cornified, paravaginal squamous epithelium of the labia majora and the noncornified squamous epithelial lining of the lower third of the vagina. The epithelium of the graft loses its cornified layer and becomes nonhair-bearing; its cytology and histology mimic normal vaginal epithelium. Postoperative function and sexual contentment were reported to be satisfying.CONCLUSIONS: The followups of 17 patients who underwent this operation in the last 16 years show optimal cosmetic and functional results.     

Incorporation of microporous Teflon tracheal prostheses in rabbits: evaluation of surgical aspects

Because tracheal prostheses made of nonporous silicone rubber develop granulation tissue at the anastomoses, we tested a prosthesis made of a microporous material (polytetrafluoroethylene, Teflon) to see whether this problem could be avoided and the prosthesis could be successfully incorporated (luminal side covered by connective tissue and epithelium). At various times after implantation in the cervical trachea of rabbits, the prostheses were inspected macroscopically for obstruction of the prosthesis lumen (lumen reduced by one-third or more) and microscopically for incorporation and inflammatory reaction (concentration of inflammatory cells) of the prosthesis. The prosthesis was successfully incorporated within 2-4 weeks in most rabbits without granulation tissue at the anastomoses. Two complications were infection of the prosthesis before incorporation was completed and obstruction of the lumen in the center of the prosthesis by granulation tissue or a deformed prosthesis wall. Both problems can be overcome, the first by giving an appropriate antibiotic for a longer period and the second by making a stiffer prosthesis. Thus, the microporous Teflon prosthesis is potentially useful as a tracheal prosthesis in rabbits.     

Results on function and safety of the Safyre-t, a hybrid transobturator vaginal sling for the treatment of stress urinary incontinence

AIMS: To examine the efficacy and safety of the Safyre-t vaginal sling. METHODS: 108 women with a Safyre-t were invited for a gynecological follow up examination. RESULTS: 79/108 patients showed up for an examination at 20 +/- 4 months 59.5% stated that they were subjectively dry. Vaginal sling erosion was found in 8.8% of the patients and a pre-erosive state in another 13.9%. The lateral silicone column could be palpated medial to the pubic bone in 47% of the patients indicating dislocation. 6/53 sexually active women complained of dyspareunia and one women stated that her partner had felt discomfort during sexual intercourse since her vaginal sling surgery. CONCLUSIONS: This study shows that despite high patient satisfaction and acceptable subjective continence rates, the Safyre-t was associated with a comparatively high rate of vaginal sling erosions and dislocations.     

Is modified in situ vaginal wall sling operation the treatment of choice for recurrent genuine stress incontinence?

PURPOSE: We evaluate objectively the results of a modified in situ vaginal wall sling operation for recurrent genuine stress incontinence and whether it is a substitute for the traditional sling procedure. MATERIALS AND METHODS: A total of 23 patients with urodynamically proved recurrent genuine stress urinary incontinence were recruited in this study. Patients were treated with a modified needle urethropexy technique using an island of in situ vaginal skin as a sling to support the bladder neck and urethra. Surgical outcome was evaluated subjectively and objectively at a median of 15 months. A total of 42 patients who underwent a traditional polytetrafluoroethylene sling operation served as controls. RESULTS: The cure rate of the vaginal wall sling operation was 34.8% by objective assessment, which was lower than that of the traditional sling procedure (88.1%, p <0.05). The subjective success rate demonstrated the same results (vaginal sling 60.9% versus traditional sling 92.9%, p <0.05). The risk factors for operation failure were lower maximal urethral pressure, lower urethral closing pressure, narrow vaginal capacity and previous anterior colporrhaphy or a Stamey operation (all p <0.05). In 3 cases suburethral epithelial inclusion cysts were specific complications of the operation. There was no prolonged urinary retention or urethral erosion. CONCLUSIONS: Based on our results, we do not believe that the vaginal wall sling operation should be recommended for all recurrent genuine stress urinary incontinence cases and especially not for those with factors predictive of surgical failure. Further studies are needed to investigate and clarify the possible causes of failure.     

Long-term efficacy of a vaginal sling procedure in a rat model of stress urinary incontinence

PURPOSE: We examined the long-term efficacy of a newly created vaginal sling procedure for the restoration of leak point pressure (LPP) in a rat model of stress urinary incontinence (SUI). MATERIAL AND METHODS: A total of 20 female Sprague-Dawley rats were randomly assigned to 1 of 4 groups, namely normal control, SUI plus vaginal sling, SUI plus sham sling and SUI only. SUI was created in the latter 3 groups by bilateral pudendal nerve transection (PNT). In the sling procedure a 2 x 0.3 cm strip of polypropylene mesh was placed at the mid urethral level. Animals in the SUI plus sham sling group underwent vaginal dissection only. After 5 weeks LPP was measured 4 or 5 times in each rat and the mean was determined. The Kruskal-Wallis and Wilcoxon rank sum tests were used to evaluate whether levels of measurements differed across and between groups. RESULTS: Mean LPP +/- SD in control rats was 48.8 +/- 10.2 cm H2O. PNT decreased LPP to 23.5 +/- 7.4 cm H2O. Sling placement improved LPP at 5 weeks to 35.5 +/- 2.3 cm H2O, whereas LPP in the sham sling group was 29.1 +/- 4.9 cm H2O. LPP recovery in the sling group was significantly above levels for PNT (p = 0.037). LPP in the sling group did not differ statistically from that in the control group (p = 0.11). CONCLUSIONS: The newly created vaginal sling model restores the LPP in the rat model of SUI in the long term (5 weeks). This model could be used to address research questions related to the sling procedure.     

吊带完整性对恢复大鼠SUI模型漏尿点压作用的实验研究

目的：验证剪断尿道下的吊带未消除吊带抗尿失禁作用的假说,探讨尿道吊带的无张力原则.方法：用持续阴道扩张（VD）的方法预先在40只雌性wistar大鼠建立压力性尿失禁（SUI）模型.10只接受完整的尿道吊带手术;10只植入完整的尿道吊带后,把吊带的尿道下部分剪断一半;10只植入完整的尿道吊带后,把吊带的尿道下部分完全剪断;10只接受了伪吊带手术.术后6周,所有大鼠通过预先放置的耻骨上导管测定crede手法诱导的腹腔漏尿点压（ALPP）,并测定膀胱内压.Kruskal-Wallis H检验比较数据,P〈0.05为差异有统计学意义.结果：吊带完全切断组、吊带切断一半组和吊带完整组都可同样升高ALPP,且都显著高于伪手术组的值（分别为24.9、26.7、27.9vs20.7cmH2O,P〈0.0001）.4组排尿高峰压无显著的差别,表示吊带术的各组不存在膀胱出口梗阻（BOO）.吊带完全切断组、吊带切断一半组和吊带完整组的膀胱顺应性6周后同伪手术组相比显著降低（P=0.007、0.05、0.05）.结论：吊带尿道下部分的完整性并不是吊带治疗SUI大鼠模型所必需的.然而吊带手术可以降低膀胱的顺应性.这可以解释在临床中观察到的同吊带手术有关的排尿功能障碍.     

Rapid and efficient clearance of airway tissue granulocytes through transepithelial migration

BACKGROUND: Clearance of tissue granulocytes is central to the resolution of airway inflammation. To date the focus has been on apoptotic mechanisms of cell removal and little attention has been given to alternative processes. The present study explores transepithelial migration as a mechanism of cell clearance. METHOD: Guinea pig tracheobronchial airways where eosinophils are constitutively present in the mucosal tissue were studied. A complex topical stimulus (allergen challenge) was applied and the fate of the eosinophils was determined by selective tracheobronchial lavage and histological examination of the tissue. RESULTS: Within 10 minutes of the allergen challenge, massive migration of eosinophils into the airway lumen occurred together with a reduction in tissue eosinophil numbers. Cell clearance into the lumen continued at high speed and by 30 and 60 minutes the tissue eosinophilia had been reduced by 63% and 73%, respectively. The marked transepithelial migration (estimated maximal speed 35,000 cells/min x cm2 mucosal surface) took place ubiquitously between epithelial cells without affecting epithelial integrity as assessed by transmission and scanning electron microscopy. Eosinophil apoptosis was not detected but occasional cytolytic eosinophils occurred. CONCLUSION: This study shows that luminal entry has a remarkably high capacity as a granulocyte elimination process. The data also suggest that an appropriate stimulus of transepithelial migration may be used therapeutically to increase the resolution of inflammatory conditions of airway tissues.     

Role of sling integrity in the restoration of leak point pressure in the rat vaginal sling model

PURPOSE: We tested the hypothesis that cutting the sling at its suburethral section does not cancel its anti-incontinence effect. We also examined the long-term effects of the sling on bladder function in a recently validated rat model of vaginal sling. MATERIALS AND METHODS: Stress urinary incontinence was created in 60 female Sprague-Dawley rats by the previously established method of bilateral pudendal nerve transection. Under anesthesia 20 animals received a vaginal sling, 20 received a vaginal sling in which the suburethral portion of the sling was cut immediately after placement and 20 received a sham vaginal sling. Six weeks after the procedures leak point pressure was determined and a cystometrogram was done using anesthesia in each animal via a previously implanted suprapubic catheter. Kruskal-Wallis and pairwise separate rank multiple comparison tests were performed with a significance level of 0.05. RESULTS: The cut and intact slings increased leak point pressure similarly and these values were significantly higher than that of the sham sling (24.9 and 27.9 cm H2O, respectively, vs 20.7, p <0.0001). Peak micturition pressure was not significantly different among the 3 groups, indicating absent bladder outlet obstruction in the sling groups. Bladder compliance was significantly decreased 6 weeks after placement of a cut or intact sling compared with the sham sling (p = 0.007 and 0.05, respectively). CONCLUSIONS: An intact suburethral portion is not a requirement for sling effectiveness in the rat model of stress urinary incontinence. However, the sling procedure decreases bladder compliance. This may explain the observed voiding dysfunction associated with sling procedures.     

Histologic evaluation of human cadaveric fascia lata in a rabbit vagina model

The purpose of this study was to evaluate the histologic response of human cadaveric fascia lata after vaginal implantation. Freeze-dried, gamma-irradiated cadaveric fascia lata from three lots was implanted between the rectovaginal membrane and vaginal epithelium in New Zealand white rabbits. Rabbits were killed at 2, 4, 8, and 12 weeks after implantation. At necropsy, gross findings were described and specimens for routine cultures were taken. Histologic evaluation determined graft integrity, neovascularization, inflammatory response, and host tissue incorporation. Nine rabbits were available for histologic analysis and 14 for gross and microbiologic analysis. Vaginal erosions occurred with three grafts. The remainder were adherent to the surrounding tissues. Erosion was associated with bacterial colonization of the graft. Autolysis of one graft occurred at 4 weeks. Over time, the inflammatory response decreased and neovascularization increased; by 12 weeks, the graft collagen was replaced by host collagen. Cadaveric fascia lata serves as scaffolding for host tissue incorporation with replacement by host collagen.Oral/Poster presentation at the Annual Meeting of the Society of Gynecologic Surgeons, Orlando, Florida, March 2001.     

利用假孕小鼠建立小鼠行经模型的研究

目的利用假孕小鼠建立小鼠行经模型,并与以往的小鼠行经模型做对比。方法NIH雌鼠与输精管结扎的NIH雄鼠晚间合笼交配,翌日晨见阴栓为假孕第0天。第3.5天于左侧子宫角注射25μl花生油诱导蜕膜化,右侧子宫角为对照;第5.5天切除双侧卵巢(作为0 h),分别在0、8、12、16、24、32和48 h各时点行颈椎脱臼处死小鼠,收集子宫,观察组织形态学,阴道细胞学涂片观察出血情况。结果子宫在0 h可见广泛蜕膜化;8 h上皮有部分脱落,部分蜕膜化细胞出现核固缩;12 h子宫腔上皮基本脱落,核固缩凋亡坏死的区域继续扩大;1 6 h可见蜕膜化组织崩解;24 h崩解组织剥离;32 h组织开始修复;48 h组织修复完好。血清孕酮(P)浓度在切除卵巢后8 h开始快速下降,48 h降至0 h浓度的1/7。结论利用假孕小鼠人工诱导蜕膜化后,切除双侧卵巢可以模拟子宫内膜崩解脱落和再生。     

Complications of synthetic graft materials used in suburethral sling procedures

Problems relating to the erosion of sling material, through either the vagina or the urethra, have been encountered with almost all kinds of synthetic sling materials. We present four unusual cases of women using different synthetic materials and the complications that occurred. The biopsies were examined histologically and analyzed for collagen and inflammatory reactions. Four patients who underwent suburethral slingplasty previously with different sling materials required surgical management for complications, including one intravesical Ethibond migration, vaginal mucosal mesh erosion in two patients, and one proximal urethral overcorrection with intravesical erosion. We reviewed the literature regarding the amount of mesh erosion and connective tissue reaction with synthetic materials. The efficiency of mesh removal was assessed. The four patients maintained urinary continence after urethrolysis and removal of the mesh. Fibrosis and severe inflammatory reactions were found in the connective tissue adjacent to the mesh as well as the Prolene mesh. Technically, it would be easier to remove the graft of patch sling if rejection or erosion occurs.     

Laryngeal Oncocytic Cystadenoma with Rare Location and Clinicopathological Aspects

Laryngeal oncocytic cysts and cystadenomas are uncommon and observed in 0.1–1% of laryngeal biopsy specimens. A 66-year-old male was admitted to the hospital with a hoarse voice of 6 months duration. On laryngoscopic examination, a lesion of the left anterior vocal cord was present. It was excised by direct laryngoscopy and histopathologic examination revealed a cystic cavity with papillary projections into the lumen. The epithelial lining comprised bland oncocytic epithelium. These findings are characteristic of laryngeal oncocytic cystadenoma. Endoscopic excision is curative in these lesions. Oncocytic cystadenoma is a rare, cystic neoplasm that occurs in late adulthood. It may be considered in the clinicopathologic differential diagnosis of laryngeal lesions.     

Do histologic changes in the skin-lined neovagina of male-to-female transsexuals really occur?

Controversy exists on whether or not the epidermal keratinizing squamous epithelium of skin grafts and flaps applied to line a neovagina changes histologically to a nonkeratinizing mucosal type squamous epithelium after vaginoplasty in male-to-female transsexuals. To end this discussion, the aim of this study was to objectify the short-term and long-term histologic aspect of this neovaginal epithelial lining. Biopsies were taken from the epithelium lining of the neovagina of 9 male-to-female transsexuals, from the moment of vaginoplasty up to 14 years after. These were stained with hematoxylin-eosin and periodic acid-Schiff stain for histologic comparison to normal vaginal biopsies. Because no changes that might have been induced by local influences or hormonal therapy were found, we concluded that short-term and long-term changes in the histologic aspect of inverted skin flaps do not occur after penile and scrotal skin vaginoplasty in male-to-female transsexuals.     

Selective growth of epithelial basal cells from human prostate in a three-dimensional organ culture

BACKGROUND: A three-dimensional organotypic culture method has been developed for selectively growing epithelial basal cells from human benign prostate. METHODS: Tissue fragments were cultured on sponges for several weeks and the viability of luminal and basal epithelium and cellular responses to 4,5alpha-dihydrotesterone (DHT) stimulation were studied. RESULTS: The gland tissue could be successfully maintained showing preservation of ducts and lobules as in vivo. Without DHT, a progressive hyperplasia of basal cells was observed: these cells proliferated with retention of the lumen or forming nests with squamous differentiation, lining the surface of the fragment and migrating to the underlying sponge. In contrast, secretory cells disappeared. Epithelial cells isolated from long-term cultures showed a typical basal cell-immunophenotype. DHT-treated tissues maintained a much higher percentage of luminal cells than untreated tissues. CONCLUSIONS: These systems allow the study of proliferation and differentiation of basal cells within their natural microenvironment as well as prostate pathobiology.