Craig V. Comiter

All Publications

• Improving the accuracy of prolapse and incontinence procedure epidemiology by utilizing both inpatient and outpatient data INTERNATIONAL UROGYNECOLOGY JOURNAL Elliott, C. S., Rhoads, K. F., Comiter, C. V., Chen, B., Sokol, E. R. 2013; 24 (11): 1939-1946

  Abstract

  INTRODUCTION AND HYPOTHESIS: The epidemiologic description of pelvic organ prolapse (POP) and stress urinary incontinence (SUI) procedures is documented in several large studies using national database cohorts. These studies, however, may underestimate the number of procedures performed because they only capture procedures performed in either the inpatient or outpatient settings alone. We present a complete annual description of all inpatient and outpatient surgeries for POP and SUI in California. METHODS: We reviewed a record of all inpatient and outpatient POP and SUI surgeries performed in California in 2008 using data from the Office of Statewide Health Planning (OSHPD). RESULTS: In 2008, 20,004 and 20,330 women in California underwent POP and SUI procedures, respectively. Of these, 3,134 (15.6 %) and 9,016 (44.3 %) were performed in an outpatient setting. The age-adjusted rates of POP and SUI were 1.20 and 1.20 per 1,000 US females, respectively. This correlates to 186,000 POP and 186,000 SUI procedures per year nationally. Vaginal apical suspensions were more common in those undergoing surgery as an inpatient (45.1 vs 19.4 %). The use of mesh to augment prolapse repairs was similar (22.3 % inpatient vs 19.3 % outpatient). SUI procedures performed in the outpatient setting were more likely to be performed as stand-alone procedures (82.9 vs 18.8 %, respectively). CONCLUSIONS: In California, 16 % of POP and 44 % of SUI procedures were performed in an outpatient surgical setting in 2008. Epidemiologic studies of POP and SUI should account for the fact that a substantial number of repairs are performed in the outpatient setting in order to achieve accuracy.

  View details for DOI 10.1007/s00192-013-2113-z

  View details for Web of Science ID 000325828800020

  View details for PubMedID 23640007

• To sling or not to sling at time of abdominal sacrocolpopexy: a cost-effectiveness analysis. journal of urology Richardson, M. L., Elliott, C. S., Shaw, J. G., Comiter, C. V., Chen, B., Sokol, E. R. 2013; 190 (4): 1306-1312

  Abstract

  OBJECTIVES: To compare the cost-effectiveness of three strategies for use of a mid-urethral sling (MUS) to prevent occult stress urinary incontinence (SUI) in those undergoing abdominal sacrocolpopexy (ASC). METHODS: Using decision-analysis modeling, we compared cost-effectiveness over a 1 year post-operative time period of three treatment approaches: 1) ASC alone with deferred option for MUS; 2) ASC with universal concomitant MUS; and 3) preoperative urodynamic study (UDS) for selective MUS. Using published data, we modeled probabilities of SUI after ASC with or without MUS, the predictive value of UDS to detect occult SUI, and the likelihood of complications after MUS. Costs were derived from Medicare 2010 reimbursement rates. The main outcome modeled was incremental cost effectiveness ratio (ICER) per quality-adjusted life years (QALY) gained. In addition to base-case analysis, one-way sensitivity analyses were performed. RESULTS: In our model, universally performing MUS at the time of ASC was the most cost-effective approach, with an incremental cost per QALY gained of $2867 when compared to performing ASC alone. Preoperative UDS was more costly and less effective than universally performing intraoperative MUS. The cost-effectiveness of ASC + MUS was robust to sensitivity analysis, with a cost-effectiveness ratio consistently below $20,000 per QALY. CONCLUSIONS: Universal concomitant MUS is the most cost-effective prophylaxis strategy for occult SUI in women undergoing ASC. The use of pre-operative UDS to guide MUS placement at the time of ASC is not cost-effective.

  View details for DOI 10.1016/j.juro.2013.03.046

  View details for PubMedID 23524201

• Labioplasty for hypertrophic labia minora contributing to recurrent urinary tract infections. Female pelvic medicine & reconstructive surgery Wu, J. A., Braschi, E. J., Gulminelli, P. L., Comiter, C. V. 2013; 19 (2): 121-123

  Abstract

  Reduction labioplasty for hypertrophic labia minora is often performed for aesthetic reasons by cosmetic vaginal surgeons. However, hypertrophy of the labia minora can also result in significant morbidity because it causes physical discomfort during activity and interferes with the ability to maintain local hygiene and perform intermittent self-catheterization in certain patients.We describe a case in which a commonly used technique for reduction labioplasty was performed on a patient who had difficulty performing intermittent catheterization and report on the aesthetic and functional outcomes.A linear resection labioplasty was performed in a 13-year-old girl who was having increasing difficulty performing intermittent self-catheterization because of redundant labial tissue. She was also developing frequent recurrent urinary tract infections thought to be secondary to difficulty maintaining local hygiene and reduced compliance with her intermittent catheterization regimen.An excellent cosmetic and functional result was achieved with the procedure. Comparison of preoperative and postoperative photographs demonstrates the extent of the reduction labioplasty. The patient has not had any more difficulty with catheterization or recurrent urinary tract infections in 30 months of follow-up.Reduction labioplasty is indicated for hypertrophic labia minora for more than aesthetic reasons. We describe a case in which the procedure allowed the patient to more easily perform intermittent catheterization and helped eliminate her recurrent urinary tract infections.

  View details for DOI 10.1097/SPV.0b013e31827de473

  View details for PubMedID 23442511

• The Predictive Value of a Cystocele for Concomitant Vaginal Apical Prolapse JOURNAL OF UROLOGY Elliott, C. S., Yeh, J., Comiter, C. V., Chen, B., Sokol, E. R. 2013; 189 (1): 200-203

  Abstract

  Recent studies showing a correlation between descent of the anterior and apical vaginal compartments suggest that cystoceles may recur if associated apical prolapse is not corrected. However, to date the anatomical relationship of apical prolapse with respect to cystocele has been incompletely reported. We present the predictive value of a cystocele for clinically significant vaginal apical prolapse.We retrospectively reviewed the records of all new patient visits to a urogynecology clinic in a 30-month period. Women with a point Ba value of -1 or greater (stage 2 cystocele and above) were included in analysis. Predictive values of clinically significant apical prolapse, defined as point C -3 or greater, were calculated and stratified by cystocele stage.A total of 385 women were included in study. Point Ba was the leading edge of prolapse in 83.9% of cases. The position of Ba strongly correlated with that of the vaginal apex (Spearman ρ = 0.769, p <0.001). Overall 59.7% of patients had a point C of -3 or greater. The finding of clinically significant apical prolapse increased significantly with increasing Ba values. Of patients with stage 2, 3 and 4 cystocele point C was -3 or greater in 42%, 85% and 100%, respectively.The finding of stage 2 or greater cystocele is highly suggestive of clinically significant apical vaginal descent to -3 or greater. Furthermore, as cystocele stage increases, the predictive value of apical prolapse also increases. Surgeons contemplating cystocele repair should have high suspicion for vaginal apical prolapse and consider concomitant repair.

  View details for DOI 10.1016/j.juro.2012.08.177

  View details for Web of Science ID 000312604800066

  View details for PubMedID 23174246

• Maximum Isometric Detrusor Pressure to Measure Bladder Strength in Men With Postprostatectomy Incontinence UROLOGY Elliott, C. S., Comiter, C. V. 2012; 80 (5): 1111-1115

  Abstract

  To describe the use of isovolumetric detrusor pressure (Piso) in men with postprostatectomy incontinence and compare the rates of detrusor underactivity using Piso versus other common measurements/surrogates of bladder strength.We evaluated 62 men referred to our institution during a 3-year period for workup of postprostatectomy incontinence. During videourodynamic evaluation, the maximum Piso was measured using a mechanical stop test--with the examiner gently occluding the penile urethra during volitional voiding. Statistical analysis was performed to evaluate the effect of patient variables on Piso.The mean Piso was 54.6 ± 25.4 cm H(2)O. The Piso was <50 cm H(2)O in 40%. Isometric strength did not significantly correlate with age, interval since radical prostatectomy, abdominal leak point pressure, maximal urethral closure pressure, or pad use. The bladder contractility index and other approximations of detrusor underactivity were not predictive of low isometric pressure.Detrusor underactivity is relatively common in men with postprostatectomy incontinence, with 40% demonstrating a Piso <50 cm H(2)O. Our data do suggest, however, that the use of common bladder contractility nomograms, such as the bladder contractility index, might not be appropriate in this population.

  View details for DOI 10.1016/j.urology.2012.07.025

  View details for Web of Science ID 000310566300043

  View details for PubMedID 22990061

• Editorial Comment to Bone-anchored sling using the Mini Quick Anchor Plus and polypropylene mesh to treat post-radical prostatectomy incontinence: Early experience INTERNATIONAL JOURNAL OF UROLOGY Comiter, C. V. 2012; 19 (10): 960-961

  View details for DOI 10.1111/j.1442-2042.2012.03084.x

  View details for Web of Science ID 000309067500017

  View details for PubMedID 22788535

• A New Quadratic Sling for Male Stress Incontinence: Retrograde Leak Point Pressure as a Measure of Urethral Resistance JOURNAL OF UROLOGY Comiter, C. V., Nitti, V., Elliot, C., Rhee, E. 2012; 187 (2): 563-568

  Abstract

  Objective methods are essential for evaluating post-prostatectomy incontinence. While symptom score and pad weight may be the most useful methods to evaluate preoperative vs postoperative continence, neither is useful for guiding intraoperative sling tension. The Virtue quadratic sling (Coloplast, Humlebaek, Denmark) is a new device for treating post-prostatectomy incontinence that combines a transobturator and prepubic surgical approach. We examined urethral resistance by measuring retrograde leak point pressure during key portions of the surgery.A total of 22 consecutive men who elected to undergo Virtue sling surgery were evaluated with retrograde leak point pressure before and during the surgery. Retrograde leak point pressure was measured via perfusion sphincterometry at baseline, after transobturator tensioning, after prepubic tensioning, and after transobturator and prepubic arms were secured in place.Mean patient age was 70 years. Mean baseline retrograde leak point pressure was 33.4 ± 8.8 cm water. After transobturator tensioning, mean retrograde leak point pressure increased to 43.3 ± 6.8 cm water. After prepubic tensioning mean retrograde leak point pressure was 55.8 ± 8.7, and final retrograde leak point pressure after transobturator and prepubic fixation increased to 68.8 ± 6.0 cm water. Each mean retrograde leak point pressure value was significantly higher than the preceding value.The Virtue sling provides ventral urethral elevation using a transobturator approach, and a long segment of urethral compression against the genitourinary diaphragm via a straightforward prepubic technique without the risks of bone screws or retropubic needle passage. Transobturator and prepubic components of the quadratic fixation contributed to increasing urethral resistance as measured by intraoperative retrograde leak point pressure. This quadratic technique has a potentially greater ability to provide urethral compression than does a purely perineal or transobturator sling.

  View details for DOI 10.1016/j.juro.2011.09.152

  View details for Web of Science ID 000299070400070

  View details for PubMedID 22177174

• Robot-Assisted Versus Open Sacrocolpopexy: A Cost-Minimization Analysis JOURNAL OF UROLOGY Elliott, C. S., Hsieh, M. H., Sokol, E. R., Comiter, C. V., Payne, C. K., Chen, B. 2012; 187 (2): 638-643

  Abstract

  Abdominal sacrocolpopexy is considered a standard of care operation for apical vaginal vault prolapse repair. Using outcomes at our center we evaluated whether the robotic approach to sacrocolpopexy is as cost-effective as the open approach.After obtaining institutional review board approval we performed cost-minimization analysis in a retrospective cohort of patients who underwent sacrocolpopexy at our institution between 2006 and 2010. Threshold values, that is model variable values at which the most cost effective approach crosses over to an alternative approach, were determined by testing model variables over realistic ranges using sensitivity analysis. Hospital billing data were also evaluated to confirm our findings.Operative time was similar for robotic and open surgery (226 vs 221 minutes) but postoperative length of stay differed significantly (1.0 vs 3.3 days, p <0.001). Base case analysis revealed an overall 10% cost savings for robot-assisted vs open sacrocolpopexy ($10,178 vs $11,307). Tornado analysis suggested that the number of institutional robotic cases done annually, length of stay and cost per hospitalization day in the postoperative period were the largest drivers of cost. Analysis of our hospital billing data showed a similar trend with robotic surgery costing 4.2% less than open surgery.A robot-assisted approach to sacrocolpopexy can be equally or less costly than an open approach. This depends on a sufficient institutional robotic case volume and a shorter postoperative stay for patients who undergo the robot-assisted procedure.

  View details for DOI 10.1016/j.juro.2011.09.160

  View details for Web of Science ID 000299070400102

  View details for PubMedID 22177180

• Male incontinence surgery in the 21st century: past, present, and future CURRENT OPINION IN UROLOGY Comiter, C. V. 2010; 20 (4): 302-308

  Abstract

  Surgery is the mainstay for treating postprostatectomy stress urinary incontinence. Although the artificial urinary sphincter (AUS) remains a popular treatment option, a decade worth of innovations have expanded the role of male sling surgery.AUS surgery has an approximately 80-85% success rate, regardless of the degree of incontinence. The bone-anchored male sling has a similar success rate in men with mild-to-moderate leakage, but is less efficacious in those with severe incontinence. A transobturator approach has simplified the procedure, but appears best suited for men with milder degrees of incontinence. A new quadratically fixed sling that achieves a broader area of urethral compression by combining a transobturator and suprapubic approach has recently been introduced, with the aim of greater efficacy, while maintaining the low morbidity of sling surgery.The male sling and AUS are equally efficacious for the treatment of mild-to-moderate stress urinary incontinence. The sling appears to have a lower risk of infection, erosion, and urethral atrophy. The AUS remains the most efficacious treatment for severe stress urinary incontinence and for radiated patients. Recent changes in male sling surgery may improve efficacy in men with more severe incontinence.

  View details for DOI 10.1097/MOU.0b013e328339b795

  View details for Web of Science ID 000278536500007

  View details for PubMedID 20531090

• Editorial comment. Urology Comiter, C. V. 2010; 75 (3): 532-533

  View details for DOI 10.1016/j.urology.2009.07.1273

  View details for PubMedID 20211360

• Editorial comment. Urology Comiter, C. V. 2010; 75 (2): 436-437

  View details for DOI 10.1016/j.urology.2009.08.040

  View details for PubMedID 20152501

• Chronic Sacral Nerve Stimulation Prevents Detrusor Structural and Functional Changes Associated with Bladder Outlet Obstruction-A Rat Model NEUROUROLOGY AND URODYNAMICS Comiter, C. V., Mazar, C., Phull, H., Salkini, M. 2010; 29 (5): 783-788

  Abstract

  Bladder outlet obstruction (BOO) can mediate structural and functional detrusor changes, which can lead to bothersome lower urinary tract symptoms. We investigate if sacral nerve stimulation (SNS) can prevent these structural and functional changes in a rat model of BOO.24 female Sprague-Dawley rats (250 gm) were divided into 4 groups: control (CTRL), BOO, SNS, and both (BOO/SNS). BOO was achieved by partially occluding the proximal urethra. SNS involved stimulating the S1-S4 dorsal roots with a unipolar S1 lead, 8 hours daily. Urodynamics were performed at baseline and after 6 weeks. Bladders were harvested, stained, and scored for detrusor hypertrophy and fibrosis (scale = 1-5).BOO caused an increase in mean voiding pressure (P(det) = 35 +/- 2 mmHg vs. 23 +/- 1 mmHg, p = 0.02), an increase in mean bladder capacity (C = 1230 +/- 250 microl vs. 484 +/- 60 microl, p = 0.03), and a decrease in mean volume at first non-voiding contraction (67 +/- 16 microl vs. 110 +/- 24 microl, p = 0.02) compared to CTRL. Addition of SNS neither significantly affected P(det) (30 +/- 3 mm Hg vs. 35 +/- 2 mmHg, p = 0.2), nor C (630 +/- 90 microl vs. 1230 +/- 250 microl, p = 0.06) compared to BOO, but eliminated non-voiding contractions. Detrusor hypertrophy and fibrosis were both significantly greater in BOO vs. CTRL and vs. BOO/SNS.Partial BOO caused functional and structural changes in the rat bladder. SNS in obstructed rats prevents these alterations, without adversely affecting detrusor contractility.

  View details for DOI 10.1002/nau.20820

  View details for Web of Science ID 000279299700015

  View details for PubMedID 20127841

• The effect of sildenafil citrate on bladder outlet obstruction: a mouse model BJU INTERNATIONAL Beamon, C. R., Mazar, C., Salkini, M. W., Phull, H. S., Comiter, C. V. 2009; 104 (2): 252-256

  Abstract

  To investigate if sildenafil citrate can inhibit the functional and structural changes of the detrusor in a murine model of bladder outlet obstruction (BOO). Phosphodiesterase type 5 (PDE-5) inhibitors have recently been used for treating urinary symptoms associated with prostatic obstruction, but it is unclear whether PDE-5 inhibition acts on the prostatic urethra or the bladder.In 18 male Balb/CAN mice, partial BOO was created and the mice allowed to survive for 6 weeks. Half of the mice (nine) were treated with oral sildenafil citrate daily (10 mg/kg) by oral lavage (BOO + V), and half (nine) were not (BOO). Six mice were used as sham-operated controls and received no sildenafil. The mice were assessed by urodynamics at baseline and after 6 weeks, with a measurement of volume at first uninhibited non-voiding contraction (V(DO1)), bladder capacity (BC), and detrusor pressure during void (Pdet). At 6 weeks, bladders were harvested, fixed and sectioned, and stained with haematoxylin and eosin (H&E) and trichrome stain. Detrusor muscle hypertrophy and fibrosis were evaluated on a scale of 1 (decreased) to 3 (increased), by two urologists and one pathologist unaware of the treatment group; the results were compared with those from normal controls.BOO mice had a significantly greater BC than control mice, with a mean (SD) of 153 (66) vs 58 (13) microL (P = 0.004). Treatment with sildenafil did not significantly alter BC. BOO caused an increase in Pdet compared to controls, with a mean (SD) of 25 (7) vs 12 (5) cm H2O. P(det) was not significantly different after treatment with sildenafil. The median V(DO1) as a percentage of BC was significantly lower in BOO than in control mice (20% vs 53%, P > 0.03) and increased significantly after sildenafil treatment (20% vs 44%, P = 0.04). BOO was associated with a greater bladder weight than in control mice, with a mean (SD) of 89 (32) vs 27 (6) mg (P = 0.001), which was decreased with sildenafil treatment, to 40 (14) vs 89 (32) mg (P = 0.013). BOO caused an increase in detrusor muscular hypertrophy vs control mice, with a median H&E score of 3 vs 2 (P = 0.01) and an increase in fibrosis vs control mice, with a median trichrome score of 3 vs 2 (P = 0.01). BOO + V mice had reduced muscular hypertrophy and fibrosis, with a median H&E score of 3 vs 2 (P = 0.01) and a median trichrome score of 3 vs 1 (P = 0.01).BOO mediates both functional and structural changes in the mouse bladder. Six weeks of obstruction caused an increase in BC, detrusor overactivity and voiding pressure, and mediated an increase in bladder weight, detrusor muscle hypertrophy and collagen deposition in the lamina propria and smooth muscle. Treatment with 6 weeks of oral sildenafil beginning at the time of BOO prevented the increase in detrusor overactivity without affecting voiding pressures, and prevented the increase in detrusor muscle hypertrophy and collagen deposition that otherwise occurred with BOO. It appears therefore that sildenafil citrate acts on the bladder rather than on the outlet.

  View details for DOI 10.1111/j.1464-410X.2008.08324.x

  View details for Web of Science ID 000267425900020

  View details for PubMedID 19154466

• Editorial comment. The management of postprostatectomy stress urinary incontinence. Urology Comiter, C. V. 2009; 73 (6): 1368-?

  View details for DOI 10.1016/j.urology.2008.11.056

  View details for PubMedID 19482159

• Sacral nerve stimulation to treat nonobstructive urinary retention in women. Current urology reports Comiter, C. V. 2008; 9 (5): 405-411

  Abstract

  Nonobstructive urinary retention is an uncommon finding in women that may represent a difficult management problem for urologists and patients. Pharmacotherapy and urethral dilatation are rarely successful, and clean intermittent catheterization may be cumbersome. Those patients who cannot self-catheterize may be subjected to an indwelling catheter. Sacral nerve stimulation is a minimally invasive treatment for nonobstructive urinary retention, with 10 years of data documenting its long-term safety and efficacy. This minimally invasive treatment can restore satisfactory voiding in most patients and should be a routine part of treatment for this rare but important condition.

  View details for PubMedID 18702925

• The 'ventral urethral elevation plus' sling: a novel approach to treating stress urinary incontinence in men BJU INTERNATIONAL Comiter, C. V., Rhee, E. Y. 2008; 101 (2): 187-191

  Abstract

  To evaluate the urodynamic changes after placing a novel 'ventral urethral elevation plus' (VUE+) sling (Levera, Caldera Medical, Agoura Hills, CA, USA) in a cadaveric study, and in our initial experience in two patients.In two male cadavers (A and B) the maximum urethral closure pressure (MUCP) and retrograde leak-point pressure (RLPP) were measured before and after transperineal placement of the Levera sling. A 5.5 x 7 cm sling, with two 1.5 x 22.5 cm inferior extensions and two 1.5 x 25 cm superior extensions, was placed over the bulbar urethra. The inferior extensions were passed using the transobturator approach, and the superior extensions by a prepubic approach. This procedure was offered to two men (C and D) with severe neurogenic intrinsic sphincter deficiency.The mean baseline MUCP in specimen A was 55 cmH2O and the RLPP 35 cmH2O; after placing the sling the respective values increased to 75 and 70 cmH2O. In specimen B the respective mean values were 56 and 50 cmH2O, and after placing the sling were 82 and 75 cmH2O. In patient C, the RLPP increased from 17 cmH2O before surgery to 65 cmH2O afterward, and in patient D, from 20 to 70 cmH2O. At the 12-month follow-up, there was complete resolution of urinary incontinence in both patients.The VUE+ Levera sling provides urethral compression against the perineal membrane using a straightforward pre-pubic approach, and ventral elevation and compression of the bulbous urethra using the transobturator approach, avoiding the risks associated with of bone screws and retropubic needle passage. In our initial two patients stress incontinence was cured at 1 year of follow-up. A long- term follow-up and a larger prospective study of the VUE+ sling is needed to objectively assess the efficacy of this novel procedure.

  View details for DOI 10.1111/j.1464-410X.2007.07277.x

  View details for Web of Science ID 000251764000010

  View details for PubMedID 17970788

• Surgery Insight: surgical management of postprostatectomy incontinence - the artificial urinary sphincter and male sling NATURE CLINICAL PRACTICE UROLOGY Comiter, C. V. 2007; 4 (11): 615-624

  Abstract

  Stress urinary incontinence in men is usually a result of intrinsic sphincter deficiency following prostate cancer surgery. Active conservative management with fluid restriction, medication management and pelvic floor exercises is indicated for the first 12 months. If bothersome incontinence persists, urodynamic evaluation is indicated in order to assess detrusor storage function, contractility and sphincteric integrity. Standard surgical options include urethral bulking agents, artificial urinary sphincter (AUS) and male sling. Periurethral injection of bulking agents is satisfactory in only a minority of patients, leaving AUS and male sling as the most common surgical treatments. In patients with severe urinary incontinence, AUS seems to have a higher rate of success than the male sling. Furthermore, AUS is indicated in men with detrusor hypocontractility as adequate detrusor contractility is needed to overcome the fixed resistance of the sling. In patients with milder levels of stress incontinence, the two techniques have approximately equal efficacy in the short-to-intermediate term. While current reports of the male sling are generally limited to 1-4 years' follow-up, the infection, erosion, and revision rate for the male sling seem somewhat lower than that for the AUS in appropriately chosen patients.

  View details for DOI 10.1038/ncpuro0935

  View details for Web of Science ID 000250585500011

  View details for PubMedID 17982438

• Angiotensin II plays a role in acute murine experimental autoimmune cystitis BJU INTERNATIONAL Phull, H., Salkini, M., Purves, T., Funk, J., Copeland, D., Comiter, C. V. 2007; 100 (3): 664-667

  Abstract

  To investigate whether angiotensin II (AII) receptor antagonism decreases the inflammation and oedema in acute murine experimental autoimmune cystitis (EAC), as interstitial cystitis (IC) might have an autoimmune component and AII has been implicated in autoimmune-mediated vascular congestion, oedema and scarring.Female Balb/cAN mice were divided into three treatment groups (eight in each group) that were autoimmunized with bladder homogenate to induce EAC. One group received an AII type 1 receptor (AT(1)) antagonist, one group an AII type 2 receptor (AT(2)) antagonist, and one group remained untreated (EAC). A control and sham-injected group were also included. After 10 weeks, bladders were removed, sectioned, and stained with haematoxylin and eosin.Grossly, there was no thickening or adhesions in the bladders of the control or sham-injected mice. In five of seven surviving EAC bladders, there were dense adhesions to surrounding peritoneal structures. There were also adhesions and bladder thickening in all of the AT(2) antagonist-treated mice (though in a milder form) but in only two of seven surviving AT(1) antagonist-treated mice. There was no inflammation or oedema in the sham and control groups. All the EAC bladders were inflamed, with submucosal oedema and urothelial detachment from the lamina propria. In the AT(1) antagonist-treated mice there was no inflammation or oedema. By contrast, all AT(2) antagonist-treated mice had moderate inflammation and minor detachment of the urothelium from the lamina propria.AT(1) receptor blockade ameliorated the inflammatory infiltration, submucosal oedema, and urothelial detachment associated with EAC in mice. This was achieved to a lesser extent by AT(2) receptor blockade. If some patients with IC have a pathophysiology similar to that of EAC mice, there might be potential benefit from AII receptor blockade.

  View details for DOI 10.1111/j.1464-410X.2007.07035.x

  View details for Web of Science ID 000248523000042

  View details for PubMedID 17550411

• The role of angiotensin II in stress urinary incontinence: A rat model NEUROUROLOGY AND URODYNAMICS Phull, H., Salkini, M., Escobar, C., Purves, T., Comiter, C. V. 2007; 26 (1): 81-88

  Abstract

  Pharmacological treatment for stress urinary incontinence (SUI) is limited to the use of non-selective alpha-agonists, which are often ineffective. Non-adrenergic mechanisms have also been implicated in urethral closure, including angiotensin II (Ang-II), which has been demonstrated throughout the urinary tract. We investigate the role of Ang-II in urethral tone in a rat model of SUI.Abdominal leak point pressure (ALPP) and retrograde urethral pressure profilometry (RLPP) were measured in 70 female virgin rats. Thirty rats underwent pudendal nerve injury (PNT), 30 had circumferential urethrolysis (U-Lys), and 10 had sham surgery. Rats received daily doses of Angiotensin Type 1 (AT-1) receptor inhibitor (20 mg/kg), Angiotensin Type 2 (AT-2) receptor antagonist (10 mg/kg), or Ang-II (2 mg/kg).Following U-Lys, RLPP and ALPP decreased from 21.4 +/- 2.0 and 39.2 +/- 3.3 mm Hg, to 13.1 +/- 1.5 and 21.6 +/- 1.9 mmHg, respectively (P < 0.01). After PNT, RLPP, and ALPP decreased from 21.0 +/- 1.6 and 41.9 +/- 3.0 mmHg to 13.1 +/- 1.5 and 24.7 +/- 3.3 mmHg, respectively (P < 0.01). AT-1 inhibitor caused significant decrease in RLPP and ALPP from 21.0 +/- 6.2 and 41.8 +/- 9.4 mmHg, to 12.0 +/- 3.8 and 25.6 +/- 6.6 mmHg, respectively (P < 0.01). Likewise, AT-2 treatment reduced RLPP and ALPP from 21.4 +/- 6.3 and 40.1 +/- 1.7 mmHg, to 13.5 +/- 5.7 and 31.0 +/- 7.2 mmHg, respectively (P < 0.01). Following surgery, Ang-II administration restored RLPP and ALPP to baseline presurgical values.AT-1 and AT-2 receptor inhibition significantly lowers urethral resistance, comparable to either neurogenic or urethrolytic injury. Ang-II treatment restored urethral tone in rats with intrinsic sphincter dysfunction. Ang II appears to serve a functional role in the maintenance of urethral tone and stress continence.

  View details for DOI 10.1002/nau.20339

  View details for Web of Science ID 000243487500016

  View details for PubMedID 17029249

• Surgery Insight: Management of failed sling surgery for female stress urinary incontinence NATURE CLINICAL PRACTICE UROLOGY Comiter, C. V. 2006; 3 (12): 666-674

  Abstract

  Sling surgery has replaced Burch colposuspension as the most common surgery for women with stress urinary incontinence (SUI). While incontinence surgery has become a routine part of urologic care, the management of surgical complications and recurrent incontinence can be quite difficult. It is important that the urologic surgeon is well informed about the most common complications that are associated with sling surgery, and how to best manage them. In addition, the management of recurrent incontinence following sling surgery should follow a stepwise approach, with appropriate diagnostic studies, conservative treatment if possible, and surgery if necessary. While sling surgery in the patient with urethral hypermobility is often straightforward, reoperation for recurrent incontinence can be more technically challenging. In the patient with a fixed and incompetent urethra, periurethral bulking agents, pubovaginal sling, spiral sling, or artificial urinary sphincter placement may be indicated.

  View details for DOI 10.1038/ncpuro0657

  View details for Web of Science ID 000242442500009

  View details for PubMedID 17149383

• Highlights from the combined Society of Urodynamics and Female Urology and International Society of Pelvic Neuromodulation Annual Meeting JOURNAL OF UROLOGY Lemack, G. E., Siegel, S., Comiter, C., Damaser, M., Kobashi, K., Payne, C., Rodriguez, L., Wright, E. J. 2006; 175 (5): 1852-1856

  View details for DOI 10.1016/S0022-5347(05)00976-6

  View details for Web of Science ID 000236928400073

  View details for PubMedID 16600778

• The male perineal sling - a viable alternative to the artificial urinary sphincter NATURE CLINICAL PRACTICE UROLOGY Comiter, C. V. 2006; 3 (3): 118-119

  View details for DOI 10.1038/ncpuro0429

  View details for Web of Science ID 000235845100002

  View details for PubMedID 16528266

• Complications of transvaginal silicone-coated polyester synthetic mesh sling UROLOGY Govier, F. E., Kobashi, K. C., Kuznetsov, D. D., Comiter, C., Jones, P., Dakil, S. E., James, R. 2005; 66 (4): 741-745

  Abstract

  To report a premarket multicenter trial to test the feasibility of a transvaginal silicone-coated polyester synthetic mesh sling in women with anatomic incontinence.Fifty-one patients in four centers underwent transvaginal placement of a silicone-coated polyester synthetic mesh sling (American Medical Systems) during an 8-month period. Of the 51 patients, 31 were part of a prospective institutional review board-approved feasibility trial in three centers funded by American Medical Systems (group 1) and 20 underwent implantation by a single surgeon and their data were retrospectively reviewed (group 2). The studies were done concomitantly, and all slings were fixed transvaginally with bone anchors. All patients in group 1 were followed up at 4 weeks, 6 months, and 1 year (as applicable) with repeat questionnaires, physical examinations, and pad tests.In group 1, 20 patients completed 6 months of follow-up. Ten patients (32%) required a second surgical procedure at an average of 183 days (range 68 to 343) postoperatively. Eight patients (26%) had vaginal extrusion of the mesh, one (3%) required sling lysis, and one (3%) required sling removal because of infection. In group 2, 8 patients (40%) underwent sling removal for vaginal extrusion at a mean of 160 days (range 83 to 214).Transvaginally placed silicone-coated mesh slings used for the treatment of urinary incontinence demonstrated an unacceptably high vaginal extrusion rate in this study. Once identified, this study was immediately terminated, and this product was not marketed for this application in the United States.

  View details for DOI 10.1016/j.urology.2005.04.027

  View details for Web of Science ID 000232953100010

  View details for PubMedID 16230128

• The male perineal sling: Intermediate-term results NEUROUROLOGY AND URODYNAMICS Comiter, C. V. 2005; 24 (7): 648-653

  Abstract

  In men with stress urinary incontinence (SUI) due to sphincteric incompetence, surgical options include periurethral injection of bulking agents, implantation of an artificial urinary sphincter (AUS), and sling surgery. Short-term results of the male sling have generally been favorable. We report the intermediate-term results of the bone-anchored male perineal sling with a median of 4 years and minimum of 2 years follow-up.From March 2000 to April 2003, 48 patients (average age = 68 years) underwent male sling surgery. Patients were evaluated pre-operatively and post-operatively via history, physical examination, pad score, and administration of the incontinence section of the UCLA/RAND prostate cancer index (PCI).Pre-operatively all patients rated their incontinence as severe, and used >or=3 pads daily. Median follow-up was 48 months (range = 24-60). Average pad usage decreased from 4.6 +/- 2.1 pads per day to 1.0 +/- 1.7 pads per day (P < 0.01). Median UCLA PCI incontinence score increased from 63-343 (P < 0.01). Overall, 31/48 patient (65%) were cured of their leakage (no problem, no pads), 7/48 (15%) were much improved (small problem, 1 pad), 3/48 (6%) were mildly improved (moderate problem, 2 pads daily), and 7/48 (15%) failed (big problem, >or=3 pads).Intermediate-term results for the male sling demonstrate a success rate comparable to that of the AUS (80%

  View details for DOI 10.1002/nau.20166

  View details for Web of Science ID 000233094100012

  View details for PubMedID 16167352

• Ciprofloxacin or tamsulosin in men with chronic prostatitis/chronic pelvic pain syndrome - A randomized, double-blind trial ANNALS OF INTERNAL MEDICINE Alexander, R. B., PROPERT, K. J., Schaeffer, A. J., Landis, J. R., Nickel, J. C., O'Leary, M. P., Pontari, M. A., McNaughton-Collins, M., Shoskes, D. A., Comiter, C. V., Datta, N. S., Fowler, J. E., Nadler, R. B., Zeitlin, S. I., Knauss, J. S., Wang, Y. L., Kusek, J. W., Nyberg, L. M., Litwin, M. S. 2004; 141 (8): 581-589

  Abstract

  Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) in men is principally defined by pain in the pelvic region lasting more than 3 months. No cause of the disease has been established, and therapies are empirical and mostly untested. Antimicrobial agents and alpha-adrenergic receptor blockers are frequently used.To determine whether 6-week therapy with ciprofloxacin or tamsulosin is more effective than placebo at improving symptoms in men with refractory, long-standing CP/CPPS.Randomized, double-blind trial with a 2 x 2 factorial design comparing 6 weeks of therapy with ciprofloxacin, tamsulosin, both drugs, or placebo.Urology outpatient clinics at 10 tertiary care medical centers in North America.Patients were identified from referral-based practices of urologists. One hundred ninety-six men with a National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) score of at least 15 and a mean of 6.2 years of symptoms were enrolled. Patients had received substantial previous treatment.The authors evaluated NIH-CPSI total score and subscores, patient-reported global response assessment, a generic measure of quality of life, and adverse events. Interventions: Ciprofloxacin, 500 mg twice daily; tamsulosin, 0.4 mg once daily; a combination of the 2 drugs; or placebo.The NIH-CPSI total score decreased modestly in all treatment groups. No statistically significant difference in the primary outcome was seen for ciprofloxacin versus no ciprofloxacin (P = 0.15) or tamsulosin versus no tamsulosin (P > 0.2). Treatments also did not differ significantly for any of the secondary outcomes.Treatment lasting longer than 6 weeks was not tested. Patients who had received less pretreatment may have responded differently.Ciprofloxacin and tamsulosin did not substantially reduce symptoms in men with long-standing CP/CPPS who had at least moderate symptoms.

  View details for Web of Science ID 000224652300001

  View details for PubMedID 15492337

• The male sling for stress urinary incontinence: 24-month followup with questionnaire based assessment JOURNAL OF UROLOGY Ullrich, N. F., Comiter, C. V. 2004; 172 (1): 207-209

  Abstract

  Stress urinary incontinence after prostate surgery can be a bothersome problem, adversely affecting quality of life. We performed a prospective study of the male perineal sling for the treatment of stress urinary incontinence with a minimum 1-year followup.A total of 36 patients (average age 67 years old) underwent male sling surgery. Patients underwent preoperative and postoperative evaluation for bother due to urinary incontinence using the UCLA Prostate Cancer Index urinary function section as well as pad score.Median followup was 25 months (range 12 to 42). After surgery 24 (67%) patients were pad-free, 5 (14%) used 1 pad, 4 (11%) used 2 pads and 3 (8%) continued to use 3 or more pads daily. Overall, mean pad use +/- SD decreased from 4.6 +/- 2.5 to 0.64 +/- 1.0 pads daily (p <0.001). A total of 30 (83%) patients reported a small to no bother from urine leakage after surgery, 3 (8%) considered leakage a moderate problem, while 3 (8%) continued to consider it a big problem. The median UCLA Prostate Cancer Index urinary function score was improved from 33 before surgery to 330 after surgery (p <0.001). There were no instances of erosion, infection or prolonged retention.Medium term results for the male sling demonstrate a success rate comparable to that of the artificial urinary sphincter (67% pad-free rate and 92% improvement). This technique has established a low morbidity and has not been associated with any significant complications. Longer followup will ultimately establish whether this technique represents a viable long-term alternative to artificial urinary sphincter for the treatment of bothersome stress urinary incontinence in men.

  View details for DOI 10.1097/01.ju.0000128652.99627.14

  View details for Web of Science ID 000222115700050

  View details for PubMedID 15201775

• The male sling for stress urinary incontinence: Urodynamic and subjective assessment JOURNAL OF UROLOGY Ullrich, N. F., Comiter, C. V. 2004; 172 (1): 204-206

  Abstract

  We prospectively examined whether the fixed urethral resistance of the perineal male sling for the treatment of stress incontinence causes significant bladder outlet obstruction or de novo voiding dysfunction.A total of 22 patients (average age 67 years old) were evaluated before and after surgery with videourodynamics, the self-administered UCLA Prostate Cancer Index incontinence section and pad score.Mean followup was 25 months (range 6 to 42). All patients complained of a moderate to severe problem before surgery. After surgery 16 (73%) reported a very small problem/no problem, 3 (14%) a moderate problem and 3 (14%) reported a big problem. Average pad use +/- SD decreased from 4.6 +/- 2.5 to 0.74 +/- 1.0 pads (p <0.01). Median UCLA Prostate Cancer Index incontinence score increased from 82 to 313, p <0.001. Mean retrograde leak point pressure (RLPP) increased from 30.4 +/- 15.9 to 59.9 +/- 9.7 cm water. Bladder outlet obstruction did not develop in any patients after surgery. Average maximum flow rate did not change significantly (17.7 +/- 6.5 vs 19.2 +/- 9.7 ml per second, p = 0.6). Nor was there a significant change in detrusor pressure at maximum flow rate (40.3 +/- 9.2 vs 45.8 +/- 14.7 cm water, p = 0.3). While de novo urgency or urge incontinence did not develop in any patients, 2 of 5 patients with a moderate/big leakage problem demonstrated postoperative detrusor overactivity on cystometry. Both individuals requiring more than 3 pads daily had a postoperative RLPP of less than 50 cm water.Pad use, leak point pressure and urinary incontinence scores are significantly improved after sling surgery. Fixed resistance does not lead to bladder outlet obstruction. Postoperative RLPP less than 50 cm water and urodynamic detrusor overactivity are associated with increased pad use and bother.

  View details for DOI 10.1097/01.ju.0000132146.79081.da

  View details for Web of Science ID 000222115700049

  View details for PubMedID 15201774

• Incisionless pubovaginal fascial sling using transvaginal bone anchors for the treatment of stress urinary incontinence. TheScientificWorldJournal Vasavada, S. P., Comiter, C. V., Raz, S. 2004; 4: 357-363

  Abstract

  Bladder neck suspension (BNS) for stress urinary incontinence (SUI) can have significant morbidity, including bleeding, infection and pain. In an effort to reduce this potential morbidity, we have devised a technique which provides the same suburethral support as a standard anterior vaginal wall sling (AVWS), but without a vaginal or suprapubic incision. We describe this minimally invasive technique.From April 1998 to February 1999, 85 women underwent an incisionless suburethral fascial sling procedure. A transvaginal bone drill was used to place a bone anchor loaded with #1 prolene suture into the inferior aspect of the pubic bone on either side of the urethra. A subepithelial tunnel was created at the level of the bladder neck. A 2 x 7 cm segment of cadaveric fascia lata was placed through the subepithelial tunnel. The sutures were passed through the fascia 5mm from either edge, effectively creating a 6.0 cm sling. Finally, the sutures are tied up to the pubic symphysis.Follow-up was via a self-administered questionnaire and patient interview. Recurrent SUI was noted in 2/85 (3%). New onset urge incontinence was present in 4/85 (5%). Permanent urinary retention has not occurred in either group. All procedures were performed on an outpatient basis and no operative complications occurred.Early results for the incisionless sling compare favorably with the long term results for the AVWS. This minimally invasive approach has thus far not been associated with any significant complications. Elimination of the vaginal and suprapubic incisions has not compromised efficacy, and appears to reduce the incidence of urge incontinence. Long term follow-up will establish the lasting efficacy of this novel surgical technique.

  View details for PubMedID 15349559

• High rate of vaginal extrusion of silicone-coated polyester sling UROLOGY Comiter, C. V., Colegrove, P. M. 2004; 63 (6): 1066-1070

  Abstract

  To report the results of a pilot study evaluating the suitability of silicone-coated polyester as a suburethral sling material for female stress incontinence surgery.Ten women with stress or mixed urinary incontinence were prospectively evaluated with history and physical examination, pad test, urodynamic studies, and the Incontinence-Quality of Life questionnaire. The 2 x 7-cm sling was secured with transvaginal bone anchors placed through an anterior vaginal wall incision. Patients were evaluated at 1, 6, and 12 months by history and physical examination, pad test, and the Incontinence-Quality of Life and Success Rate and Overall Patient Satisfaction questionnaires.Ten patients (mean age 62.3 years) underwent successful placement of the suburethral sling. The Incontinence-Quality of Life scores improved from a mean total score of 43.3 +/- 14.6 preoperatively to 97.7 +/- 14.4 at 1 year postoperatively (P <0.001). The Success Rate and Overall Patient Satisfaction questionnaires completed at 1 year demonstrated a mean satisfaction rating of 8.9 +/- 1.7 (scale 1 to 10), and the mean reported improvement in incontinence was 90% +/- 16.3%. The mean pad weight decreased from 103.1 +/- 33.2 g preoperatively to 1.6 +/- 1.01 g at 1 year (P <0.007). Two patients (20%) developed vaginal extrusion of the suburethral sling at 6 and 10 months. The slings were removed surgically. Both women healed without incident and reported continued continence at 1 year without additional surgical intervention.Placement of a suburethral sling using transvaginal bone anchors and silicone-coated polyester is an effective surgical treatment for stress urinary incontinence at 1 year. The high rate of vaginal extrusion in our series limits its utility.

  View details for DOI 10.1016/j.urology.2004.01.053

  View details for Web of Science ID 000222000400016

  View details for PubMedID 15183951

• Correlation among maximal urethral closure pressure, retrograde leak point pressure, and abdominal leak point pressure in men with postprostatectomy stress incontinence UROLOGY Comiter, C. V., Sullivan, M. P., Yalla, S. V. 2003; 62 (1): 75-78

  Abstract

  To assess the correlation among abdominal leak point pressure (ALPP), maximal urethral closure pressure (MUCP), and retrograde leak point pressure (RLPP) in the evaluation of men with stress urinary incontinence (SUI) after radical prostatectomy.Patients were evaluated with a self-administered questionnaire regarding pad use and with multichannel videourodynamics. The ALPP, MUCP, and RLPP were compared with each other and with the severity of SUI.The mean ALPP was 49.4 +/- 24.4 cm H(2)O. The mean MUCP was 52.0 +/- 21.1 cm H(2)O. The mean RLPP was 48.0 +/- 13.5 cm H(2)O. No statistically significant difference in the mean values of the three parameters was found. Regression analysis revealed a statistically significant correlation among the three parameters: RLPP versus MUCP, r = 0.59, P <0.005; MUCP versus ALPP, r = 0.75, P <0.0001; and RLPP versus ALPP, r = 0.79, P <0.0001. ALPP, MUCP, and RLPP were each significantly related to pad use.Intrinsic sphincter deficiency is the primary cause of SUI after radical prostatectomy. Therefore, evaluation of intrinsic sphincter function is important in the treatment of postprostatectomy SUI. In incontinent men after radical prostatectomy, with a dysfunctional bladder neck and proximal sphincter unit, the intrinsic function of this distal sphincter may be assessed equally well by evaluating the resistance to antegrade leakage, retrograde leakage, or profilometric measurement of the urethral closure pressure. RLPP and MUCP offer reliable alternatives to ALPP for the evaluation of postprostatectomy SUI.

  View details for DOI 10.1016/S0090-4295(03)00123-7

  View details for Web of Science ID 000183892600019

  View details for PubMedID 12837426

• Sacral neuromodulation for the symptomatic treatment of refractory interstitial cystitis: A prospective study JOURNAL OF UROLOGY Comiter, C. V. 2003; 169 (4): 1369-1373

  Abstract

  The efficacy of sacral neuromodulation for the treatment of symptoms in patients with refractory interstitial cystitis was evaluated.A total of 25 patients with a mean age of 47 years and refractory interstitial cystitis were prospectively evaluated with a trial of sacral nerve stimulation. Patients who demonstrated 50% improvement in frequency, nocturia, voided volume and average pain qualified for permanent sacral nerve stimulator implantation. Treatment success was measured by voiding diary, report of average pain, and response to the Interstitial Cystitis Symptom Index and Interstitial Cystitis Problem Index.Of the 25 patients 17 qualified for permanent sacral nerve stimulator implantation. At an average of 14 months followup mean daytime frequency and nocturia improved from 17.1 to 8.7 and 4.5 to 1.1, respectively (p <0.01). Mean voided volume increased from 111 to 264 ml. (p <0.01). Report of average pain decreased from 5.8 to 1.6 points on a scale of 0 to 10 (p <0.01). Interstitial Cystitis Symptom and Problem Index scores decreased from 16.5 to 6.8 and 14.5 to 5.4, respectively (p <0.01). Of the 17 patients 16 (94%) with a permanent stimulator demonstrated sustained improvement in all parameters at the last postoperative visit.Results of this prospective clinical study demonstrate that sacral neuromodulation is a safe and effective treatment for the dysfunctional voiding and pelvic pain in patients with interstitial cystitis who are refractory to other forms of treatment.

  View details for DOI 10.1097/01.ju.0000053863.96967.5a

  View details for Web of Science ID 000181639700034

  View details for PubMedID 12629364

• Endometriosis of the urinary tract UROLOGIC CLINICS OF NORTH AMERICA Comiter, C. V. 2002; 29 (3): 625-?

  Abstract

  Genitourinary endometriosis is a rare manifestation of a common disease. Ectopic endometrial tissue may extrinsically involve or intrinsically invade the bladder or ureter, and, less commonly, the urethra or kidney. Bladder involvement usually presents with irritative symptoms, whereas ureteral disease may present with asymptomatic renal failure. Therefore, a high index of suspicion is necessary, and genitourinary endometriosis should be considered in all symptomatic women with a history of cesarean delivery of other gynecologic surgery. In women beyond reproductive age, definitive surgical treatment is preferred, with removal of the ectopic tissue, relief of obstruction, and castration with or without hysterectomy. In those who desire future fertility, conservative surgery and/or hormonal therapy is often recommended.

  View details for Web of Science ID 000179417900013

  View details for PubMedID 12476526

• The male sling for stress urinary incontinence: A prospective study JOURNAL OF UROLOGY Comiter, C. V. 2002; 167 (2): 597-601

  Abstract

  This is a report of a prospective study of the male sling for treating stress urinary incontinence.A total of 21 men underwent sling surgery. There were 2 titanium screws loaded with polypropylene suture placed in each descending pubic ramus through a 3.5 cm. perineal incision at the level of the bulbar urethra. A polypropylene mesh was placed over the urethra and tied to the bone anchors, adjusting sling tension to a compression pressure of 60 cm. water. Followup was done with the incontinence section of the University of California, Los Angeles/RAND Prostate Cancer Index.Mean followup was 12 months (range 5 to 21). Overall, incontinence was cured in 16 (76%) patients, substantially improved (stress urinary incontinence very small or small problem, 1 pad daily) in 3 (14%), somewhat improved (moderate problem-2 pads) in 1 and procedure failed (no improvement) in 1 (5%). The patients with stress urinary incontinence after undergoing transurethral prostatectomy were cured, as was the individual with myelomeningocele. Of the 18 patients with stress urinary incontinence after radical prostatectomy 13 were cured, including 1 of 2 who underwent previous artificial urinary sphincter placement and 2 of 3 adjuvant radiation. There was significant improvement in each survey question, and the total score improved from a mean plus or minus standard deviation of 65 +/- 11 preoperatively to 397 +/- 29 postoperatively (p <0.001). There was no retention, infection, erosion or de novo voiding dysfunction.This minimally invasive sling surgery has not been associated with any significant complication, and early results compare favorably with artificial urinary sphincter. By compressing only the ventral urethra the risk of urethral erosion and atrophy is reduced. Prior radiation or artificial urinary sphincter does not appear to be a contraindication to sling surgery.

  View details for Web of Science ID 000173212600035

  View details for PubMedID 11792925

• Repair of enterocele and vault prolapse: transvaginal culdosuspension. Techniques in urology Comiter, C. V. 2001; 7 (2): 146-151

  Abstract

  Transvaginal culdosuspension for treatment of enterocele and vaginal vault prolapse is described. Surgical principles include high ligation of the hernia sac, obliteration of the cul-de-sac, and support of the vaginal cuff high on the levator plate. The normal vaginal axis is restored, and adequate vaginal depth is provided for normal sexual activity.One hundred four patients underwent transvaginal culdosuspension in conjunction with enterocele repair (64 patients) or vaginal hysterectomy (40 patients). Two culdosuspension sutures support the vaginal vault to the origin of the sacrouterine and cardinal ligaments, and the cul-de-sac is obliterated with two pursestring sutures.One hundred patients were followed-up for a mean of 17.3 months. Recurrent vault prolapse or enterocele occurred in four patients. Complications were rare, and there were no instances of vaginal foreshortening, urinary retention, vaginal skin necrosis, bladder perforation, or rectovaginal fistula.Transvaginal culdosuspension is a safe and effective surgery for enterocele and vaginal vault prolapse. This technique restores the normal vaginal depth and axis, resulting in a sexually functional vagina.

  View details for PubMedID 11383993

• Cystoscopic light test to aid in the differentiation of high-grade pelvic organ prolapse UROLOGY Vasavada, S. P., Comiter, C. V., Raz, S. 1999; 54 (6): 1085-1087

  Abstract

  It remains quite difficult to distinguish a high-grade cystocele from an enterocele or high rectocele on the basis of physical examination findings alone. We have employed the use of a cystoscopic light test during preoperative or intraoperative endoscopy to assist in differentiating these entities.

  View details for Web of Science ID 000084172800032

  View details for PubMedID 10604714

• Transvaginal culdosuspension: Technique and results UROLOGY Comiter, C. V., Vasavada, S. P., Raz, S. 1999; 54 (5): 819-822

  Abstract

  Numerous techniques have been described for supporting the vaginal vault after enterocele repair and hysterectomy. We describe a transvaginal culdosuspension that obliterates the cul-de-sac and supports the vaginal cuff high on the levator plate. The normal vaginal axis is restored, and adequate vaginal depth is provided for normal sexual activity.One hundred four patients, aged 48 to 90 years (mean age 71), underwent transvaginal culdosuspension in conjunction with enterocele repair (62 patients), vaginal hysterectomy (20 patients), or both (22 patients). Two culdosuspension sutures support the vaginal vault to the origin of the sacrouterine and cardinal ligaments, and the cul-de-sac is obliterated with two pursestring sutures. Concomitant prolapse was repaired in 82 patients, bladder neck suspension in 50, cystocele repair in 45, and rectocele repair in 76.One hundred patients were followed up at a mean of 17.3 months (range 6.5 to 35). Recurrence of enterocele or vault prolapse occurred in 4 patients. All patients who had preoperative stress incontinence were cured of leakage. Complications were rare, and there were no instances of vaginal foreshortening, urinary retention, vaginal skin necrosis, bladder perforation, or rectovaginal fistula.Transvaginal culdosuspension is a safe and effective procedure for treating and preventing enterocele and vaginal vault prolapse. This technique restores the normal vaginal depth and axis, resulting in a sexually functional vagina.

  View details for Web of Science ID 000083536100012

  View details for PubMedID 10565740

• Grading pelvic prolapse and pelvic floor relaxation using dynamic magnetic resonance imaging UROLOGY Comiter, C. V., Vasavada, S. P., Barbaric, Z. L., Gousse, A. E., Raz, S. 1999; 54 (3): 454-457

  Abstract

  With significant vaginal prolapse, it is often difficult to differentiate among cystocele, enterocele, and high rectocele by physical examination alone. Our group has previously demonstrated the utility of magnetic resonance imaging (MRI) for evaluating pelvic prolapse. We describe a simple objective grading system for quantifying pelvic floor relaxation and prolapse.One hundred sixty-four consecutive women presenting with pelvic pain (n = 39) or organ prolapse (n = 125) underwent dynamic MRI. The "H-line" (levator hiatus) measures the distance from the pubis to the posterior anal canal. The "M-line" (muscular pelvic floor relaxation) measures the descent of the levator plate from the pubococcygeal line. The "O" classification (organ prolapse) characterizes the degree of visceral prolapse beyond the H-line.The image acquisition time was 2.5 minutes per study. Each study cost $540. In the pain group, the H-line averaged 5.2 +/- 1.1 cm versus 7.5 +/- 1.5 cm in the prolapse group (P <0.001). The M-line averaged 1.9 +/- 1.2 cm in the pain group versus 4.1 +/- 1.5 cm in the prolapse group (P <0.001). Incidental pelvic pathologic features were commonly noted, including uterine fibroids, ovarian cysts, hydroureter, urethral diverticula, and foreign body.The HMO classification provides a straightforward and reproducible method for staging and quantifying pelvic floor relaxation and visceral prolapse. Dynamic MRI requires no patient preparation and is ideal for the objective evaluation and follow-up of patients with pelvic prolapse and pelvic floor relaxation. MRI obviates the need for cystourethrography, pelvic ultrasound, or intravenous urography and has become the study of choice at our institution for evaluating the female pelvis.

  View details for Web of Science ID 000082251800015

  View details for PubMedID 10475353

• New technique for antegrade collagen injection for post-radical prostatectomy stress urinary incontinence UROLOGY Loughlin, K. R., Comiter, C. V. 1999; 53 (2): 410-411

  Abstract

  A new modification for antegrade collagen injection into the bladder neck is described. A 16F Rusch suprapubic catheter is used to access the bladder. A 15.5F Storz cystoscope is then placed through the sheath and the collagen injection needle is then placed through the cystoscope in the usual manner. This technique permits more rapid bladder access with less bleeding and leakage of irrigation fluid than using guide wires and Amplatz dilators.

  View details for Web of Science ID 000078219700033

  View details for PubMedID 9933065

• Effusion cytology of renal cell carcinoma CANCER CYTOPATHOLOGY Renshaw, A. A., Comiter, C. V., Nappi, D., Granter, S. R. 1998; 84 (3): 148-152

  Abstract

  Effusions in patients with renal cell carcinoma are rare; the clinicopathologic features of these patients have not been described fully.All effusions from patients with renal cell carcinoma obtained between 1986 and 1997 at the study institution were reviewed.Twelve effusions from 9 patients were benign, and 8 effusions from 7 patients were malignant. Patients with sarcomatoid tumors presented early with benign effusions, and patients with papillary tumors presented later with malignant effusions. Patients with clear cell tumors were intermediate. The majority of patients who developed malignant effusions had tumors that were classified as T3 or higher (according to the American Joint Committee on Cancer) at the time of resection. Tumor cells had abundant clear to vacuolated cytoplasm, large nuclei, and prominent nucleoli. Cells from clear cell and papillary tumors could not be distinguished in effusion specimens unless papillae were present. At last follow-up 13 of 15 patients were dead of disease within 2 years of the onset of effusion (median 24 weeks; range, 1-93 weeks), including 7 of 9 patients with benign effusions.Malignant effusions due to renal cell carcinoma most commonly occur in patients with papillary and clear cell tumors. Malignant effusions from these two tumor types are difficult to distinguish unless papillae are present. Effusions associated with renal cell carcinoma confer a poor prognosis.

  View details for Web of Science ID 000074241000005

  View details for PubMedID 9678728

• Prognostic features of teratomas with malignant transformation: A clinicopathological study of 21 cases JOURNAL OF UROLOGY Comiter, C. V., Kibel, A. S., Richie, J. P., Nucci, M. R., Renshaw, A. A. 1998; 159 (3): 859-863

  Abstract

  Teratomas with malignant transformation comprise up to 6% of metastatic teratomas. The prognosis of patients with these tumors can vary considerably. We delineate factors that may be related to prognosis in a cohort of men with teratoma with malignant transformation.We analyzed pathological features, treatment, response, recurrence, time to recurrence, subsequent followup and survival for 21 patients (median age 28 years) diagnosed with teratoma with malignant transformation during a 7-year period at our institution.Malignant nongerm cell elements were present in the primary tumor in 11 cases (52%). Of 18 patients with testicular primaries 17 (94%) presented with metastatic disease. Despite aggressive treatment with surgery and chemotherapy 17 of 21 cases (81%) recurred (median time 6 months). Overall, 5 patients (24%) died of disease (median survival 23 months), 5 (24%) are alive with metastases (median followup 41 months) and 11 (52%) have no evidence of disease (median followup 50 months). Progression/recurrence was substantially greater for 2 of 2 cases with a mediastinal origin, 3 of 4 with rhabdomyosarcomatous differentiation and 5 of 6 with neural differentiation compared with the remainder of the cohort (p < 0.05).Teratomas with malignant transformation are usually metastatic at presentation, have a high recurrence rate and are more aggressive than teratomas without malignant transformation. Prognosis is especially poor for mediastinal teratomas with malignant transformation and for those with neural or rhabdomyosarcomatous differentiation. Complete surgical resection of residual or recurrent disease appears to offer the best chance for prolonged survival.

  View details for Web of Science ID 000071913700065

  View details for PubMedID 9474169

• Effect of angiotensin II on corpus cavernosum smooth muscle in relation to nitric oxide environment: in vitro studies in canines INTERNATIONAL JOURNAL OF IMPOTENCE RESEARCH Comiter, C. V., Sullivan, M. P., Yalla, S. V., Kifor, I. 1997; 9 (3): 135-140

  Abstract

  In extracavernosal vascular tissue, smooth muscle tone is modulated by a balance between angiotensin II (Ang II) and nitric oxide (NO). We hypothesized that these substances also play an important role in regulating cavernosal smooth muscle contractility. We therefore studied the in vitro effects of an Ang II receptor antagonist and a nitric oxide synthase (NOS) inhibitor on the contractile effects of Ang II, phenylephrine, and electrical field stimulation in canine corpus cavernosum. Ang II caused a dose-dependent contraction of cavernosal smooth muscle which was inhibited by the Ang II receptor antagonist and augmented by NOS inhibition. Contractions induced by phenylephrine or electrical stimulation were diminished by the Ang II receptor antagonist, and augmented by NOS inhibition. We conclude that Ang II plays an important role in modulating cavernosal smooth muscle tone, and that the contractile effect of Ang II on cavernosal tissue is modulated by the local NO environment.

  View details for Web of Science ID A1997XV62100005

  View details for PubMedID 9315490

• Urodynamic risk factors for renal dysfunction in men with obstructive and nonobstructive voiding dysfunction JOURNAL OF UROLOGY Comiter, C. V., Sullivan, M. P., Schacterle, R. S., Cohen, L. H., Yalla, S. V. 1997; 158 (1): 181-185

  Abstract

  Urodynamic investigation of men with lower urinary tract symptoms, usually attributed to benign prostatic hyperplasia, often reveals bladder outlet obstruction, detrusor instability and/or diminished vesical compliance. We investigated whether these urodynamic abnormalities alone or in combination contribute to renal dysfunction.A total of 161 men with lower urinary tract symptoms was evaluated by urodynamics, and outlet obstruction, detrusor instability and decreased compliance (30 ml./cm. water or less) were noted. Serum blood urea nitrogen (BUN) and creatinine were measured. Cases were categorized according to the urodynamic diagnosis. Mean values of serum BUN and creatinine as well as the incidence of elevated BUN and creatinine were compared among groups.Of the cohort 54 men (34%) had elevated BUN and 19 (12%) had elevated serum creatinine. No significant correlation was found between the degree of obstruction and BUN or creatinine level. Mean serum BUN and creatinine, and the incidence of abnormal laboratory tests did not significantly differ among those with outlet obstruction, detrusor instability, both conditions or neither condition. However, in patients with outlet obstruction and detrusor instability there was a significantly increased incidence of azotemia in the subgroup with diminished compliance (78%) versus the subgroup with normal compliance (36%).In men with voiding dysfunction of a nonneurogenic etiology outlet obstruction with or without detrusor instability does not appear to be a risk factor for elevated BUN and creatinine. However, when decreased bladder compliance is associated with a combination of outlet obstruction and detrusor instability, this risk is substantially increased.

  View details for Web of Science ID A1997XC69200058

  View details for PubMedID 9186351

• Retrograde leak point pressure for evaluating postradical prostatectomy incontinence UROLOGY Comiter, C. V., Sullivan, M. P., Yalla, S. V. 1997; 49 (2): 231-236

  Abstract

  To evaluate a technique of measuring the retrograde leak point pressure (RLPP) for assessing men with postradical prostatectomy stress urinary incontinence (SUI).We measured RLPP in adult men by retrograde infusion of the distal urethra while simultaneously recording intraurethral pressure. The reproducibility of this test, and its dependence on urethral infusion rate, bladder volume, and anterior urethral catheter position, were evaluated. RLPP and abdominal leak point pressure (ALPP) measurements were performed in postradical prostatectomy patients. RLPP was compared with ALPP and with severity of incontinence determined by pad usage.Repeated RLPP measurements were not significantly different and did not change with bladder volume up to half capacity or with the location of the catheter in the anterior urethra. The differences between RLPP measurements with infusion rates of 2, 4, and 8 mL/min were also not significant. Twenty-seven men were evaluated 6 to 108 months after surgery. Of these, 22 (81%) demonstrated SUI. Mean RLPP in men without SUI (79.2 +/- 14 cm H2O) was significantly higher than in men with SUI (51.9 +/- 13 cm H2O, P < 0.01). In men with SUI, ALPP and RLPP were significantly correlated, and ALPP (49.8 +/- 24 cm H2O) was not significantly different from RLPP (51.9 +/- 13 cm H2O) Pad use and RLPP were also significantly related.RLPP measurements are reproducible and simple to perform. The pressure at which leakage occurs is easily identifiable as the plateau pressure. RLPP correlates significantly with the lowest of multiple ALPP measurements in men with SUI. This technique represents a reliable urodynamic alternative for evaluating men with postradical prostatectomy SUI.

  View details for Web of Science ID A1997WH46700016

  View details for PubMedID 9037285

• Prediction of prostatic obstruction with a combination of isometric detrusor contraction pressure and maximum urinary flow rate UROLOGY Comiter, C. V., Sullivan, M. P., Schacterle, R. S., Yalla, S. V. 1996; 48 (5): 723-729

  Abstract

  Because isometric detrusor contraction pressure (Piso) increases with outlet obstruction and maximum urinary flow rate (Qmax) tends to decrease with obstruction, we hypothesize that specific criteria consisting of a combination of high Piso and low Qmax may be able to differentiate obstructive from nonobstructive voiding dysfunction better than either parameter alone.Two hundred five men with lower urinary tract symptoms underwent uroflowmetry and videourodynamics, including cystometry, continuous outlet occlusion test, and micturitional urethral pressure profilometry. Combined threshold values of Qmax of less than 12 mL/s and Piso of 100 cm H2O or greater were used to predict obstruction, whereas threshold values of Qmax of at least 12 mL/s and Piso less than 100 cm H2O were used to predict nonobstruction.Of the 205 patients, 103 (50%) were significantly obstructed and 102 (50%) were only mildly obstructed or nonobstructed. Of the total population, 151 patients (74%) were categorized by the combined flow and contractility criteria. Of the categorized patients, 141 (93%) were correctly diagnosed with regard to infravesical obstruction (sensitivity 89%, specificity 97%, positive predictive value 97%, and negative predictive value 91%).A combination of Qmax and Piso criteria can predict obstructive and nonobstructive voiding dysfunctions with high positive and negative predictive values in most patients with lower urinary tract symptoms. Combining the results of uroflowmetry and isometric tests may help to guide treatment strategies that may improve the outcome of selected therapeutic options compared with strategies based on symptoms or uroflowmetry alone. Furthermore, this approach forms a basis for interpreting various noninvasive methods that have recently been introduced for the purpose of diagnosing bladder outlet obstruction.

  View details for Web of Science ID A1996VR74800013

  View details for PubMedID 8911516

• Burned-out primary testicular cancer: Sonographic and pathological characteristics JOURNAL OF UROLOGY Comiter, C. V., Renshaw, A. A., Benson, C. B., Loughlin, K. R. 1996; 156 (1): 85-88

  Abstract

  Rarely, a testicular scar is discovered in a patient with a presumed extragonadal germ cell tumor. Of 6 patients originally diagnosed with retroperitoneal extragonadal germ cell tumors who had echogenic foci on scrotal sonography 5 had definite histological evidence of a regressed primary testicular cancer.Six men 21 to 36 years old presented with palpably normal testes and a presumed retroperitoneal extragonadal germ cell tumor. After chemotherapy each patient underwent retroperitoneal lymph node dissection and ipsilateral orchiectomy. The entire testis was submitted for histological evaluation and all calcifications were identified.Scrotal sonography revealed an echogenic focus or foci in all cases, which corresponded to intratubular hematoxyphilic bodies in 2. In 3 cases the echogenic foci were intratubular psammoma bodies close to a fibrous scar with hemosiderin deposition, 1 of which contained a focus of intratubular germ cell neoplasia. The hematoxyphilic bodies appeared larger and more intensely echogenic on sonography than the psammoma bodies. The remaining case had stromal calcifications near the rete testis.The hematoxyphilic bodies and fibrosis with hemosiderin deposits are believed to represent remnants of testicular carcinoma. Our finding of intratubular germ cell neoplasia provides further proof that testicular carcinomas regress. In 5 of 6 patients (83%) with presumed extragonadal germ cell tumors we showed definite pathological evidence of a burned-out testicular carcinoma. With a presumed retroperitoneal germ cell tumor and palpably normal testes, sonographic demonstration of an echogenic lesion in the absence of a hypoechoic mass probably represents a burned-out primary neoplasm.

  View details for Web of Science ID A1996UQ31700024

  View details for PubMedID 8648846

• Micturitional urethral pressure profilometry UROLOGIC CLINICS OF NORTH AMERICA Sullivan, M. P., Comiter, C. V., Yalla, S. V. 1996; 23 (2): 263-?

  Abstract

  The technique of micturitional urethral pressure profilometry using a trilumen catheter provides a method of assessing the dynamic behavior of the lower urinary tract during voiding. This method of evaluation is simple to perform, highly reproducible, accurate, and clinically useful not only in diagnosing the presence of outlet obstruction, but also in identifying its location and assessing its severity. The rationale for the use of this technique, the interpretation of the results, and various pressure profile configurations are discussed.

  View details for Web of Science ID A1996UL94600010

  View details for PubMedID 8659026

• Fungal bezoar and bladder rupture secondary to Candida tropicalis UROLOGY Comiter, C. V., McDonald, M., Minton, J., Yalla, S. V. 1996; 47 (3): 439-441

  Abstract

  Candidal urinary tract infections typically occur in a host with compromised immune function. Although usually associated with aerobic bacterial infections, emphysematous cystitis occasionally complicates fungal infections of the lower urinary tract, especially in diabetics. Another uncommon occurrence is formation of a "fungus ball" leading to obstructive uropathy. We present a case of bladder rupture in a patient with emphysematous cystitis and obstructing fungal bezoar caused by Candida tropicalis. Various factors predispose to fungal urinary tract infection, including diabetes mellitus, neurogenic bladder, antibiotic usage, and the presence of an indwelling urinary catheter.

  View details for Web of Science ID A1996UA32700031

  View details for PubMedID 8633419

• DETACHED CILIARY TUFTS IN THE EPIDIDYMIS - A LESSON IN APPLIED ANATOMY UROLOGY Comiter, C. V., BRUNING, C. O., Morgentaler, A. 1995; 46 (5): 740-742

  Abstract

  We report a case of detached ciliary tufts (DCTs) discovered in the aspirate from an epididymal cyst in a 30-year-old man undergoing epididymal exploration for obstructive azoospermia. The specimen was initially misdiagnosed as a parasite due to its appearance and spontaneous motion on fresh smear. Since standard urology and histology texts identify ciliated cells only in the efferent duct of the male genital tract, the source of DCTs in this patient was mysterious. However, on further review, histologic studies have demonstrated that the first portion of the epididymis represents an extension of the efferent ducts and is lined with cilia. The fact that the caput epididymis is composed of branched efferent ducts has significant implications for our understanding of congenital absence of the vas, epididymal sperm aspiration, spermatoceles, and epididymal physiology.

  View details for Web of Science ID A1995TE46600029

  View details for PubMedID 7495135

• NONPALPABLE INTRATESTICULAR MASSES DETECTED SONOGRAPHICALLY JOURNAL OF UROLOGY Comiter, C. V., Benson, C. J., CAPELOUTO, C. C., Kantoff, P., Shulman, L., Richie, J. P., Loughlin, K. R. 1995; 154 (4): 1367-1369

  Abstract

  There is controversy concerning the implications of impalpable testicular masses. We examine the sonographic findings and pathology of such tumors.Between 1985 and 1994, 3,019 scrotal ultrasound studies were performed for various indications and 15 impalpable masses were discovered.Pathological study revealed 5 seminomas, 6 nonseminomas, 2 "burned-out" tumors, 1 lipoma and 1 granuloma.Impalpable intratesticular masses are likely to be malignant. Any young man with retroperitoneal or visceral masses should undergo scrotal ultrasound. A testicular mass is likely to be the primary cancer but it may be regressed. Persistent scrotal pain may be a presentation of malignancy and should be evaluated with ultrasound.

  View details for Web of Science ID A1995RU47200028

  View details for PubMedID 7658540

• GLUCOCORTICOID-REMEDIABLE ALDOSTERONISM - A RARE HEREDITARY FORM OF ADRENOCORTICOTROPIC HORMONE-REGULATED MINERALOCORTICOID HYPERTENSION JOURNAL OF UROLOGY Comiter, C. V., CAPELOUTO, C. C., Tobin, M. S., Dluhy, R. G., Richie, J. P. 1995; 154 (2): 510-512

  View details for Web of Science ID A1995RJ05000046

  View details for PubMedID 7609119