PURPOSE Despite the good long-term results of transurethral resection of the prostate (TURP), intraoperative blood loss and TUR syndrome produce morbidity. Thus, TURP is still considered invasive therapy. Many minor invasive alternative treatment modalities have been developed in recent years. MATERIAL AND METHODS To minimize the risk of bleeding, we have improved on the high-frequency technology. The output signals of commercially available high-frequency generators were modulated such that each cut results in an efficient coagulation zone in the tissue with excellent cutting quality. RESULTS Laboratory and in vitro studies using porcine kidneys as well as clinical trials showed good cutting characteristics accompanied by a significant reduction of bleeding. As a result, blood transfusions were less necessary, TUR syndrome occurred less often, the indwelling catheter could be removed earlier in the postoperative period, and hospitalization time was reduced. CONCLUSIONS We believe that this improved high-frequency technology, termed coagulating intermittent cutting, results in blood-sparing tissue resection and reduction of morbidity.
PURPOSE Over the past few years, there has been increasing interest in using male slings for postprostatectomy incontinence (PPI). Currently, three different forms of the male sling has been described: one using synthetic materials and two using human fascia or dermis. This article will give a historical perspective on the male sling and describe the surgical techniques and early results using two different types of male slings using fascia or dermis. MATERIALS AND METHODS From 1997 to 1999, nine patients with PPI underwent a bladder neck sling procedure using a combined perineal and abdominal approach. All patients had a suprapubic incision to expose the rectus muscle and to place a suprapubic tube. Since 1999, we have used a wide cadaveric fascial or dermal sling placed at the proximal bulbar urethra. Using an entirely perineal approach, the sling ends are fixated to the inferior pubic rami using bone anchors. RESULTS Of 9 patients with bladder neck slings, 6 are dry, 1 is significantly improved, and 2 have failed, at a mean follow-up of 13 months. For the perineal male sling, 26 (45%) of 58 patients were completely dry, and overall 47 (81%) of 58 were significantly improved or were dry at a mean 6 months postoperatively. Neither group had significant complications. CONCLUSIONS Both male slings appear to be safe and effective procedures for treating PPI; however, longer follow-up and additional experience are needed to determine their true role in the treatment of PPI.
PURPOSE:The aim of this study was to assess retrospectively the influence of prostate size and the effect of isotope selection on implant quality in patients undergoing transperineal ultrasound-guided permanent prostate brachytherapy. PATIENTS AND METHODS:Two hundred forty-eight consecutive patients without prior transurethral resection of the prostate gland underwent permanent seed implantation using either iodine 125 or palladium 103 as monotherapy or a boost following moderate doses of external-beam radiation therapy from January 1998 through November 1999. Postimplant dosimetry was obtained on day 0 using thin slice computed tomography (CT) scans. Dosimetric quality was reported in terms of the following parameters: D90, V100, V150, and V200, where D90 is defined as the minimum dose covering 90% of the prostate volume, and V100, V150, and V200 are defined as the percentage volume of the prostate receiving at least 100%, 150%, and 200% of the prescribed minimal peripheral dose (mPD), respectively. In addition, the urethral dose was evaluated. Preimplant prostate size was divided into the following categories: <20, 20-30, 30-40, 40-50, and >50 cm3. Prostate volume was determined via transrectal ultrasound volumetric study. In addition, within each of the five size categories, the effect of isotope on implant quality was evaluated. RESULTS:No statistically significant volume dependence in D90, V100, or urethral doses was discerned, whereas V150 and V200 were volume dependent. Between isotopes, the following differences in dosimetric quality were statistically significant: V100, V150, V200, and mean and medial urethral dose. 125I implants had higher values of V100 (95% vs. 94%, p = .004) and urethral dose (118% vs. 110% of mPD, p < .001), and 103Pd implants had higher V150 and V200 (57% vs. 51% and 31% vs. 22%, respectively). Only the isotopic differences in V200 persisted for all the volumetric subgroups. There was no significant overall volume dependence based on neoadjuvant hormone use or nonuse for any of the quality parameters analyzed. CONCLUSIONS:The most important indicators of the quality of dosimetric coverage, V100 and D90, were not dependent on preimplant prostate volume or use of neoadjuvant hormones. The mean, median, and maximum urethral doses also showed no dependence on prostate size. Although there were isotopic differences in day 0 dosimetric parameters following permanent prostate brachytherapy, we do not consider the magnitude of any of these differences to be clinically significant.
PURPOSE:The aim of this study was to evaluate the 2-year clinical outcome of patients who underwent holmium laser resection of the prostate (HoLRP) for management of benign prostatic hyperplasia (BPH).MATERIALS AND METHODS:All patients who underwent HoLRP before October 1995 were contacted by mail. Each patient completed an American Urological Association (AUA) symptom score index, a questionnaire, and a urinary flow rate. The questionnaire was used to evaluate the frequency of complications, incontinence, recatheterization, and patient satisfaction.RESULTS:Two hundred twelve patients were contacted and 168 responded. Of these, 100 patients successfully completed all three investigations and had all preoperative information available. Mean length of follow-up was 27.5 months (range 24 to 34 months). Mean peak urinary flow was 21.6 mL/s (range 6 to 34 mL/s), mean voided volume was 348 mL (range 146 to 1,387 mL), and mean AUA symptom score index was 6.8 (range 0 to 27). Eighty-eight percent of patients stated they would have HoLRP again for management of their BPH. The perioperative recatheterization rate was 9%. Reoperation rate with a minimum of 2 years of follow-up was 5%; three patients required a bladder neck incision and two patients required a revision HoLRP. Urethral strictures occurred in 4% of patients, and 1% of patients had persistent incontinence requiring pads.CONCLUSIONS:Medium-term clinical results of HoLRP confirm that patient satisfaction is excellent, with complication rates similar to those historically reported for transurethral resection of the prostate (TURP). The HoLRP technique is an effective and durable surgical alternative to standard TURP.
In spite of the high and lasting efficiency of transurethral prostatectomy, intraoperative blood loss results in increased morbidity in this procedure. This led to the development of many alternative treatment modalities in the last years. To minimize the risk of bleeding, we improved the high-frequency technology in several steps. To achieve this, the output signals of commercially available high-frequency generators were modulated to the effect that each cut results in an efficient coagulation zone in the tissue at excellent cutting quality. Laboratory and in vitro studies using porcine kidneys as well as clinical trials showed good cutting characteristics accompanied by a significant reduction of bleeding. As a result, blood transfusions were less necessary, the transurethral catheter could be removed earlier in the postoperative period, and hospitalization time was significantly reduced. In conclusion, the improved high-frequency technology in form of the "coagulating intermittent cutting" results in a blood-sparing tissue resection with a consecutive reduction of morbidity.
PURPOSE:Periurethral bulking agents continue to be used as a minimally invasive alternative for management of stress urinary incontinence in men and women. Agents and delivery techniques will be evaluated and compared.MATERIALS AND METHODS:The only agents currently approved by the United States Food and Drug Administration (FDA) include glutaraldehyde cross-linked collagen, autologous fat, and carbon bead/carrier gel technology. Several other agents are undergoing FDA trial evaluation. These agents differ in material characteristics (particle size, viscosity) that, in some cases, produce different immediate and delayed tissue responses or reactions.RESULTS:Initial subjective cure rates with collagen are acceptable, but the majority of women require reinjection. The risk of allergic phenomena complicates collagen use. Carbon-based material appears to parallel collagen in durability, with the significant advantage of a nonimmunogenic response within host tissues. Autologous fat injection achieves early results similar to those with collagen, but is limited by resorption and fibrous replacement as well as local discomfort associated with harvesting procedures. Experience with newer agents is limited. Patient characteristics also influence response to injectable agents.CONCLUSIONS:Injectable agent materials and delivery techniques continue to evolve. The optimal material is yet to be defined.
PURPOSE:Salvage cystoprostatectomy has evolved as a safe and potentially curative treatment option for patients with radiation recurrent bladder cancer. Although orthotopic bladder replacement remains the preferred form of urinary diversion, there is minimal information about its role in salvage cystectomy series. We describe our limited experience in this regard.MATERIAL AND METHODS:We evaluated the operative characteristics and outcome of two patients with muscle invasive transitional cell carcinoma (TCC) of the urinary bladder after failed high-dose radiation therapy (mean 6,490 cGy). Both patients underwent salvage cystoprostatectomy with Studer-type ileal neobladder reconstruction. Existing literature on the topic is reviewed.RESULTS:Final histopathology showed pT3 N0 M0 TCC urinary bladder with no recent evidence of tumor recurrence. There was no mortality or major perioperative complication. Mean surgery time was 590 minutes, and mean blood loss was 1,600 mL, with 3.5 U of packed cell transfusion per patient. Mean length of stay was 15 days. Postoperative complications included urinary tract infection in both cases. Prolonged urinary leakage, metabolic derangements, and loose stools were seen in one case. At a mean follow-up of 17 months, both patients have well-preserved upper tracts, normal renal function, good capacity neobladders, and satisfactory postvoid emptying. Both patients are fully continent.CONCLUSIONS:Salvage cystoprostatectomy with orthotopic bladder replacement is a safe and effective management option in a select group of radiation recurrent bladder cancer patients.
Incontinence is a frequent complication of continent cutaneous urinary diversion that usually requires surgical intervention for correction. We report a novel nonsurgical therapy for reservoir incontinence in a woman who underwent anterior pelvic exenteration with formation of an Indiana pouch urinary diversion for treatment of adenocarcinoma of the urethra. When she subsequently developed urinary incontinence that was only partially responsive to anticholinergic therapy, stomal continence was restored by using a disposable urethral occlusion device.
PURPOSE:The aim of this study was to prospectively assess the outcome in men treated with temporary catheter drainage and tamsulosin after an episode of acute urinary retention (AUR).MATERIALS AND METHODS:Thirty-three consecutive men with AUR were treated with tamsulosin 0.4 mg daily for at least 4 days before a trial of voiding. Those men who were able to void adequately continued taking tamsulosin and were evaluated at 2-week and 3-month follow-up. After 3 months, additional follow-up was obtained at regular intervals as determined by the treating physician.RESULTS:Median follow-up was 6.5 months. Mean urine volume at the time of initial bladder drainage was 790 mL. Eighty-eight percent (29/33) of men were able to void initially. Transurethral prostatectomy or intermittent catheterization were necessary in 9 (27%) of 33 patients during the follow-up period. A poor quality-of-life score on the initial International Prostate Symptom Score (p = .038) and a high postvoid residual volume 2 weeks after catheter removal (p = .013) correlated with failure of medical therapy. Patients with AUR after nonurologic surgery had a significantly better outcome than those with AUR that did not occur postoperatively. Mean symptom score, quality-of-life score, and postvoid residual urine volume were 12.9, 2.7, and 111 mL, respectively, at 2-week follow-up and were 11.9, 2.8, and 61.7 mL, respectively, at 3-month follow-up. Mean peak urinary flow rate at 3 months was 7.7 mL/s.CONCLUSIONS:Tamsulosin appears to be helpful in the management of men with AUR. The majority of men were able to avoid surgery after temporary catheter drainage.
PURPOSE:The aim of this study was to test the effectiveness of a modified Foley catheter for improving the results of hypospadias repair by decreasing the incidence of obstruction.MATERIALS AND METHODS:Seventy-two patients (age 3 to 21 years) with variable types of hypospadias were treated. Bladder drainage was performed by urethral catheter insertion. The patients were divided equally into two groups of 36 patients each, according to the type of catheter used. In the first group of patients, a Foley catheter was inserted; in the second group, a modified Foley catheter (hole-end catheter) was introduced for urine drainage.RESULTS:Fourteen patients (19.4%) required secondary surgical repair: 8 (22.2%) in the first group and 6 (16.7%) in the second group. The rate of complications was lower in the second group than in the first group (25% and 50%, respectively). In the first group, 4 patients (11.1%) had urethral catheter obstruction: one was relieved by catheter flushing using sterile normal saline and three by suprapubic diversion. In the second group, urine retention was recorded in 2 patients (5.5%) and relieved by saline wash.CONCLUSION:The hole-end catheter provides better bladder drainage with the ability to easily dislodge precipitations.
PURPOSE:This study was designed to compare the prevalence of prostatic bacterial growth between circumcised and uncircumcised males and determine whether the lack of circumcision results in a change in the incidence of bacterial seeding following prostate needle biopsy.MATERIALS AND METHODS:Forty-six men (21 circumcised and 25 uncircumcised) undergoing ultrasound and biopsy to rule out prostate cancer were evaluated with questionnaires regarding previous history of urinary tract infection (UTI), any symptoms suggestive of UTI, and obstructive voiding symptoms. None of the patients received preprocedure antibiotics. Preprocedure and postprocedure urine samples, prostate biopsy core, and postprocedure blood samples were obtained for culture. After the cultures were obtained, patients received oral antibiotics.RESULTS:Patient characteristics between circumcised and uncircumcised patients were similar in terms of age, prostate-specific antigen level, voiding symptoms, history of UTI, prostate biopsy technique, and incidence of prostate cancer. The prevalence of preprocedure bacteriuria was slightly higher in the uncircumcised men (14 [56%] of 25 patients) vs. the circumcised men (8/21 [38%] patients), although this was not statistically significant (r = .2, p = .1). The prevalence of postprocedure bacteriuria was significantly higher (p = .04) in the uncircumcised men (12/25 [48%] patients) vs. the circumcised men (4/21 [19%] patients). No correlation was found between circumcision status and incidence of bacterial colonization in the prostate tissue. A statistically significant difference (p = .003) was found between the lack of circumcision and postprocedure bacteremia.CONCLUSIONS:Circumcision status does not effect the prevalence of bacterial growth in the urine and the prostate tissue. Uncircumcised men have a higher incidence of bacteriuria and bacteremia following prostate needle biopsies.
Urethral obstruction following surgical treatment of stress incontinence can result in a wide spectrum of symptoms ranging from mild urgency to complete retention at its most extreme. Management of these symptoms can be challenging and requires a careful history, pelvic examination, and urodynamics in some instances. In patients refractory to medications or conservative measures, urethrolysis is commonly used to treat the underlying outlet obstruction. The selection of which urethrolysis technique to use can be difficult, as many different methods have been described. In many cases, the choice of technique can be tailored to the original procedure(s) that caused the obstruction. Multiple urethrolysis procedures using a transvaginal approach have been described. One type involves perforation of the endopelvic fascia through a lateral approach. This urethrolysis usually is successful in treating obstruction after needle suspensions and pubovaginal slings, whereas retropubic procedures such as a Marshall-Marchetti-Krantz (MMK) or Burch procedure may require an anterior urethrolysis using a suprameatal approach. In cases where a Burch or MMK was performed and a sling subsequently placed, a combined lateral and anterior approach may be needed to treat the obstruction. In certain cases, a suprapubic approach may be required when the vaginal anatomy was drastically altered or a prior transvaginal urethrolysis failed. Using a urethrolysis technique tailored to the procedure that caused the obstruction, most cases of iatrogenic urethral obstruction should be treatable and result in resumption of normal voiding without producing stress urinary incontinence.
Isolated crural venous leak is an uncommon cause of erectile dysfunction. Recent data have suggested that ligation of the crura in men with this condition may result in significant improvement in erectile function. This report outlines the criteria for patient selection and the technique we use to accomplish crural ligation.
PURPOSE:Renal ultrasound changes after pediatric pyeloplasty were reported recently in the literature, mainly on unstented pyeloplasties. We evaluated the time to improvement or resolution of hydronephrosis in pediatric patients who underwent double-J stented pyeloplasty for ureteropelvic junction (UPJ) obstruction and compared our results to unstented pyeloplasties.MATERIALS AND METHODS:Ultrasonic grading of hydronephrosis after double-J stented pyeloplasty was performed according to the Society for Fetal Urology criteria at intervals of 0 to 3. 3 to 6, 6 to 12, and greater than 12 months postoperatively. Twenty-six pyeloplasties met all criteria for inclusion. The median patient age was 4 months.RESULTS:Of the 26 pyeloplasties studied, 18 kidneys had grade 4, 7 grade 3, and I grade 2 hydronephrosis. Twenty-two percent of kidneys with grade 4 hydronephrosis had resolution of pyelocaliectasis at the 0- to 3-month ultrasound examination; all of these kidneys had the stents removed prior to being studied. No patient with improvement of hydronephrosis worsened on subsequent examinations. All but three patients improved over 1-year follow-up: 11 (42%) to grade 0, 5 (19.2%) to grade 1, 6 (23%) to grade 2, and 1 (3.8%) to grade 3. The average final grade was 1.56 for grade 4 and 0.57 for grade 3 hydronephrosis. This represented more rapid improvement than unstented pyeloplasties. Average indwelling time for double-J stent was 52 days.CONCLUSIONS:Improvement and sometimes resolution of hydronephrosis after internal double-J stented pyeloplasty for UPJ obstruction is rapid and can occur within the first 3 months postoperatively. One year postoperatively, the majority of renal units have grade 2 hydronephrosis or less. We recommend the use of indwelling double-J ureteral stents in all pediatric patients undergoing dismembered pyeloplasty for UPJ obstruction to allow for more rapid improvement and possible resolution ofpyelocaliectasis. Further comparison of stented vs. unstented pyeloplasty is needed.
PURPOSE:Refractory genitourinary pain is a common but difficult condition to treat. Examples of chronic genitourinary pain include orchalgia, interstitial cystitis, pain after bladder suspension surgery, nonbacterial prostatitis, and genital pain related to lumbosacral neuropathy. We report our experience with oral gabapentin treatment for this condition. Gabapentin is an anticonvulsant with unclear but therapeutic effects on neurologic pain.MATERIALS AND METHODS:Twenty-one patients referred with refractory genitourinary pain were treated with oral gabapentin. There were 9 men and 12 women. In the male patients, the location of pain was testicle (4), bladder (2), penis (1), or prostate (2). In female patients, the pain was located in the urethra (4), bladder (6), vulva (1), or vagina (1). The dose of gabapentin was titrated from 300 up to 2,100 mg/day. Subjective pain severity and 10-cm visual pain scale was used before and 6 months after therapy.RESULTS:The mean dose of gabapentin was 1,200 mg/day (range 300-2,100 mg). Ten of 21 patients reported subjective improvement of their pain. The remaining patients did not perceive any improvement. Gabapentin was well tolerated; only 4 patients dropped out due to side effects. The most common adverse effects were dizziness and drowsiness. Five of 8 patients with interstitial cystitis reported improvement.CONCLUSIONS:Although only 10 of 21 patients improved with gabapentin, this cohort included only patients with refractory genitourinary pain that failed a wide range of prior treatments. Gabapentin belongs in the armaterium of the urologist who treats genitourinary pain.
We describe a new type of pubovaginal sling that uses autologous fascia and minimizes the discomfort of harvest. The harvest is technically easy. The results are comparable to those of other slings previously described.
Posterior vaginal wall laxity is one manifestation of pelvic organ prolapse in the female. Recognition and repair of the inherent anatomical defects present in this condition are essential in order to ensure a satisfactory surgical result.A successful operation for posterior vaginal wall prolapse will often involve repair of three discreet abnormalities in support of the posterior vaginal wall, including the pelvic floor, posterior vaginal wall fascia, and perineal musculature. An overaggressive repair is to be assiduously avoided as this can lead to excessive narrowing of the vaginal canal and considerable postoperative symptoms including dyspareunia.Durable restoration of anatomical support can be achieved in >80% of cases. Functional results in symptomatic patients undergoing posterior vaginal wall prolapse repair do not appear to be as successful in some areas.Successful surgical repair of posterior vaginal wall prolapse requires a thorough understanding of the anatomy and pathophysiology involved in this condition. A careful anatomical dissection and reconstruction will result in successful anatomical repair in the majority of patients with minimal morbidity.
PURPOSE:Lack of mucosal regrowth on denuded bowel segments is considered a prerequisite for successful grafting of cultured urothelial cells for bladder augmentation. This study was designed to establish a technique for clean and complete de-epithelialization of the intestinal mucosa.MATERIALS AND METHODS:A segment of the small bowel was isolated in six microminipigs. The isolated segment was detubularized and the submucosa injected with HEPES-buffered saline, elevating the mucosa from the underlying tissue and allowing removal with ease. One portion was resected and, along with a portion of the removed mucosa and a sample of the full-thickness bowel, submitted for histologic evaluation. Another portion of the bowel segment remained denuded while the final denuded segment was covered with polyglactin mesh. After 3 days, 1 week, and 3 weeks, specimens from each of the bowel segments were collected for histologic assessment. Immunoperoxidase labeling was performed to confirm the presence or absence of mucosal regrowth.RESULTS:All intestinal segments showed no mucosal regrowth at the 3-day, 1-week, and 3-week incubation periods. Minimal reaction between the denuded bowel segment and the mesh was evident in all of the pigs.CONCLUSIONS:In the porcine model, intestinal mucosa can be removed completely using submucosal injection. This technique may be useful in future clinical studies involving bladder augmentation using denuded bowel.
PURPOSE:Midurethral synthetic sling procedures for treatment of stress urinary incontinence (SUI) are gaining increased attention from surgeons specializing in female pelvic reconstructive techniques seeking successful patient outcomes through reproducible simplicity. This report describes the procedural steps and methods used to maximize the potential for successful outcomes using techniques of midurethral synthetic sling placement. Reported complications and surgical outcomes are reviewed with respect to patient selection and minimizing the potential for morbidity and mortality as long-term clinical experience is accumulated.MATERIALS AND METHODS:Tension-free vaginal or transvaginal tape (TVT) and the recently introduced percutaneous vaginal tape (PVT) are two new procedural choices for placement of synthetic sling material at the midurethra. Both procedures use sling material composed of polypropylene mesh, a nonabsorbable synthetic material, placed at the level of the midurethra via an antegrade (PVT, using a percutaneous ligature carrier) suprapubic approach or retrograde (TVT, using vaginal trocars) vaginal approach. Patient selection, procedural techniques, and methods described are based on observations obtained or reported from clinical experience. Outcomes and complications for TVT are derived from a literature review of all published articles in Index Medicus from 1996 to 2000.RESULTS:The experience with TVT for the last 5 years is encouraging. At 3-year follow-up for TVT, reported cure rates for SUI range from 80% to 95%. A multitude of worldwide reports on PVT with shorter follow-up support the findings of the TVT experience. Reproducible findings with midurethral synthetic slings are the short operative times recorded for the sling procedure, ease of technical performance, minimal patient discomfort, and a high rate of early return of normal voiding function. The rate of complications such as obstructive voiding or de novo instability (0-15%) and urinary retention necessitating a secondary procedure (2-4%) appear to be equal to the rates of contemporary competing technologies and procedures for treatment of SUI.CONCLUSIONS:Preliminary reports and the experience at our institution suggest that the techniques of midurethral synthetic sling placement of TVT and PVT are reproducible, easy to master, and minimally invasive with respect to tissue handling. Although complications with all anti-incontinence procedures exist, understanding the anatomical considerations and methodology of these unique procedures should minimize patient morbidity, avoid patient mortality, and produce a high rate of durable success.
PURPOSE:Interstitial laser therapy (ILT) was performed without discontinuing warfarin anticoagulation therapy in eight patients (mean international normalized ratio 2.8 +/- 0.8) with benign prostatic hyperplasia. Three patients were in urinary retention and had failed voiding trials. Five had severe symptoms (mean American Urological Association symptom score 22 +/- 7) and had failed medical therapy.MATERIALS AND METHODS:Interstitial laser therapy was performed using the Indigo model 830e LaserOptic Treatment System with the patient under local anesthesia. Mean operative time was 25 minutes and mean total laser energy was 6,785 J.RESULTS:After surgery, spontaneous voiding was achieved by 7 of the 8 patients at 1 week and by all 8 patients at 3 weeks. At 3-month follow-up, mean American Urological Association symptom score was 13 +/- 5, and mean peak urinary flow rate had increased to 12.2 +/- 3.2 mL/s from 8.8 mL/s (excluding retention) before surgery. Interstitial diode laser therapy appears to be a safe and effective technique for treatment of benign prostatic hyperplasia in the fully anticoagulated patient.
