Interstitial Cystitis and Female Sexual Dysfunction

OBJECTIVES

To use the Female Sexual Function Index (FSFI) to compare female sexual dysfunction in patients with interstitial cystitis/painful bladder syndrome (IC) with that in controls.

METHODS

Consecutive patients with IC and asymptomatic controls were tested for voiding diary voided volumes, Pelvic Pain and Urgency/Frequency Questionnaire scores, and FSFI scores.

RESULTS

Of the 97 subjects, 75 had IC and 22 were controls. The mean age was 38 and 43 years (P = 0.09), the voided volume was 165 mL and 294 mL (P <0.0001), and the Pelvic Pain and Urgency/Frequency Questionnaire score was 18 versus 3 (P <0.0001) for the IC and control groups, respectively. The total adjusted FSFI scores differed between patients with IC and the controls (20.2 +/- 9.6 versus 29.0 +/- 6.8, respectively, P <0.001). Using 26.55 as the cutpoint, 51 patients with IC (68%) had an abnormal FSFI score versus 3 controls (14%; P <0.001). Patients with IC scored worse on all domains of female sexual dysfunction than did the controls (P <0.01).

CONCLUSIONS

The results of our study have shown that female patients with IC have sexual dysfunction, including pain, more commonly than do controls.

Advances in the understanding of sress urinary incontinence and the promise of stem-cell therapy

The middle urethra and external urethral sphincter are the focus in management of stress urinary incontinence, and recent cellular-therapy research suggests a new paradigm in treatment. Cell-based therapies are most often described as using autologous multipotent stem cells procured from bone marrow in procedures that may be painful, require anesthesia, and yield low numbers of mesenchymal stem cells upon processing. In contrast, muscleand adipose-derived stem cells can be obtained easily in large quantities under local anesthesia. Instead of lifting the urethra with a sling or bulking up the urethral sphincter with collagen, we now have the potential to restore function with the use of autologous stem cells.

Lower urinary tract dysfunction due to multiple sclerosis

Multiple sclerosis (MS) is a chronic neurological disease that commonly affects lower urinary tract function. In fact, change in bladder function may be the presenting complaint in as many as 10% of patients suffering from this condition and eventually up to 80% of patients with MS will suffer bladder symptoms.

Higher urinary potassium is associated with decreased stone growth after shock wave lithotripsy

PURPOSE

We correlated serum and urinary biochemical parameters with radiological evidence of stone growth after shock wave lithotripsy.

MATERIALS AND METHODS

Biochemical parameters in serum and 24-hour urine collections of 359 patients were correlated with stone growth for 2 years after shock wave lithotripsy. Each patient underwent a minimum of 2 radiological studies at 3 and 12 months and plain abdominal x-ray at 24 months. The presence and size of stones were documented by a radiologist in blinded fashion. Stone growth was defined as measurable growth of a preexisting stone or new stone formation.

RESULTS

A total of 209 patients remained stone-free or had no existing stone growth, while stone size decreased in 30. Of the remaining 120 patients with stone growth 72 had new growth and 48 had growth of preexisting stones. Urinary excretion of potassium was significantly higher in those without than with stone growth (mean 24-hour urine collection plus or minus standard deviation 62 +/- 27 versus 54 +/- 23 mmol., p = 0.009). The only parameter significantly associated with stone growth was urinary potassium. Linear regression revealed that for each 10 unit increase in urinary potassium there was a corresponding 2 mm. decrease in stone growth (p = 0.013).

CONCLUSIONS

Our results indicate that increased urinary potassium excretion correlates with a decreased risk of stone growth up to 2 years after shock wave lithotripsy, implying that a high potassium diet may be beneficial for preventing stone growth. The effect of potassium supplementation on stone formation and growth must be investigated further.

Laparoscopic excision of urachal anomalies: a review

Technological advancements have refined laparoscopic surgery and expanded its application to include many disease processes and organs. As next-generation instruments become smaller (<5 mm), secondary benefits such as cosmesis, patient satisfaction, and decreased postoperative analgesic requirements are being realized. Urachal anomalies are rare, and their management is evolving from total radical open, to needlescopic (</= 3 mm) excision. We present a case of a 25-year-old woman with a symptomatic urachal sinus that was treated with needlescopic instruments. She was discharged within 24 hours of surgery, having had a single intramuscular injection of meperidine and an excellent cosmetic result. A review of the literature reveals that to date 10 urachal anomalies have been excised laparoscopically with no complications. This technique should become the procedure of choice for the management of urachal pathology.

Pubovaginal sling using cadaveric allograft fascia for the treatment of intrinsic sphincter deficiency

PURPOSE

Pubovaginal sling is the definitive management of female stress urinary incontinence due to intrinsic sphincter deficiency. Customarily, autologous fascia has been used, although synthetic material has its proponents. Harvesting autologous fascia at surgery is associated with postoperative discomfort, and synthetic material has a history of infection and erosion. To assess whether allograft fascia is free from these drawbacks, we retrospectively compared the outcome of women undergoing pubovaginal sling using either autologous or cadaveric allograft fascia.

MATERIALS AND METHODS

We reviewed our experience during the last 28 months with patients treated with the pubovaginal sling for intrinsic sphincter deficiency. All patients underwent preoperative video urodynamics. The outcome was assessed using the SEAPI scoring system. Special attention was devoted to local sling tolerance. Operative time and length of hospital stay were compared between patients with allograft and autograft pubovaginal sling.

RESULTS

A total of 92 women (mean age 60 years) underwent allograft (59) or autograft (33) pubovaginal sling. Preoperative parameters, such as percent of patients who had had previous incontinence surgery, mean leak point pressure and SEAPI incontinence score, were similar in both populations. Mean followup was 11.5 months (range 1 to 28) for the overall population. The SEAPI scoring system showed that patients were markedly improved, with no significant difference between the allograft and autograft groups. Allograft and autograft pubovaginal slings were equally well tolerated, and no infection or erosion was encountered. Mean operative time and hospital stay were significantly shorter when using allograft compared to autograft fascia.

CONCLUSIONS

The success rates of allograft and autograft pubovaginal sling were equally high, and no complications related to the cadaveric origin of the allograft fascia were observed. Allograft pubovaginal sling was well tolerated, and its use significantly shortened operative time and hospital stay.

Pubovaginal sling using cadaveric allograft fascia for the treatment of intrinsic sphincter deficiency

PURPOSE

Pubovaginal sling is the definitive management of female stress urinary incontinence due to intrinsic sphincter deficiency. Customarily, autologous fascia has been used, although synthetic material has its proponents. Harvesting autologous fascia at surgery is associated with postoperative discomfort, and synthetic material has a history of infection and erosion. To assess whether allograft fascia is free from these drawbacks, we retrospectively compared the outcome of women undergoing pubovaginal sling using either autologous or cadaveric allograft fascia.

MATERIALS AND METHODS

We reviewed our experience during the last 28 months with patients treated with the pubovaginal sling for intrinsic sphincter deficiency. All patients underwent preoperative video urodynamics. The outcome was assessed using the SEAPI scoring system. Special attention was devoted to local sling tolerance. Operative time and length of hospital stay were compared between patients with allograft and autograft pubovaginal sling.

RESULTS

A total of 92 women (mean age 60 years) underwent allograft (59) or autograft (33) pubovaginal sling. Preoperative parameters, such as percent of patients who had had previous incontinence surgery, mean leak point pressure and SEAPI incontinence score, were similar in both populations. Mean followup was 11.5 months (range 1 to 28) for the overall population. The SEAPI scoring system showed that patients were markedly improved, with no significant difference between the allograft and autograft groups. Allograft and autograft pubovaginal slings were equally well tolerated, and no infection or erosion was encountered. Mean operative time and hospital stay were significantly shorter when using allograft compared to autograft fascia.

CONCLUSIONS

The success rates of allograft and autograft pubovaginal sling were equally high, and no complications related to the cadaveric origin of the allograft fascia were observed. Allograft pubovaginal sling was well tolerated, and its use significantly shortened operative time and hospital stay.

Voiding dysfunction following incontinence surgery: diagnosis and treatment with retropubic or vaginal urethrolysis

PURPOSE

A retrospective analysis was done of women undergoing urethrolysis for post-cystourethropexy voiding dysfunction to identify possible predictors of outcome.

MATERIALS AND METHODS

The charts of 51 sequential women who underwent 54 urethrolysis procedures between 1986 and 1996 were reviewed. The most common presenting symptoms were irritative in 38 patients, obstructive in 31, de novo urge incontinence in 28 and persistent retention in 12. Onset was immediate after suspension in 84% of the patients. Median time from last cystourethropexy or sling to urethrolysis was 15 months (range 4 to 268). Initial evaluation consisted of multichannel video urodynamics and cystoscopy in all women. The techniques of urethrolysis were retropubic in 35 cases, vaginal in 15 or infrapubic in 4, with simultaneous repeat suspensions performed in 63%.

RESULTS

A successful outcome with complete resolution of symptoms or significant improvement was achieved in 86% (retropubic), 73% (vaginal) and 25% (infrapubic) of the cases with a median followup of 10 months. No parameter examined, namely urodynamic variables, number of previous suspensions, time from suspension to urethrolysis or surgical approach, was a statistically significant predictor of outcome.

CONCLUSIONS

Urodynamics may not show classic obstructive voiding in women who benefit from urethrolysis. Our only absolute selection criterion for offering urethrolysis is a clear temporal relationship of symptoms to cystourethropexy. Retropubic and vaginal techniques for urethrolysis provide similar results but morbidity is seemingly less with the vaginal approach. Omental or Martius fat pad interposition may be of benefit.

Favorable outcome of pubovaginal slings for geriatric women with stress incontinence

PURPOSE

Traditionally pubovaginal slings have been associated with a greater risk of immediate morbidity and prolonged voiding dysfunction compared to other stress incontinence repairs. Because elderly patients already have inherently greater perioperative risk and prevalence of innate voiding dysfunction, there is some reluctance to construct slings in this age group. We examined the outcome of pubovaginal sling in elderly women versus younger controls to determine whether this concern is justified.

MATERIALS AND METHODS

We retrospectively analyzed the outcome of 19 geriatric women older than 70 years who underwent a pubovaginal sling procedure between 1992 and 1995, and compared the findings to those of 77 younger control women with a mean followup of 22 months. All women had video urodynamically proved stress incontinence due to intrinsic sphincter deficiency and many had coexistent bladder instability symptoms. Women with neurogenic causes for incontinence were excluded from the study.

RESULTS

Stress incontinence resolved in 100% of geriatric and 97% of control women. Preoperative instability symptoms, including urge incontinence, improved in more than 50% of patients in both groups. De novo instability symptoms arose in 10% of women in each group but were generally controlled with anticholinergics. Efficient voiding resumed within a mean of 16 days in both groups.

CONCLUSIONS

The morbidity and success rates of pubovaginal sling surgery in the elderly compare favorably to those in younger women. Advanced age alone would not dissuade us from constructing a pubovaginal sling when indicated.

Treatment of complex anterior urethral stricture disease with mesh graft urethroplasty

PURPOSE

Treatment of complex anterior urethral strictures complicated by a lack of sufficient penile skin for primary flap repair has generally consisted of 2-stage scrotal inlay urethroplasty. Scrotal skin has shortcomings, most notably hair formation, diverticula and stricture recurrence from urine induced dermatitis. As an alternative, we present our results with staged mesh graft urethroplasty using split-thickness skin, which is nonhair-bearing, easier to size and seemingly less permeable to urine penetration.

MATERIALS AND METHODS

Between 1990 and 1995, 20 men underwent mesh graft urethroplasty for complex strictures, most after failed urethroplasty. Meshed split-thickness skin graft from the thigh (17 men) or full-thickness foreskin (3) was used.

RESULTS

Overall median time to closure was 5.5 months, and 6 men required revision before closure (revision of ostia in 3, chordee release in 2 and lysis of graft adhesions in 1). A successful outcome, as evidenced by retrograde urethrography and history, was achieved in 12 of 15 men (80%) with a median followup of 38 months. Five men have not undergone closure due to patient refusal (2) or because the graft is not ready to be closed (3). Of the failures 2 men had retrograde urethrographic evidence of stricture at the proximal anastomosis and 1 had recurrent stenosis of the entire neourethra by 2 years.

CONCLUSIONS

Mesh graft urethroplasty is not a panacea but it is a valuable adjunct in the treatment of complex urethral strictures, offering comparable results to and benefits over scrotal inlay procedures. In a significant percentage of cases it is a multistage rather than a 2-stage procedure.

Kock versus right colon continent urinary diversion: comparison of outcome and reoperation rate

OBJECTIVES

To compare one surgeon's sequential experience with two types of continent cutaneous diversion; namely, the Kock pouch (KP) and the right colon pouch (RCP).

METHODS

Outcomes for the final 30 KP patients seen during the period 1989 to 1992 and the initial 30 RCP patients seen between 1992 and 1995 were analyzed retrospectively. Patients differed in median age (KP 52.5, RCP 63.5 years), in number in whom malignancy was the reason for diversion (KP 18, RCP 25), and median follow-up period (KP 50, RCP 16 months).

RESULTS

No intraoperative complications or perioperative deaths occurred. Immediate postoperative complications were mild and self-limited in both groups, with the exception of 1 RCP patient who developed life-threatening hemorrhage from a ruptured splenic artery aneurysm. KP patients had a statistically higher (P < 0.05) surgical revision requirement (16 patients, 26 revisions) than RCP patients (4 patients, 4 revisions). The majority of KP revisions were for efferent limb problems. Of the 14 KP patients not requiring revision, 4 have mild incontinence not warranting surgery. Three renal units showed new mild hydronephrosis (2 KP, 1 RCP) and are being observed. Prolonged diarrhea was present in 1 patient in each group, and vitamin B12 supplementation was required in 1 KP and 2 RCP patients.

CONCLUSIONS

The markedly higher rate of surgical revision with the Kock pouch has led to our change in practice in favor of the right colon pouch for continent cutaneous urinary diversion.

Full-thickness cutaneous martius flaps: a useful technique in female reconstructive urology

The labial fat pad is a versatile adjunct to many reconstructions. In some cases, not only is healthy tissue required for interposition, but epithelium is needed to close the vaginal defect. We report on full-thickness cutaneous Martius flaps from the medial labia majora used in complex vaginal repairs.

Bladder outlet obstruction in women

While voiding dysfunction is relatively common in women, true bladder outlet obstruction is a rare condition and may be present in a misleading manner. To make an accurate diagnosis and tailor appropriate treatment, urodynamic investigation is required. However, even sophisticated urodynamic studies have limitations in predicting obstruction as a complication of anti-incontinence surgery and response to ureterolysis.

Endoscopic management of the obliterated anastomosis following radical prostatectomy

PURPOSE

We evaluated an endoscopic technique to treat the challenging problem of an obliterated anastomosis following radical prostatectomy.

MATERIALS AND METHODS

Four men with a mean 2.25 cm. obliterative defect underwent visual internal urethrotomy along a sternal guide wire passed under direct antegrade and retrograde vision. Men then performed self-dilation according to an increasing interval protocol.

RESULTS

All 4 men maintained anastomotic patency for a mean followup of 12.5 months and 1 no longer requires self-calibration. There were no complications of this procedure.

CONCLUSIONS

Endoscopic management coupled with self-dilation offers a safe, minimally invasive option for difficult, long obliterative anastomotic defects following radical prostatectomy.

New stone formation: a comparison of extracorporeal shock wave lithotripsy and percutaneous nephrolithotomy

PURPOSE

There is theoretical concern that stone recurrence rates may be higher following extracorporeal shock wave lithotripsy (ESWL) compared to other techniques because of residual stone debris.

MATERIALS AND METHODS

We documented all new stone formations in 298 consecutive patients who initially achieved a stone-free status following ESWL for renal calculi less that 2 cm in largest dimension, and compared the findings to those of 62 patients treated with percutaneous nephrolithotomy without ultrasonic fragmentation. Stone-free status was assessed by a centrally reviewed plain abdominal film and renal tomograms at 3 months. A plain abdominal film was repeated at 12 and 24 months to detect recurrence.

RESULTS

New stones formed in 22.2% of patients after ESWL and 4.2% after percutaneous nephrolithotomy at 1 year (p = 0.004), and in 34.8% versus 22.6%, respectively, at 2 years (p =0.190). Furthermore, more new stones recurred in the lower and mid calices compared to baseline location in the ESWL group (chi-square <0.0001), which was not observed in the percutaneous nephrolithotomy group.

CONCLUSIONS

Our data support a trend toward higher stone recurrence rates in ESWL treated patients, which may be due to microscopic sand particles migrating to dependent calices and acting as a nidus for new stone formation.

Magnetic resonance imaging after intraurethral collagen injected for stress urinary incontinence

PURPOSE

Magnetic resonance imaging (MRI) was performed to evaluate the results of intraurethral collagen injected stress urinary incontinence.

MATERIALS AND METHODS

A total of 32 women underwent MRI of the pelvis at a median of 12 months after the last injection. The appearance, volume and position of the intraurethral collagen were assessed by 1 radiologist blinded to the outcome, and these findings were compared to clinical data to identify predictive features of success.

RESULTS

Intraurethral collagen was easily imaged by MRI and appeared as a hyperintense focus within the wall of the urethra. Neither volume nor position of retained intraurethral collagen was predictive of clinical outcome (p= 0.80 and p= 0.32, respectively). The volume of injected intraurethral collagen strongly correlated with the retained volume in clinically successful and failed cases (Pearson's r= 0.64 and r= 0.90, respectively). No evidence of local or remote pathological conditions resulting from intraurethral collagen injection was identified.

CONCLUSIONS

The position and volume of intraurethral collagen were not predictive of clinical outcome. While MRI is not recommended fro routine investigation, it is an excellent research modality for assessing the fate of intraurethral collagen injection.