A method for intraoperative adjustment of sling tension: prevention of outlet obstruction during vaginal wall sling

OBJECTIVES

To describe a simple, yet effective method of adjusting intraoperative tension on the suspending sutures of a vaginal wall sling placed for treatment of stress urinary incontinence (SUI) in the female patient.

METHODS

A cystoscope sheath is placed per urethra and inclined to approximately 20 degrees to 30 degrees relative to horizontal. The suspension sutures are tied down directly onto the rectus fascia but do not indent it. The sheath should easily rotate in the vertical plane within the urethral lumen, maintaining elastic mobility as the sutures are tied.

RESULTS

On review of the first 160 patients who have undergone vaginal wall sling using this technique of tension adjustment, no patient has had unexpected permanent urinary retention. Preoperative urgency incontinence has remained in 10 patients (less than 7%) postoperatively; 11 patients (6.8%) have had recurrent SUI during follow-up.

CONCLUSIONS

Proper adjustment of suture tension during performance of a sling procedure for SUI is critical in preventing urethral obstruction. The technique described is simple, objective, reproducible, and highly effective.

Transurethral biopsy of the prostate for persistently elevated or increasing prostate specific antigen following multiple negative transrectal biopsies

PURPOSE

Treatment of the patient with persistently elevated prostate specific antigen (PSA) levels after pathologically negative transrectal or manually directed prostate needle biopsy is unclear. We retrospectively evaluated the use of transurethral biopsy of the prostate as an adjunctive study for the diagnosis of prostate cancer in these patients.

MATERIALS AND METHODS

From January 1993 through February 1996, 71 patients underwent transurethral biopsy in conjunction with repeat prostatic needle biopsy for a persistently elevated PSA (greater than 4 ng./ml.) after previously negative needle biopsy. All patients had at least 1 previous ultrasound guided sextant prostatic needle biopsy (mean 1.85, range 1 to 7) with or without manually directed biopsies. Following negative prostatic needle biopsy these patients subsequently underwent a minimum of a 4-quadrant transurethral sampling of the prostatic fossa followed by repeat sextant prostatic needle biopsy. A subset of patients underwent sampling of the anterior prostatic tissue or transition zone using transrectal ultrasound guided prostatic needle biopsy at transurethral biopsy.

RESULTS

Of the 71 patients with elevated PSA (mean 16.2 ng./ml., range 4.2 to 171) 17 (24%) had prostate cancer on the repeat prostatic needle biopsy. Both patients who had prostate cancer on the transurethral biopsy specimens also had prostate cancer on the repeat prostatic needle biopsy specimens. A total of 68 patients had benign prostatic tissue and 1 had high grade prostatic intraepithelial neoplasia on transurethral biopsy specimens. Of 19 patients with high grade prostatic intraepithelial neoplasia on the initial prostatic needle biopsy, transurethral biopsy specimens revealed no prostate cancer or prostatic intraepithelial neoplasia. Repeat prostatic needle biopsy in these patients with high grade prostatic intraepithelial neoplasia revealed prostate cancer in 6 and high grade prostatic intraepithelial neoplasia in 4.

CONCLUSIONS

In patients with persistently elevated or increasing serum PSA after a previously negative prostatic needle biopsy, transurethral biopsy is not a useful adjunct in diagnosing prostate cancer. In this high risk group of patients transurethral biopsy adds little or no diagnostic value to prostatic needle biopsy even in those with high grade prostatic intraepithelial neoplasia.

Strategy for repeat biopsy of patients with prostatic intraepithelial neoplasia detected by prostate needle biopsy

PURPOSE

We evaluated the strategy for repeat biopsy of patients with prostatic intraepithelial neoplasia without concurrent carcinoma detected on prostate needle biopsy.

MATERIALS AND METHODS

Of 1,275 consecutive patients undergoing prostate needle biopsy 61 were identified with prostatic intraepithelial neoplasia but without concurrent prostate carcinoma. Of the 61 patients 53 had undergone repeat biopsy. The medical records, transrectal ultrasound, and operative and pathological reports of these patients were reviewed.

RESULTS

Repeat biopsy was done in 53 patients with prostatic intraepithelial neoplasia, yielding carcinoma in 15, prostatic intraepithelial neoplasia without carcinoma in 8 and benign tissue in 30. The yield of carcinoma from repeat biopsy of a prostatic intraepithelial neoplasia site was 8.3% (7 of 84 sites). A total of 18 sites of carcinoma was detected by repeat biopsy of a previous random biopsy site (8), a prostatic intraepithelial neoplasia site only (5), a transrectal ultrasound nodule (3), a palpable nodule and prostatic intraepithelial neoplasia site (1), and a transrectal ultrasound nodule and prostatic intraepithelial neoplasia site (1). Carcinoma was as frequently detected by repeat biopsy of a prostatic intraepithelial neoplasia site (6 patients) as by random repeat biopsy (6 patients).

CONCLUSIONS

Repeat prostate needle biopsy of patients with prostatic intraepithelial neoplasia should include random repeat biopsy and repeat biopsy of transrectal ultrasound abnormalities as well as previous sites of prostatic intraepithelial neoplasia.