Efficacy and safety of an alternative onabotulinumtoxinA injection paradigm for refractory overactive bladder

AIMS

In studies utilizing a 20-injection-site paradigm of onabotulinumtoxinA treatment for overactive bladder (OAB), some patients performed clean intermittent catheterization (CIC). An alternative injection paradigm of fewer injections targeting the lower bladder may reduce the need for CIC by maintaining upper bladder function. This study evaluated the efficacy and safety of an unapproved alternative 10-injection-site paradigm targeting the lower bladder.

METHODS

In this phase 4, double-blind, parallel-group study, patients with OAB and urinary incontinence (UI) for ≥6 months with ≥3 episodes of urinary urgency incontinence (no more than 1 UI-free day) and ≥8 micturitions per day over 3 days during screening were randomized 2:1 to onabotulinumtoxinA 100 U or placebo injected at 10 sites in the lower bladder.

RESULTS

Of 120 patients, 78 in the onabotulinumtoxinA group and 39 in the placebo group had efficacy assessments. In the double-blind phase, mean change from baseline at week 12 in daily frequency of UI episodes was greater with onabotulinumtoxinA (-2.9) versus placebo (-0.3) (least squares mean difference [LSMD]: -2.99, p < 0.0001). Achievement of 100% (odds ratio [OR]: 6.15 [95% confidence interval, CI: 0.75-50.37]), ≥75% (OR: 7.25 [2.00-26.29]), and ≥50% improvement (OR: 4.79 [1.87-12.28]) from baseline in UI episodes was greater with onabotulinumtoxinA versus placebo. Reductions from baseline in the daily average number of micturitions (LSMD: -2.24, p < 0.0001), nocturia (LSMD: -0.71, p = 0.0004), and urgency (LSMD: -2.56, p < 0.0001) were greater with onabotulinumtoxinA than with placebo. Treatment benefit was improved or greatly improved in the onabotulinumtoxinA group (74.0% of patients) versus placebo (17.6%) (OR: 13.03 [95% CI: 3.23-52.57]). Mean change from baseline in Incontinence Quality of Life score was greater with onabotulinumtoxinA versus placebo (LSMD: 24.2, p = 0.0012). Two of 78 (2.6%) patients in the onabotulinumtoxinA group used CIC during the double-blind period; no females used CIC during the double-blind period. Commonly reported adverse events (≥5%) were urinary tract infection (UTI), dysuria, and productive cough for both groups; rate of UTI was higher with onabotulinumtoxinA versus placebo.

CONCLUSION

In patients treated with onabotulinumtoxinA for OAB with UI, an unapproved alternative injection paradigm targeting the lower bladder demonstrated efficacy over placebo, with a low incidence of CIC.

Development and use of machine learning models for prediction of male sling success A proof-of-concept institutional evaluation

INTRODUCTION

For mild to moderate male stress urinary incontinence (SUI), transobturator male slings remain an effective option for management. We aimed to use a machine learning (ML )-based model to predict those who will have a long-term success in managing SUI with male sling.

METHODS

All transobturator male sling cases from August 2006 to June 2012 by a single surgeon were reviewed. Outcome of interest was defined as 'cure': complete dryness with 0 pads used, without the need for additional procedures. Clinical variables included in ML models were: number of pads used daily, age, height, weight, race, incontinence type, etiology of incontinence, history of radiation, smoking, bladder neck contracture, and prostatectomy. Model performance was assessed using area under receiver operating characteristic curve (AUROC), area under precision-recall curve (AUPRC), and F1-score.

RESULTS

A total of 181 patients were included in the model. The mean followup was 56.4 months (standard deviation [SD ] 41.6). Slightly more than half (53.6%, 97/181) of patients had procedural success. Logistic regression, K-nearest neighbor (KNN ), naive Bayes, decision tree, and random forest models were developed using ML. KNN model had the best performance, with AUROC of 0.759, AUPRC of 0.916, and F1-score of 0.833. Following ensemble learning with bagging and calibration, KNN model was further improved, with AUROC of 0.821, AUPRC of 0.921, and F-1 score of 0.848.

CONCLUSIONS

ML-based prediction of long-term transobturator male sling is feasible. The low numbers of patients used to develop the model prompt further validation and development of the model but may serve as a decision-making aid for practitioners in the future.

Time for a mandatory urology rotation? Adequacy of urological exposure during medical school - a survey of graduates of the University of the West Indies, Trinidad and Tobago

INTRODUCTION

To objectively assess the self-reported adequacy and utility of exposure of our students to urology during their training.

MATERIALS AND METHODS

A questionnaire was sent to the University of the West Indies graduating class of 2018, now functioning as medical interns. A questionnaire was designed to collect information regarding respondent demographics, perceptions of their urology exposure during their medical school training as well as their attitudes towards the specialty. The survey was also designed to capture respondents' comfort levels with commonly encountered urological scenarios and investigations. The survey was distributed in February 2019 using the online survey tool, Survey Monkey.

RESULTS

A total of 196 surveys were distributed, of which 107 responses were returned. Clinic exposure was the most common form of interaction with the specialty during training. Their exposure to common urological procedures was low with only 9.3% and 4.7% having seen a circumcision or prostate biopsy respectively by graduation; 21.7% and 47.7% indicated that they were uncomfortable to review a KUB X-ray and CT respectively to identify a stone; 96.2% considered urology to be an important clinical sub-specialty but 42.4% indicated that their exposure to urology did not prepare them to manage urological conditions that they have encountered since graduation; 87.8% of respondents supported the idea of a urology rotation.

CONCLUSION

The exposure of medical students to urology during their medical training is poor. There remains much room for improvement in exposing our medical students to urology during their training. A dedicated urology rotation should be strongly considered. This study has applications not just within the Caribbean, but further afield.

Surgical management and outcomes of adult acquired buried penis with and without lichen sclerosus: a comparative analysis

PURPOSE

Adult acquired buried penis (AABP) can present with concomitant Lichen Sclerosus (LS), a chronic dermatosis that may affect surgical outcomes. Our aim was to evaluate outcomes of patients undergoing AABP repair with and without LS.

METHODS

A retrospective cohort study was performed for AABP repair patients at a single institution from 1/1991 to 12/2017. Patient characteristics and surgical and peri-operative outcomes, including success, erectile function, and complications, were collected.

RESULTS

Sixty-seven AABP patients with mean follow-up of 16.1 ± 20.4 months were identified. Overall surgical success was 91%. Overall surgical complication rate was 50.7% (23.9% Clavien-Dindo ≥ 3). Forty-two (62.7%) patients had concomitant LS. A higher proportion of patients with LS required a STSG (90% vs 60%, p = 0.005). There was no difference in surgical success (90.5% vs 92.0%, p = 0.999), overall complication rate (57.1% vs 40.0%, p = 0.212), Clavien-Dindo ≥ 3 complications (23.8% vs 24.0%, p = 0.999) or early complications (35.7% vs 32.0%, p = 0.797) between patients with and without LS, respectively. However, a higher proportion of patients with LS experienced late complications (33.3% vs 8.0%, p = 0.020), which were mainly related to wound healing. Satisfaction with erectile function was higher among patients with LS (59.5% vs 320%, p = 0.043).

CONCLUSION

AABP patients with LS behave somewhat differently than their non LS counterparts. They are more likely to require skin graft during surgical treatment. Though surgical success and complications are similar, they do experience a higher rate of late complications from impaired wound healing. Work on improving wound healing in this population should be considered.

Long-term Success Durability of Transobturator Male Sling

OBJECTIVE

To determine the long-term outcome of transobturator sling for male stress urinary incontinence (SUI) clustered according to preoperative SUI severity, and to identify predictors of treatment success durability and failure occurrence in long-term follow-up.

METHOD

A nonconcurrent study was conducted on all transobturator male sling cases performed from August 2006 to June 2012 by a single surgeon. Preoperative SUI severity was clustered into mild (≤2 ppd), moderate (3-4 ppd) or severe (≥5 ppd). Success was defined as complete dryness with 0 pads used (cured), and a patient with ≥50% improvement, satisfied without further procedures needed. Otherwise it was considered a treatment failure. Clinical variables significantly associated with long-term treatment success were determined. Time-to-event (Kaplan-Meier) and Multiple-Cox regression analysis were performed to determine predictors of long-term treatment outcome.

RESULTS

A total of 215 patients (mild-59, moderate-94, and severe-62) with a mean follow-up of 56.4 ± 41.6 months were included. On long-term follow-up, 150 (69.8%) patients-maintained treatment success and 96 (44.7%) were dry. The long-term outcome success clustered according to SUI severity as mild, moderate, and severe was 84.7%, 72.3%, and 51.6%, respectively. Kaplan-Meier with Log-rank test and Multiple Cox-regression determined that both concomitant urge incontinence and preoperative SUI severity were independent predictors of long-term durability of treatment success and failure occurrence. Preoperative SUI severity was the only predictor of long-term cure sustainability.

CONCLUSION

The time to event analysis with an average of ∼5 years postoperative follow-up has determined that the preoperative severity and presence of concomitant urge incontinence were independent predictors for long-term outcome.

Review of clinical experience on biomaterials and tissue engineering of urinary bladder

PURPOSE

In recent pre-clinical studies, biomaterials and bladder tissue engineering have shown promising outcomes when addressing the need for bladder tissue replacement. To date, multiple clinical experiences have been reported. Herein, we aim to review and summarize the reported clinical experience of biomaterial usage and tissue engineering of the urinary bladder.

METHODS

A systematic literature search was performed on Feb 2019 to identify clinical reports on biomaterials for urinary bladder replacement or augmentation and clinical experiences with bladder tissue engineering. We identified and reviewed human studies using biomaterials and tissue-engineered bladder as bladder substitutes or augmentation implants. The studies were then summarized for each respective procedure indication, technique, follow-up period, outcome, and important findings of the studies.

RESULTS

An extensive literature search identified 25 studies of case reports and case series with a cumulative clinical experience of 222 patients. Various biomaterials and tissue-engineered bladder were used, including plastic/polyethylene mold, preserved dog bladder, gelatine sponge, Japanese paper with Nobecutane, lypholized human dura, bovine pericardium, amniotic membrane, small intestinal mucosa, and bladder tissue engineering with autologous cell-seeded biodegradable scaffolds. However, overall clinical experiences including the outcomes and safety reports were not satisfactory enough to replace enterocystoplasty.

CONCLUSION

To date, several clinical experiences of biomaterials and tissue-engineered bladder have been reported; however, various studies have reported non-satisfactory outcomes. Further technological advancements and a better understanding is needed to advance bladder tissue engineering as a future promising management option for patients requiring bladder drainage.

Training Genitourinary Reconstructive Surgeons: A Survey of Graduated Fellows and Fellowship Directors

OBJECTIVE

To review the Society of Genitourinary Reconstructive Surgeons fellowship and matching process. There are currently 20 fellowships offered. A centralized match began in 2013-2014. Fellowship directors and graduated fellows were surveyed regarding their experience in their matching process, fellowship, employment opportunities, and their current practice.

METHODS

A web-based survey was distributed to fellowship graduates and directors. A total of 20 and 14 open ended and multiple-choice questions were asked, respectively. Multiple choice questions were rated using a Likert scale.

RESULTS

A total of 24/41 (59%) graduated fellows and 14/17 (82%) fellowship directors completed the survey. Overall satisfaction for the application and match process was 4/5 for both groups. Fellow respondents reported a 96%, 92%, 92%, and 88% feeling of competency in urethral reconstruction, male incontinence, urinary diversion/ureteral reconstruction, and male sexual health, respectively. A total of 92% of graduates practice in a location that they consider in their top 3 destinations. The majority, 58%, practice in academia.

CONCLUSION

The Society of Genitourinary Reconstructive Surgeons has offered a recognized fellowship since 2014. Recent graduates express positive support of their fellowship training with excellent competency and employment opportunities. Fellowship directors continue to discuss broadening training to further advance this dynamic field.

AdVance male sling

The AdVance sling (American Medical Systems, Minnetonka, MN, United States of America) is a synthetic transobturator sling, which is a safe and effective minimally invasive treatment for mild to moderate stress urinary incontinence (SUI) in male patients. This article provides a step-by-step description of our technique for placement of the AdVance male sling, including details and nuances gained from surgical experience, advice for avoidance of complications and discussion on management of complications and sling failures. Patient selection is very important, including exclusion and preoperative treatment of urethral stenosis and bladder dysfunction. Previous pelvic radiation is a poor prognostic factor. In brief, the steps of sling placement are: (I) mobilization of the corpus spongiosum (CS); (II) marking and mobilization of the central tendon; (III) passage of the helical trocar needles exiting at the apex of the angle between the CS and inferior pubic ramus; (IV) fixation of the broad part of the sling body to the CS at the previous mark; (V) cystoscopy during sling tensioning; (VI) placement of a Foley urethral catheter; (VII) Subcutaneous tunnelling of the sling arms back toward the midline; (VIII) wound closure. The most common early postoperative complication is urinary retention but long-term retention is extremely rare. Management of sling failures include placement of an artificial urinary sphincter, repeat AdVance sling, urethral bulking agent or ProACT device.

Perspectives on International Urological Volunteerism: A Survey of IVUmed Resident Scholar Alumni

INTRODUCTION

The primary intentions of international surgical programs are to directly benefit those receiving medical care, educate local physicians and staff, and improve care delivery models. IVUmed, a nonprofit organization dedicated to providing urological care to resource poor areas of the world, provides scholarship opportunities for urology trainees. We assessed the motivations and barriers of IVUmed traveling resident scholars regarding continuing international surgical work after completion of the program.

METHODS

An Internet based survey was sent to all previous IVUmed resident scholars assessing potential factors associated with repeat international service. Logistic regression was used to examine the association between survey responses and the likelihood of repeating an international service trip after completion of training.

RESULTS

Of 196 IVUmed resident scholar participants 100 (51%) responded to the survey. Of the 69 attending surgeons 17 (25%) had repeated an international service trip. Altruism (100%), personal fulfillment (99%) and practicing in a resource limited setting (94%) were the most frequently cited motivating factors for repeat participation, while lack of time (96%) was the most commonly reported barrier. Respondents in private practice were less likely to participate in a subsequent trip compared to those in an academic setting (OR 0.16, CI 0.03-0.80, p = 0.03). No other factors were associated with the likelihood of repeating an international service trip.

CONCLUSIONS

Among urologists who participated in a funded international scholarship program during residency repeat participation during the subsequent 7 years was modest. Private practitioners were less likely to repeat international service compared to academic urologists.

The Artificial Urinary Sphincter in the Management of Incontinence

Despite the emergence of different devices in the treatment of postprostatectomy urinary incontinence, the AMS 800 (American Medical Systems, Minnetonka, MN) remains the gold standard for the treatment of stress urinary incontinence in men. We reviewed the current literature regarding the indications, surgical principles, outcomes, and complications of artificial urinary sphincter placement for stress urinary incontinence after prostatectomy. Despite all the available information, heterogeneous data, different success definitions, and the lack of high-quality prospective studies with long-term follow-up, it is difficult to compare outcomes between studies. In spite of these, the perineal implantation of a single cuff artificial urinary sphincter has withstood the test of time.

Penile Amputation: Cosmetic and Functional Results

INTRODUCTION

Penile amputation is a rare type of external genital trauma. It may arise from accidental trauma, assault or self-inflicted mutilation. As with all trauma, initial management focuses on assessment and resuscitation of the patient. When available, hypothermic preservation of the detached penis should be undertaken.

AIM

This review serves to compile the current available information on etiology and management of penile amputation injuries, with focus on functional and cosmetic results.

MAIN OUTCOME MEASURES

Main outcome measures were penile cosmetics, viability, and sensation; urethral patency and graft survival, functionality.

METHODS

A literature search using Medline, PubMed (U.S. National Library of Medicine and the National Institutes of Health), and abstracts from scientific meetings was performed from 1980-2013.

RESULTS

Due to the rarity of penile amputation injuries, no randomized trials exist. Likewise, available published series on management of this condition are comprised of a small number of patients.

CONCLUSIONS

Penile amputation is rare but challenging. Current microreplantation procedures have a uniformly good result with a minimum number of post-operative complications. When microreplantation cannot be performed, older corporal reattachment techniques may be offered. When phallic reconstruction is required, a microsurgical free forearm flap phalloplasty may be performed to restore the patient with an acceptable cosmetic and functional phallus. Virasoro R, Tonkin JB, McCammon KA, and Jordan GH. Penile amputation: Cosmetic and functional results. Sex Med Rev 2015;3:214-222.

Artificial urinary sphincter for post-prostatectomy incontinence: a review

The artificial urinary sphincter remains the gold standard for treatment of post-prostatectomy urinary incontinence. The AMS 800 (American Medical Systems, Minnetonka, MN, USA) is the most commonly implanted artificial urinary sphincter. Having been on the market for almost 40 years, there is an abundance of literature regarding its use, but no recent review has been published. We reviewed the current literature regarding the indications, surgical principles, outcomes and complications of artificial urinary sphincter implantation for stress urinary incontinence after prostatectomy. A PubMed search was carried out for articles on the artificial urinary sphincter from 1995 to present. The review was centered on articles related to the use of the AMS 800 for stress urinary incontinence in males after prostatectomy. Relevant articles were reviewed. The majority of patients will achieve social continence (1 pad per day) after artificial urinary sphincter implantation; however, rates of total continence (no pad usage) are significantly lower. Patient satisfaction outcomes average greater than 80% in most series. Potential complications requiring reoperation include infection (0.5-10.6%) and urethral erosion (2.9-12%). Revision surgeries are most commonly as a result of urethral atrophy, which ranges from 1.6 to 11.4%. The 5-year Kaplan-Meier freedom from reoperation ranges from 50 to 79%, while the 10-year Kaplan-Meier freedom from mechanical failure is 64%. The artificial urinary sphincter is a reliable device with good outcomes. As expected with any prosthetic device, complications including mechanical failure, infection, erosion and recurrent incontinence remain significant concerns. Despite known complications, the patient satisfaction rates after artificial urinary sphincter implantation remain high. Appropriate patient counseling and adherence to surgical principles are imperative.

Extended outcomes in the treatment of male stress urinary incontinence with a transobturator sling

OBJECTIVE

To review extended patient outcomes after male transobturator sling placement for stress urinary incontinence.

METHODS

A retrospective review of a prospectively maintained database for patients with at least 12 months of postoperative follow-up after AdVance male sling placement was performed. Success was defined as a dry safety pad or less (cured) or >50% improvement in pads used per day and patient satisfaction (improved). Patients requiring repeat continence procedures were considered failures.

RESULTS

We reviewed data from 102 patients with a minimum of 12 months of follow-up (mean ± standard deviation 36.2 ± 16.5 months). The mean age at surgery was 66.1 years, and 86.4% had previously undergone a prostatectomy. At 12 months, 24 months, and final follow-up, success rates were 74%, 63%, and 62%, respectively. Although cure rates also declined over time, 40% of patients experienced a durable cure with no complaints of wet pads at final follow-up. Complications were minimal and similar with previous reports. Multivariate Cox regression analysis revealed detrusor overactivity and an elevated detrusor pressure and peak flow negatively predicted being cured using sling placement.

CONCLUSION

AdVance sling placement continues to represent a viable option in the treatment of male stress incontinence. Although a decrease in efficacy over time was observed, a substantial portion of patients can expect a durable cure.

Helping patients with voiding dysfunction: What are our current options?

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Outcome of penile revascularization for arteriogenic erectile dysfunction after pelvic fracture urethral injuries

OBJECTIVE

To review our experience with penile revascularization for patients with bilateral occlusion of the deep internal pudendal arteries after pelvic fracture urethral injury (PFUI).

MATERIALS AND METHODS

We identified 17 patients who had undergone penile revascularization with end-to-side anastomosis of the deep inferior epigastric artery to the dorsal penile artery from July 1991 to December 2010. Success was defined as achieving erections sufficient for intercourse with or without pharmacologic assistance.

RESULTS

All patients had had a PFUI causing arterial insufficiency and erectile dysfunction not responsive to pharmacologic intervention. Of the 17 patients, 4 (24%) underwent revascularization before and 13 (76%) after PFUI repair. The mean age at revascularization was 32.7 years (range 17-54). At an average follow-up of 3.1 years, the surgery was successful in 14 of the 17 patients (82%). In patients with erectile dysfunction as an indication for surgery, successful erections were achieved in 11 of 13. For those who underwent revascularization to prevent ischemic stenosis of the urethral repair, 3 of 4 achieved successful erections, and all subsequent urethral surgeries were successful. The penile duplex ultrasound parameters showed clinically and statistically significant improvements after revascularization. No operative complications developed. The average hospital length of stay was 4.7 days. Four patients experienced early postoperative complications, including an abdominal wall hematoma requiring evacuation in one, penile edema in two, and a superficial surgical site infection in one. No late complications occurred.

CONCLUSION

Penile arterial revascularization in select patients can allow for successful treatment of PFUIs and the refractory erectile dysfunction caused by them.

Urodynamic changes and initial results of the AdVance male sling

OBJECTIVES

To present the urodynamic changes and early results associated with the AdVance male sling. The AdVance male sling is a treatment option for postprostatectomy incontinence (PPI), with the goal of eliminating urinary incontinence without affecting voiding parameters. A concern of any procedure in treating men with PPI is whether the treatment induces obstruction and causes retention.

METHODS

Data were prospectively collected from 13 patients undergoing AdVance male sling placement for PPI. Urodynamic testing was performed at baseline and repeated at 6 months postoperatively. A 24-hour pad test and the Incontinence Quality of Life questionnaire were completed preoperatively and at 3 and 6 months postoperatively.

RESULTS

The median age at the procedure was 63.3 years (range 44.7-74.7). The mean preoperative and 6-month postoperative patient-reported pad use was 4.52 and 1.04, respectively (2-tailed t test, P = .0009). The 24-hour pad test, performed preoperatively and at 6 months postoperatively, yielded a pad weight of 779.3 and 67.6 g, respectively (P = .03). The Valsalva leak point pressure improved significantly (P = .032), but the detrusor voiding pressure, postvoid residual urine volume, and maximal and average flow rates remained relatively unchanged. At 3 and 6 months postoperatively, the Incontinence Quality of Life scores had improved significantly compared with the preoperative scores (P <.01).

CONCLUSIONS

These results are encouraging, because this series has demonstrated a significant improvement in patient-reported pad use, 24-hour pad test weights, and Valsalva leak point pressure without signs of obstruction. The improvement in incontinence was accompanied without any changes in the other voiding parameters and with significant improvement in the quality-of-life measures. Ongoing studies with longer follow-up are pending to compare their results with these promising early results.

Long-term followup for excision and primary anastomosis for anterior urethral strictures

PURPOSE

We report our experience and long-term followup of patients undergoing excision and primary anastomotic reconstruction for anterior urethral strictures.

MATERIALS AND METHODS

From July 1986 to May 2006 the charts of 260 patients who underwent excision with primary anastomosis at our center for bulbar urethral stricture were reviewed. Patient age ranged from 14 to 78 years (mean 38.4), stricture length ranged 0.5 to 4.5 cm (mean 1.9). Patients who had surgery within the last 5 years were contacted by telephone if their 6-month postoperative cystoscopic evaluation was patent and they had not visited the clinic afterward.

RESULTS

After a mean followup of 50.2 months 257 patients (98.8%) were symptom-free and required no further procedures. Recurrent stricture occurred early in 2 patients and late in 1 patient. Two patients opted for intermittent dilations, and a single direct visual internal urethrotomy was performed in 1 patient 4 years postoperatively. One of the patients who elected dilation subsequently elected urethral reconstruction, which was done successfully. Complications encountered were position related neuropraxia in 9 (3.4%), early urinary tract infection in 13 (5%), chest related in 5 (1.9%), scrotalgia in 4 (1.5%) and wound related in 4 (1.5%). All resolved within the early postoperative period. Erectile dysfunction was encountered in 6 (2.3%) patients, of whom 4 had a history of significant straddle trauma, 4 responded well to oral pharmacotherapy and 1 elected to not have the erectile dysfunction treated.

CONCLUSIONS

Excision with primary anastomosis for anterior urethral stricture has a high success rate of 98.8% with durable long-term results in most patients. Complications are few, of short duration and self-limited. Where applicable, we believe that the procedure clearly is the choice for short anterior urethral strictures.

Open reconstruction of pediatric and adolescent urethral strictures: long-term followup

PURPOSE

Pediatric urethral stricture disease represents a significant surgical challenge. Published operative series of pediatric urethral reconstruction include small numbers or lack long-term followup. We examined the long-term outcome of open reconstructive techniques for pediatric urethral strictures.

MATERIALS AND METHODS

From March 1987 through August 2002, 17 boys 7 to 17 years old underwent open urethral reconstruction with followup. Trauma was the etiology in 88% of cases. Nine patients had anterior urethral stricture and 8 had traumatic posterior urethral disruption. Strictures secondary to failed hypospadias correction were not included in analysis. In 10 patients (59%) previous management with open or endoscopic procedures had failed. Followup in all patients consisted of symptomatic evaluation, voiding cystourethrography and flexible urethroscopy.

RESULTS

One-stage perineal urethral reconstruction was performed in all patients without retropubic or transpubic dissection. All patients were stricture-free and continent at a mean followup of 67 months. A total of 18 open surgical procedures were needed. A patient with posterior urethral disruption required reoperation for recurrent stricture disease but had excellent long-term results after the second operation. Chordee, penile shortening and urethral diverticula were not noted during followup.

CONCLUSIONS

Open urethral reconstruction of adolescent and pediatric strictures provides excellent long-term results with minimal morbidity. When considering the importance of repair durability in the pediatric urethral stricture population, urethral reconstruction should be strongly considered the primary treatment option. Endoscopic procedures should be reserved for patients with short bulbar strictures associated with minimal spongiofibrosis. As in the literature, we do not advocate repeat direct vision internal urethrotomy.

Dependency of detrusor contractions on calcium sensitization and calcium entry through LOE-908-sensitive channels

1. The subcellular mechanisms regulating stimulus-contraction coupling in detrusor remain to be determined. We used Ca(2+)-free solutions, Ca(2+) channel blockers, cyclopiazonic acid (CPA), and RhoA kinase (ROK) inhibitors to test the hypothesis that Ca(2+) influx and Ca(2+) sensitization play primary roles. 2. In rabbit detrusor, peak bethanechol (BE)-induced force was inhibited 90% by incubation for 3 min in a Ca(2+)-free solution. By comparison, a 20 min incubation of rabbit femoral artery in a Ca(2+)-free solution reduced receptor-induced force by only 5%. 3. In detrusor, inhibition of sarcoplasmic reticular (SR) Ca(2+) release by 2APB, or depletion of SR Ca(2+) by CPA, inhibited BE-induced force by only 27%. The CPA-insensitive force was abolished by LaCl3. By comparison, 2APB inhibited receptor-induced force in rabbit femoral artery by 71%. 4. In the presence of the non-selective cation channel (NSCC) inhibitor, LOE-908, BE did not produce an increase in [Ca(2+)]i but did produce weak increases in myosin phosphorylation and force. 5. Inhibitors of ROK-induced Ca(2+) sensitization, HA-1077 and Y-27632, inhibited BE-induced force by approximately 50%, and in combination with LOE-908, nearly abolished force. 6. These data suggest that two principal muscarinic receptor-stimulated detrusor contractile mechanisms include NSCC activation, that elevates [Ca(2+)]i and ROK activation, that sensitizes cross bridges to Ca(2+).

Differential effects of sex hormones and phytoestrogens on peak and steady state contractions in isolated rabbit detrusor

PURPOSE

Recent evidence suggests that sex steroids may produce rapid inhibition of voltage operated Ca2+ channels (VOCCs). Detrusor smooth muscle is highly dependent upon Ca2+ influx for receptor-activated contractions. Thus, we examined the relative effectiveness of a select group of sex steroids and dietary phytoestrogens to relax detrusor contracted with the muscarinic receptor agonist, bethanechol (BE) and the purinergic P2X receptor agonist, alpha,beta-methylene ATP (alpha,beta-MeATP).

MATERIALS AND METHODS

Isolated strips of rabbit detrusor were secured to isometric force transducers in a tissue bath and length-adjusted until maximum contractions were achieved. Peak (P) contractile responses were recorded for alpha,beta-MeATP (P(ATP)) and BE (P(BE)) and steady-state (SS) responses were recorded for BE (SS(BE)) in the presence and absence of selected sex steroids and phytoestrogens (10 microM, unless indicated).

RESULTS

The L-type VOCC inhibitor, nifedipine (1 to 10 microM), completely inhibited P(ATP) but reduced SS(BE) by approximately 50%, whereas the VOCC and non-VOCC inhibitor, SKF 96365, inhibited SS(BE) by approximately 95%, suggesting that P(ATP) was entirely dependent on L-type VOCCs, but (BE)-induced contractions depended also on activation of non-VOCCs. 17Beta-estradiol (estradiol) and progesterone inhibited P(ATP) by approximately 60% and 20%, respectively, and 32 microM estradiol and ethinyl estradiol inhibited SS(BE) by approximately 80 and 95%, respectively. Inhibition by estradiol was potentiated, rather than blocked, by the nuclear estrogen receptor antagonist, tamoxifen. Moreover, tamoxifen alone nearly completely relaxed SS(BE). The inactive metabolite of estradiol, 17alpha-estradiol, inhibited both P(ATP) and P(BE) by approximately 40%. Testosterone had no effect on P(ATP) and P(BE). The phytoestrogen and tyrosine kinase inhibitor, genistein, inhibited SS(BE) by 44%, whereas daidzein, a phytoestrogen without tyrosine kinase inhibitory activity, produced only a 7% inhibition. None of the phytoestrogens examined inhibited P(BE), whereas all inhibited P(ATP) by approximately 20 to 35%. A comparison of inhibition of (BE) and alpha,beta-MeATP-induced contractions by selected estrogen isomers showed some distinct differences. For example, estrone did not inhibit P(BE) or SS(BE), but inhibited P(ATP) by approximately 20%, whereas DES inhibited SS(BE) by nearly 90%, but P(ATP) by a lesser degree (approximately 70%).

CONCLUSIONS

Our data support the hypothesis that 17beta-estradiol, ethinyl estradiol, DES, tamoxifen and genistein may relax detrusor contractions by inhibition of both VOCCs and non-VOCCs. Moreover, our data show that genistein, a dietary phytoestrogen with tyrosine kinase inhibitory activity, selectively reduced alpha,beta-MeATP-induced peak and BE-induced steady-state contractions, sparing the maximum response to BE. Lastly, the inactive isomer, 17alpha-estradiol, inhibited both BE- and alpha,beta-MeATP-induced contractions. These data suggest that certain dietary phytoestrogens (for example, genistein) or sex steroids, especially those with weak activity at the nuclear steroid site (for example, 17alpha-estradiol), or tamoxifen may prove therapeutically useful in treating overactive bladder caused by elevated muscarinic and purinergic receptor activation.

Rapid effects of estrogen and progesterone on tone and spontaneous rhythmic contractions of the rabbit bladder

Previous studies indicate that bladder instability in man may be associated with increased spontaneous rhythmic contractile activity. Ca(2+) influx plays a central role in smooth muscle contractions, and recent evidence suggests that steroid hormones rapidly affect Ca(2+) influx. Therefore we tested the hypothesis that estrogen and progesterone modulates spontaneous rhythmic detrusor contractions. Tissues were secured to isometric force (F) transducers in tissue baths and length-adjusted until K(+)-depolarization produced maximum contractions (F(o)). Spontaneous rhythmic contractions (SRC) were sampled before and immediately after addition of estradiol or progesterone (10(-5) M) to tissue baths. The average frequency and amplitude of SRC were, respectively, 0.156 Hz and 0.053 F/F(o) (n = 24). Estradiol caused an immediate reduction in SRC, such that by 10 min, tone, frequency and amplitude were each reduced by, respectively, 36%, 46% and 47% (n = 7, P < 0.05). However, progesterone caused an immediate weak contraction, and at steady state (10 min), progesterone increased frequency of SRC by 152% but decreased SRC amplitude by 50% (n = 10, P < 0.05). Novel therapies using unique steroids that do not interact with genomic receptors may potentially reduce bladder smooth muscle activity, thereby reducing detrusor instability.

Comparative quality-of-life analysis after radical prostatectomy or external beam radiation for localized prostate cancer

OBJECTIVES

To determine and compare quality-of-life (QOL) evaluations from patients who received external beam radiation therapy or radical prostatectomy for the treatment of localized prostate cancer, and to compare differences in QOL assessments for urinary and sexual function after radical prostatectomy as reported by patient and physician.

METHODS

Two hundred three patients treated by radical prostatectomy and 257 patients treated by external beam irradiation, all beyond 12-month follow-up after therapy, responded to a QOL questionnaire. The difference in responses with regard to bladder, bowel, and sexual function, overall satisfaction with treatment, and choice of the same treatment were assessed. Satisfaction with and choice of the same treatment were also specifically assessed according to bowel and bladder function and current disease status. The medical records of patients treated by radical prostatectomy were reviewed by an independent data manager to record the physician's assessment of continence and sexual function for comparison with that patient's assessment as noted in the questionnaire.

RESULTS

Problems with urinary continence were more frequent among patients treated by radical prostatectomy; problems with gastrointestinal function were more frequent after irradiation. Sexual dysfunction was similar in both groups, although surgical patients experienced a greater impact on sexual relationships. The physician estimates of urinary continence were more favorable than the patient-reported outcomes. However, the physician estimate of sexual function closely approximated that of the patient. Preservation of sexual function among patients who underwent nerve-sparing surgery was disappointingly low. Only for the response to the question dealing with difficulty in achieving an erection was there a statistically significant benefit for patients receiving nerve-sparing versus non-nerve-sparing procedures. Patient satisfaction with and choice of the same treatment varied according to function and current disease status. Patients who had incontinence or bowel dysfunction or had evidence of recurrent disease were statistically less likely to choose the same treatment again when compared with functional and disease-free counterparts. Because irradiated patients were on average 6 years older than surgical patients, responses were adjusted for age; adjustment for age did not alter results.

CONCLUSIONS

QOL is determined by the treatment received, by the assessment source, and by the patient's function and disease status at the time of assessment. Prospective and longitudinal studies will more accurately quantify immediate and chronic alterations in QOL. Uniformity of evaluation through consolidation of QOL instruments will permit more accurate cross-series and cross-treatment comparisons.

Intravesical dimethyl sulfoxide for primary amyloidosis of the bladder

Primary bladder amyloidosis is a rare disease. Treatment recommendations are necessarily anecdotal. We report a case of a 52-year-old woman treated successfully with intravesical dimethyl sulfoxide instillation.

Laparoscopic pyelolithotomy

Laparoscopic surgery has been applied to virtually every aspect of urinary tract disease. Presented is a case of laparoscopic-extended pyelolithotomy accomplished in a 16-month-old child with a large cystine stone that occupied the child's entire renal pelvis. Although not the first pyelolithotomy accomplished laparoscopically, we believe this to be the first extended laparoscopic pyelolithotomy and also believe this is the youngest patient in whom laparoscopic pyelolithotomy has been done. Extracorporeal shock wave lithotripsy and percutaneous and endoscopic stone techniques have drastically modified the management of urolithiasis. However, select cases in which these techniques may not be applicable (such as this toddler with bulky cystine lithiasis) may require open surgery. The laparoscopic approach represents an excellent, yet less-invasive option.