Depression and Coping Behaviors Are Key Factors in Understanding Pain in Interstitial Cystitis/Bladder Pain Syndrome

BACKGROUND

Interstitial Cystitis/Bladder Pain Syndrome (IC/BPS) is a urologic chronic pelvic pain syndrome with suboptimal treatment outcomes. Catastrophizing is an empirically supported risk factor for greater IC/BPS pain.

AIMS

In this study, a moderated multiple mediation model is tested in which several additional psychosocial risk factors (depression, illness and wellness-focused behavioral coping strategies) are proposed as mediators or moderators in the existing relationship between catastrophizing and IC/BPS pain.

DESIGN

The present questionnaire study employed a cross-sectional design.

SETTINGS AND PARTICIPANTS

Female patients with an IC/BPS diagnosis (n = 341) were recruited at tertiary care sites.

METHODS

Participants completed questionnaires assessing pain, catastrophizing, behavioral coping strategies, and depressive symptoms. Aggregate factor scores were calculated following exploratory factor analyses.

RESULTS

It was found that patients with a greater tendency to catastrophize were more likely to engage in illness-focused coping strategies, which contributed to the reporting of greater sensory and affective pain. Furthermore, this mediating effect of illness-focused coping on affective pain was more likely to occur in those patients reporting greater depressive symptoms.

CONCLUSIONS

Illness-focused behavioral coping is an important mechanism between maladaptive pain cognition and aspects of patient pain, with patients reporting greater depressive symptoms at increased risk for elevated pain. Patient management techniques, including screening for catastrophizing, coping, and depression, are recommended to enrich IC/BPS management.

Depression and catastrophizing predict suicidal ideation in tertiary care patients with interstitial cystitis/bladder pain syndrome

INTRODUCTION

We sought to evaluate psychosocial factors as predictors of suicidal ideation (SI) in a tertiary care outpatient sample of women suffering from interstitial cystitis/bladder pain syndrome (IC/BPS).

METHODS

The patients are women managed at tertiary care centres (n=190). Controls were recruited from the community (n=117). Both groups completed questionnaires on demographics, pain (McGill Pain Questionnaire), IC/BPS symptoms, and psychological variables. Univariate and multivariate hierarchical regression modelling was conducted to examine the strength of associations and unique effects of psychosocial variables on patient SI.

RESULTS

Compared to 6% in healthy controls, 23% of patients endorsed SI in the past two weeks. Correlations between SI, depression, and catastrophizing across controls and cases show that for controls, SI is associated with greater pain (0.31; p<0.01) and depression only (0.59; p<0.01). For tertiary care centre cases, SI is associated with pain (0.24; p<0.01), depression (0.64; p<0.01), and catastrophizing (0.35; p<0.01). Regression analyses indicated that psychosocial variables accounted for a significant amount of variance over and above IC/BPS symptoms. Catastrophizing (i.e., helplessness) about pain and depression were significant univariate predictors of SI, but only depression predicted SI in multivariable analyses.

CONCLUSIONS

Limitations of this study include its cross-sectional design and primarily correlation-based statistics. The present study is the first to implicate multiple psychosocial risk factors over and above IC/BPS-specific symptoms and patient pain experience in SI in women with IC/BPS. Depression in particular is uniquely important in predicting suicidality. These results support a multidisciplinary, proactive approach to IC/BPS involving not only treatment of disease symptoms, but also early detection/treatment of associated psychosocial problems.

Practice patterns of post-radical prostatectomy incontinence surgery in Ontario

INTRODUCTION

We assess the practice patterns of artificial urinary sphincter (AUS) and urethral sling insertion after radical prostatectomy (RP) from a large population-based cohort.

METHODS

We examined 25 346 men in Ontario, Canada who underwent RP between 1993 and 2006. Using hospital and cancer registry data, we identified patients who subsequently underwent an incontinence procedure. We characterized the practice patterns of post-prostatectomy incontinence procedures across Ontario during the study interval.

RESULTS

A total of 703 (2.8%) men underwent subsequent insertion of an AUS and 282 (1.1%) underwent a urethral sling procedure (985 total incontinence procedures, 3.9%) over the study period. During the study period, 121 hospitals performed RP. Among them, 32 (26%) hospitals performed both RP and AUS/sling procedures, and 89 (74%) performed RP only. Four hospitals performed AUS/sling procedures but not RP. Of the 36 institutions that performed AUS/sling procedures, the median annual case volume was 0.29 (interquartile range: 0.083-0.75). Of all incontinence procedures, 56% were performed at 3 academic institutions. When examining observed rates of AUS/sling procedures compared with expected rates from the overall cohort, 15 of 32 hospitals (47%) performed significantly fewer incontinence procedures than expected given their RP case volume (p range: <0.0001-0.0390) and 5 (16%) performed significantly more (p range: <0.0001-0.038).

CONCLUSIONS

A small number of academic institutions provide most of the surgical care for men with incontinence following RP in Ontario. Many centres that perform RP refer out to other centres to surgically manage their patients' incontinence.

Autologous muscle derived cells for treatment of stress urinary incontinence in women

PURPOSE

We assess the 12-month safety and potential efficacy of autologous muscle derived cells for urinary sphincter repair (Cook MyoSite Incorporated, Pittsburgh, Pennsylvania) in women with stress urinary incontinence.

MATERIALS AND METHODS

Pooled data from 2 phase I/II studies with identical patient selection criteria and outcome measures were analyzed. Enrolled patients had stress urinary incontinence refractory to prior treatment and no symptom improvement during the last 6 months. Patients received intrasphincter injection of 10 (16), 50 (16), 100 (24) or 200×10(6) (24) autologous muscle derived cells for urinary sphincter repair, derived from biopsies of each patient's quadriceps femoris. The primary outcome measure was safety, determined by incidence and severity of adverse events. Potential efficacy was measured by changes in 3-day voiding diaries, 24-hour pad tests, and UDI-6 and IIQ-7 scores.

RESULTS

A total of 80 patients underwent injection of autologous muscle derived cells for urinary sphincter repair, and 72 completed diaries and pad tests at 12-month followup. No adverse events attributed to autologous muscle derived cells for urinary sphincter repair were reported. Higher dose groups tended to have greater percentages of patients with at least a 50% reduction in stress leaks and pad weight at 12-month followup. All dose groups had statistically significant improvement in UDI-6 and IIQ-7 scores at 12-month followup compared to baseline.

CONCLUSIONS

Autologous muscle derived cells for urinary sphincter repair at doses of 10, 50, 100 and 200×10(6) cells appears safe. Efficacy data suggest a potential dose response with a greater percentage of patients responsive to higher doses.

Childhood sexual trauma in women with interstitial cystitis/bladder pain syndrome: a case control study

Background: The impact of early lifetime trauma on symptomseverity and quality of life of patients with interstitial cystitis/bladderpain syndrome (IC/BPS) has not been fully elucidated. Wewanted to determine and compare the prevalence and impact ofchildhood traumatic events, with an emphasis on childhood sexualabuse, on patient symptoms, quality of life and other biopsychosocialparameters.Methods: Subjects (female patients with IC/BPS and controls withoutIC/BPS) completed psychosocial phenotyping questionnaires,including a demographics/history form, and validated questionnairesfocused on presenting symptoms (IC symptom indices, pain),psychosocial parameters (depression, anxiety, pain catastrophizing,sexual functioning, social support) and quality of life. Participantsalso completed the Childhood Traumatic Events Scale.Results: Questionnaires were completed by 207 IC/BPS patientsand 117 controls matched for age, partner status and education. Itwas found that before 17 years of age, the IC/BPS cases reportedhigher prevalence of “raped or molested” compared to controls(24.0% vs. 14.7%; p = 0.047). Within the IC/BPS group, casesreporting previous sexual abuse endorsed greater sensory pain,depression and poorer physical quality of life at the present timecompared to IC cases without a sexual abuse history. In the controlsonly, those reporting previous sexual abuse endorsed more depression,anxiety, stress, social maladjustment poorer mental qualityof life in the present time. When the analysis was corrected forpotential multiple comparison error, none of the findings remainedsignificant in either the IC/BPS or control groups.Interpretation: Childhood traumatic events, in particular sexualabuse and extreme illness, are reported as more common in IC/BPS patients than controls. Early trauma, such as the occurrenceof sexual abuse, is associated with some differences in patientadjustment (e.g., pain, quality of life, depression) but this impactappears to be, at most, very modest.

Botulinum toxin A should not be first-line therapy for overactivebladder

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Health-related quality of life and economic impact of urinary incontinence due to detrusor overactivity associated with a neurologic condition: a systematic review

BACKGROUND

Patients with neurologic diseases often have neurogenic detrusor overactivity (NDO), which can result in a loss of voluntary bladder control and uncontrollable urinary incontinence (UI).The impact of UI due to NDO on patients' lives has not been well studied. The objective of this review was to assess the health-related quality of life (HRQoL) and economic burden in patients with urgency UI due to NDO in select countries in North America, the European Union, Asia, and Australia.

METHODS

Systematic literature searches and reviews of articles published in English (January 2000 to February 2011) were conducted using MEDLINE®, EMBASE®, and the Cochrane Library. Studies assessing the impact of UI on HRQoL of patients with an underlying neurologic condition of interest (i.e., multiple sclerosis, spinal cord injury, Parkinson's disease, stroke, or spina bifida) were included. Economic studies in urgency UI also were included.

RESULTS

Of 876 citations generated in the initial search, a total of 27 articles were deemed relevant: 16 articles presented HRQoL data and 11 articles presented information on the economic burden of UI. Humanistic studies used a range of HRQoL instruments to measure HRQoL burden, and the economic studies included different cost components to quantify the economic burden, making meaningful comparisons challenging. Despite this heterogeneity, the literature suggests that HRQoL in patients with UI due to NDO is worse than patients with UI in general or those with the same underlying neurologic condition without UI. In addition, urgency UI also results in substantial economic costs.

CONCLUSIONS

Incontinent patients with underlying neurologic conditions have impaired HRQoL as well as substantial economic burden attributable to UI due to NDO. There is a need for urgency UI treatments that improve HRQoL of these patients and alleviate the economic burden of this condition.

Autologous muscle derived cell therapy for stress urinary incontinence: a prospective, dose ranging study

PURPOSE

In this feasibility study we assessed the 12-month safety and potential efficacy of autologous muscle derived cells (Cook MyoSite Incorporated, Pittsburgh, Pennsylvania) as therapy for stress urinary incontinence.

MATERIALS AND METHODS

A total of 38 women in whom stress urinary incontinence had not improved with conservative therapy for 12 or more months underwent intrasphincter injection of low doses (1, 2, 4, 8 or 16 × 10(6)) or high doses (32, 64 or 128 × 10(6)) of autologous muscle derived cells, which were derived from biopsies of their quadriceps femoris. All patients could elect a second treatment of the same dose after 3-month followup. Assessments were made at 1, 3, 6 and 12 months after the last treatment. The primary end point was the incidence and severity of adverse events. In addition, changes in stress urinary incontinence severity were evaluated by pad test, diary of incontinence episodes and quality of life surveys.

RESULTS

Of the 38 patients 33 completed the study. Treatment related complications were limited to minor events such as pain/bruising at the biopsy and injection sites. Of patients who received 2 treatments of autologous muscle derived cells who were eligible for analysis, a higher percentage of those in the high dose vs the low dose group experienced a 50% or greater reduction in pad weight (88.9%, 8 of 9 vs 61.5%, 8 of 13), had a 50% or greater reduction in diary reported stress leaks (77.8%, 7 of 9 vs 53.3%, 8 of 15) and had 0 to 1 leaks during 3 days (88.9%, 8 of 9 vs 33.3%, 5 of 15) at final followup.

CONCLUSIONS

Injection of autologous muscle derived cells in a wide range of doses appears safe with no major treatment related adverse events reported. In addition, treatment with autologous muscle derived cells shows promise for relieving stress urinary incontinence symptoms and improving quality of life.

Childhood sexual trauma in women with interstitial cystitis/bladder pain syndrome: a case control study

BACKGROUND

The impact of early lifetime trauma on symptom severity and quality of life of patients with interstitial cystitis/bladder pain syndrome (IC/BPS) has not been fully elucidated. We wanted to determine and compare the prevalence and impact of childhood traumatic events, with an emphasis on childhood sexual abuse, on patient symptoms, quality of life and other biopsychosocial parameters.

METHODS

Subjects (female patients with IC/BPS and controls without IC/BPS) completed psychosocial phenotyping questionnaires, including a demographics/history form, and validated questionnaires focused on presenting symptoms (IC symptom indices, pain), psychosocial parameters (depression, anxiety, pain catastrophizing, sexual functioning, social support) and quality of life. Participants also completed the Childhood Traumatic Events Scale.

RESULTS

Questionnaires were completed by 207 IC/BPS patients and 117 controls matched for age, partner status and education. It was found that before 17 years of age, the IC/BPS cases reported higher prevalence of "raped or molested" compared to controls (24.0% vs. 14.7%; p = 0.047). Within the IC/BPS group, cases reporting previous sexual abuse endorsed greater sensory pain, depression and poorer physical quality of life at the present time compared to IC cases without a sexual abuse history. In the controls only, those reporting previous sexual abuse endorsed more depression, anxiety, stress, social maladjustment poorer mental quality of life in the present time. When the analysis was corrected for potential multiple comparison error, none of the findings remained significant in either the IC/BPS or control groups.

INTERPRETATION

Childhood traumatic events, in particular sexual abuse and extreme illness, are reported as more common in IC/BPS patients than controls. Early trauma, such as the occurrence of sexual abuse, is associated with some differences in patient adjustment (e.g., pain, quality of life, depression) but this impact appears to be, at most, very modest.

Population based study of long-term rates of surgery for urinary incontinence after radical prostatectomy for prostate cancer

PURPOSE

Urinary incontinence can be a significant complication of radical prostatectomy. It can be treated with post-prostatectomy surgical procedures. The long-term rate of patients who undergo these surgeries, including artificial urinary sphincter or urethral sling insertion, is not well described. We examined the long-term rate of post-prostatectomy incontinence surgery and factors influencing it.

MATERIALS AND METHODS

We performed a population based study of 25,346 men who underwent radical prostatectomy for prostate cancer in Ontario, Canada between 1993 and 2006. We used hospital and cancer registry administrative data to identify patients from this cohort who were later treated with surgery for urinary incontinence.

RESULTS

Of the 25,346 patients 703 (2.8%) underwent artificial urinary sphincter insertion and 282 (1.1%) underwent urethral sling placement a median of 2.9 years after prostatectomy. The probability of an artificial urinary sphincter/sling procedure increased with time from prostatectomy. Cumulative 5, 10 and 15-year Kaplan-Meier rates of an artificial urinary sphincter/sling procedure were 2.6% (95% CI 2.4-2.8), 3.8% (95% CI 3.6-4.1) and 4.8% (95% CI 4.4-5.3), respectively. Factors predicting surgery for incontinence were patient age at radical prostatectomy (HR 1.24 per decade, 95% CI 1.11-1.38, p = 0.0002), radiotherapy after surgery (HR 1.61, 95% CI 1.36-1.90, p <0.0001) and surgeon volume (49 or greater prostatectomies per year) (HR 0.59, 95% CI 0.46-0.77, p <0.0001).

CONCLUSIONS

Of patients who undergo radical prostatectomy 5% are expected to be treated with surgery for urinary incontinence during a 15-year period. Increasing patient age, radiation treatment and low surgeon volume are associated with significantly higher risk.

Mapping of pain phenotypes in female patients with bladder pain syndrome/interstitial cystitis and controls

BACKGROUND

Many bladder pain syndrome/interstitial cystitis (BPS/IC) patients report multiple pain locations outside the pelvis. No research has examined pain using a whole-body diagram, pain-associated adjustment factors, or the impact of pain in multiple body areas on patients' quality of life (QoL).

OBJECTIVE

Compare and contrast pain in BPS/IC patients and controls using a whole-body diagram (visible body areas). Examine the association between patient adjustment factors and greater number of body pain areas (pain phenotypes).

DESIGN, SETTING, AND PARTICIPANTS

Validated questionnaires were collected from diagnosed, tertiary-care, outpatient, female BPS/IC patients (n=193) and age-matched controls (n=115). Scales included a body pain area diagram, demographics/history, pain severity, BPS/IC symptoms, pain, depression, catastrophizing, and QoL.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Cross-tabulation and analysis of variance models addressed the patient and control differences.

RESULTS AND LIMITATIONS

Patients reported more pain than controls in all reported body areas. Four pain phenotypes were created based on increasing counts of body locations (BPS/IC only, BPS/IC+plus 1-3 additional locations, BPS/IC plus 4-9, BPS/IC ≥ 10). Patients reported more body pain locations, pain, urinary symptoms, depression, catastrophizing, and diminished QoL than controls. The increased-pain phenotype was associated with poorer psychosocial adjustment and diminished physical QoL, but catastrophizing and low scores for mental QoL remained stable across all patient groups. This study was cross-sectional, relying on correlation-based analyses, thus causality cannot be established.

CONCLUSIONS

Patients reported numerous systemic pain symptoms outside the areas associated with the bladder/pelvic region, and increased numbers of body pain sites were associated with poorer patient outcomes (ie, pain severity, depression). This study illustrates the significant negative impact of pain on patient adjustment in BPS/IC. These findings suggest that clinicians carefully consider pain location distributions and the potential impact of body pain phenotypes during patient evaluation and treatment planning.

Xanthogranulomatous cystitis associated with inflammatory bowel disease

Xanthogranulomatous inflammation is a benign condition characterized by the presence of multinucleated giant cells, chronic inflammatory cells and lipid-laden macrophages, known as xanthoma cells. Only 22 cases of xanthogranulomatous cystitis (XGC) have been reported in the Japanese and English literature. In this report, we describe the twenty-third case of XGC and the third case associated with inflammatory bowel disease (IBD). A 50-year-old woman with quiescent Crohn's disease was incidentally found to have a bladder mass on ultrasound. The lesion was resected through a transurethral approach. Pathology demonstrated XGC. At 3 months post-resection, there was no evidence of recurrence adjacent to the previous resection scar.

Psychosocial phenotyping in women with interstitial cystitis/painful bladder syndrome: a case control study

PURPOSE

We characterized and compared psychosocial phenotypes in a female interstitial cystitis/painful bladder syndrome cohort and an age matched cohort without that diagnosis.

MATERIALS AND METHODS

Female patients with interstitial cystitis/painful bladder syndrome and controls without the condition completed a psychosocial phenotyping questionnaire battery, including a demographics/history form and validated questionnaires focused on a range of presenting symptoms, psychosocial parameters and quality of life. Specific measures included interstitial cystitis symptom and problem index, McGill Pain Questionnaire, Medical Outcomes Study Sleep Scale, Center for Epidemiological Studies Depression Scale, State-Trait Anxiety Inventory, Pain Catastrophizing Scale, Female Sexual Functioning Index and Multidimensional Scale of Perceived Social Support and Medical Outcomes Study Short Form-12 quality of life. Direct comparisons and correlations were made to establish group differences and the strength of associations for psychosocial parameters in patients with interstitial cystitis/painful bladder syndrome.

RESULTS

Questionnaires completed by 207 patients with interstitial cystitis/painful bladder syndrome were compared to those of 117 controls matched for age, partner status and education. Compared to controls patients reported significantly more pain (total, sensory and affective), worse physical quality of life, increased sleep dysfunction, depression, catastrophizing, anxiety, stress and moderately more sexual/social function problems. These suffering, coping and social parameters correlated with the degree of general pain but stress, anxiety, depression and catastrophizing further correlated with IC specific symptoms and strongly with decreased quality of life. Pain was strongly associated with physical quality of life, while depression, catastrophizing and stress, and to a lesser extent social support were associated with poor mental quality of life.

CONCLUSIONS

Patients with interstitial cystitis/painful bladder syndrome have significant cognitive and psychosocial alterations compared to controls.

Overactive bladder

Overactive bladder (OAB) is a common condition (prevalence 14%-18% of Canadians) and has a significant negative impact on quality of life. OAB may be idiopathic or may occur with other common conditions such as bladder outlet obstruction, neurological disease, or stress incontinence. Primary care physicians may safely diagnose this condition by history and physical exam with a minimum of widely available lab tests. Management with behavioral therapies and pharmacotherapy is generally quite successful and warranted. Multiple anticholinergic medications are available and have been shown to be effective. Subtle differences in structure and mechanism of these agents may yield improved therapeutic benefit or tolerability and thus it is reasonable to try more than one drug to achieve the optimal results. For patients that fail behavioral and initial pharmacotherapy or when other complicating conditions are identified, referral to a specialist is indicated; however, the majority of patients with OAB do not require cystoscopy or urodynamics. Successful treatments for OAB do exist and it is worth screening for these disabling complaints at the primary care level.

Female stress urinary incontinence

INTRODUCTION

Stress urinary incontinence is a common and costly condition amongst community dwelling women. It can have a significant negative impact on the quality of life and yet less than half of women with urinary incontinence seek medical attention. It is important for primary care physicians to have a clear understanding of stress urinary incontinence in order to screen and manage patients who may have bothersome symptoms.

OBJECTIVE

This article aims to outline the terminology, pathophysiology, clinical evaluation and treatment of female stress urinary incontinence.

CONCLUSION

Female stress urinary incontinence can be effectively evaluated and managed in the primary setting. Specialist referral is warranted when there is complex urinary symptomatology, hematuria on work-up or failure of conservative therapy.

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.