Complications following surgery with or without radiotherapy or radiotherapy alone for prostate cancer

BACKGROUND

Men undergoing treatment of clinically localised prostate cancer may experience a number of treatment-related complications, which affect their quality of life.

METHODS

On the basis of population-based retrospective cohort of men undergoing surgery, with or without subsequent radiotherapy, or radiotherapy alone for prostate cancer in Ontario, Canada, we measured the incidence of treatment-related complications using administrative and billing data.

RESULTS

Of 36 984 patients, 15 870 (42.9%) underwent surgery alone, 4519 (12.2%) underwent surgery followed by radiotherapy, and 16 595 (44.9%) underwent radiotherapy alone. For all end points except urologic procedures, the 5-year cumulative incidence rates were lowest in the surgery only group and highest in the radiotherapy only group. Intermediary rates were seen in the surgery followed by radiotherapy group, except for urologic procedures where rates were the highest in this group. Although age and comorbidity were important predictors, radiotherapy as the primary treatment modality was associated with higher rates for all complications (adjusted hazard ratios 1.6-4.7, P=0.002 to <0.0001).

CONCLUSIONS

In patients treated for prostate cancer, radiation after surgery increases the rate of complications compared with surgery alone, though these rates remain lower than patients treated with radiation alone. This information may inform patient and physician decision making in the treatment of prostate cancer.

OnabotulinumtoxinA 100U provides significant improvements in overactive bladder symptoms in patients with urinary incontinence regardless of the number of anticholinergic therapies used or reason for inadequate management of overactive bladder

INTRODUCTION

A prespecified pooled analysis of two placebo-controlled, phase 3 trials evaluated whether the number of prior anticholinergics used or reason for their discontinuation affected the treatment response to onabotulinumtoxinA 100U in overactive bladder (OAB) patients with urinary incontinence (UI).

METHODS

Patients with symptoms of OAB received intradetrusor injections of onabotulinumtoxinA 100U or placebo, sparing the trigone. Change from baseline at week 12 in UI episodes/day, proportion of patients reporting a positive response ('greatly improved' or 'improved') on the treatment benefit scale (TBS), micturition and urgency were evaluated by number of prior anticholinergics (1, 2 or ≥ 3) and reason for their discontinuation (insufficient efficacy or side effects). Adverse events (AE) were assessed.

RESULTS

Patients had taken an average of 2.4 anticholinergics before study enrolment. OnabotulinumtoxinA reduced UI episodes/day from baseline vs. placebo, regardless of the number of prior anticholinergics (-2.82 vs. -1.52 for one prior anticholinergic; -2.58 vs. -0.58 for two prior anticholinergics; and -2.92 vs. -0.73 for three or more prior anticholinergics; all p < 0.001). The proportion of TBS responders was higher with onabotulinumtoxinA vs. placebo (69.0% vs. 37.2% for one prior anticholinergic; 58.8% vs. 24.8% for two prior anticholinergics and 56.4% vs. 22.5% for three or more prior anticholinergics; all p < 0.001). Similar results were observed regardless of the reason for discontinuation. OnabotulinumtoxinA reduced the episodes of urgency and frequency of micturition vs. placebo in all groups. AEs were well tolerated, with a comparable incidence in all groups.

CONCLUSION

In patients with symptoms of OAB who were inadequately managed by one or more anticholinergics, onabotulinumtoxinA 100U provided significant and similar treatment benefit and safety profile regardless of the number of prior anticholinergics used or reason for inadequate management of OAB. ClinicalTrials.gov: NCT00910845, NCT00910520.

Efficacy and safety of fesoterodine 8 mg in subjects with overactive bladder after a suboptimal response to tolterodine ER

AIMS

To assess fesoterodine 8 mg efficacy over time and vs. placebo in subjects with overactive bladder (OAB) who responded suboptimally to tolterodine extended release (ER) 4 mg.

METHODS

In a 12-week, double-blind trial, subjects with self-reported OAB symptoms for ≥ 6 months, mean of ≥ 8 micturitions and ≥ 2 to < 15 urgency urinary incontinence (UUI) episodes/24 h, and suboptimal response to tolterodine ER 4 mg (defined as ≤ 50% reduction in UUI episodes during 2-week run-in) were randomised to fesoterodine (4 mg for 1 week, 8 mg for 11 weeks) or placebo once daily. Change from baseline to week 12 in UUI episodes (primary end-point) was analysed in step-wise fashion: first, baseline vs. week 12 for fesoterodine; if significant, then change from baseline to week 12 for fesoterodine vs. placebo.

RESULTS

By week 12, subjects receiving fesoterodine 8 mg had significantly greater improvement from baseline vs. placebo in UUI episodes, urgency episodes and scores on the Patient Perception of Bladder Control, Urgency Perception Scale and OAB Questionnaire Symptom Bother and Health-Related Quality of Life scales and domains (all p < 0.05). 50% and 70% UUI responder rates were also significantly higher with fesoterodine 8 mg vs. placebo at week 12 (p < 0.05). Dry mouth (placebo, 4%, 12/301; fesoterodine, 16.6%, 51/308) and constipation (placebo, 1.3%, 4/301; fesoterodine, 3.9%, 12/308) were the most frequent adverse events.

CONCLUSIONS

Subjects who responded suboptimally to tolterodine ER 4 mg showed significant improvements in UUI and other OAB symptoms and patient-reported outcomes, with good tolerability, during treatment with fesoterodine 8 mg vs. placebo.

Safety and tolerability of the β3 -adrenoceptor agonist mirabegron, for the treatment of overactive bladder: results of a prospective pooled analysis of three 12-week randomised Phase III trials and of a 1-year randomised Phase III trial

AIMS

To evaluate the safety and tolerability of the β3 -adrenoceptor agonist, mirabegron, in patients with overactive bladder (OAB).

METHODS

Tolerability and safety data from three 12-week, randomised, placebo-controlled, double-blind, Phase III trials (Studies 046, 047 and 074) were pooled by treatment group. The three studies were of a similar design, although the assessed doses of mirabegron [25, 50 or 100 mg once daily (qd)] varied, and tolterodine extended release (ER) 4 mg was included as an active-control arm in Study 046 only. Tolerability and safety data from a 1-year, randomised, double-blind, Phase III trial (Study 049) are also presented. Safety variables included the incidence and severity of treatment-emergent adverse events (TEAEs), vital signs and electrocardiogram data.

RESULTS

Mirabegron (25, 50 or 100 mg qd) was safe and well-tolerated in patients with OAB over 12-week (n = 2736) and 1-year (n = 1632) periods. The incidence of TEAEs and treatment discontinuations as a result of TEAEs was low; the majority were mild in severity and few were serious. Hypertension, nasopharyngitis and urinary tract infection were the most common TEAEs with mirabegron. The mirabegron tolerability profile was similar to that seen with placebo and tolterodine ER 4 mg, except for dry mouth, which occurred, on average, five times less frequently with mirabegron than tolterodine ER 4 mg. In the pooled 12-week analysis, mirabegron 50 mg was associated with placebo-adjusted mean increases of 0.4-0.6 mmHg in blood pressure and approximately one beat per minute in pulse rate, both reversible upon treatment discontinuation. The incidence of Major Adverse Cardiovascular Events as adjudicated by an independent cardiovascular committee was low and similar across treatment groups.

CONCLUSION

The favourable tolerability profile of mirabegron in patients with OAB may allow improved treatment compliance compared with antimuscarinics, with important implications for patient outcomes.

Mirabegron for the treatment of overactive bladder: a prespecified pooled efficacy analysis and pooled safety analysis of three randomised, double-blind, placebo-controlled, phase III studies

INTRODUCTION

To examine pooled efficacy data from three, large phase III studies comparing mirabegron (50 and 100 mg) with placebo, and pooled safety data including additional mirabegron 25 mg and tolterodine extended release (ER) 4 mg results.

METHODS

This prespecified pooled analysis of three randomised, double-blind, placebo-controlled, 12-week studies, evaluated efficacy and safety of once-daily mirabegron 25 mg (safety analysis), 50 or 100 mg (efficacy and safety analyses) and tolterodine ER 4 mg (safety analysis) for the treatment of symptoms of overactive bladder (OAB). Co-primary efficacy measures were change from baseline to Final Visit in the mean number of incontinence episodes/24 h and mean number of micturitions/24 h. Key secondary efficacy end-points included mean number of urgency episodes/24 h and mean volume voided/micturitions, while other end-points included patient-reported outcomes according to the Treatment Satisfaction-Visual Analogue Scale (TS-VAS) and responder analyses [dry rate (posttreatment), ≥ 50% reduction in incontinence episodes/24 h, ≤ 8 micturitions/24 h (post hoc analysis)]. The safety analysis included adverse event (AE) reporting, laboratory assessments, ECG, postvoid residual volume and vital signs (blood pressure, pulse rate).

RESULTS

Mirabegron (50 and 100 mg once daily) demonstrated statistically significant improvements compared with placebo for the co-primary end-points, key secondary efficacy variables, TS-VAS and responder analyses (all comparisons p < 0.05). Mirabegron is well tolerated and demonstrates a good safety profile. The most common AEs (≥ 3%) included hypertension, nasopharyngitis and urinary tract infection (UTI); the incidence of hypertensive events and UTIs decreased with increasing dose. For mirabegron, the incidence of the bothersome antimuscarinic AE, dry mouth, was at placebo level and of a lesser magnitude than tolterodine.

CONCLUSION

The efficacy and safety of mirabegron are demonstrated in this large pooled clinical trial dataset in patients with OAB.

Neoadjuvant chemoradiotherapy and multivisceral resection for primary locally advanced adherent colon cancer: a single institution experience

BACKGROUND

Although there is an extensive body of literature on the role of neoadjuvant chemoradiotherapy (CRT) in the management of rectal cancer, its role in primary locally advanced adherent colon cancer (LAACC) is unclear.

OBJECTIVE

To analyzed the outcomes of neoadjuvant CRT and multivisceral resection in the management of LAACC patietns.

METHODS

We retrospectively reviewed our institutional Colorectal Carcinoma Database for 33 patients with potentially resectable, non-metastatic primary LAACC who received neoadjuvant CRT followed by multivisceral resection. CRT consisted of external beam radiation (45-50 Gy in 25 daily fractions) and concurrent 5-FU infusion (225 mg/m(2)/day).

RESULTS

There were 21 males and 12 females. Median age was 64 (31-83) and median follow-up was 36 months. All patients had microscopically clear resection margins (R0). Complete pathologic response was documented in 1 patient (3%) and 66% had ypT4b disease. Post-operative complications were observed in 36% of patients with no 30-day mortality. The 3-year overall survival and 3-year disease-free survival were 85.9% and 73.7% respectively. Two patients developed a local recurrence.

CONCLUSIONS

Neoadjuvant CRT and en-bloc multivisceral resection may result in high rates of R0 resection and excellent local control with acceptable morbidity and mortality in selected patients with LAACC.

Tolerability of solifenacin and oxybutynin immediate release in older (> 65 years) and younger (≤ 65 years) patients with overactive bladder: sub-analysis from a Canadian, randomized, double-blind study

OBJECTIVE

Overactive bladder (OAB) is a common condition whose prevalence increases with age. Antimuscarinic agents are the pharmacologic treatment of choice, but adverse events such as dry mouth may lead to early discontinuation. The purpose of this analysis was to compare the incidence and severity of dry mouth and other adverse events with solifenacin 5 mg/day and oxybutynin immediate release (IR) 15 mg/day in patients ≤ 65 years and >65 years in the Canadian VECTOR study (VEsicare in Comparison To Oxybutynin for oveRactive bladder patients).

RESEARCH DESIGN AND METHODS

VECTOR was a randomized, multicentre, prospective, double-blind, double-dummy study in 132 subjects with ≥ 1 urgency episode per 24 h, with or without urgency incontinence, and ≥ 8 micturitions per 24 h for ≥ 3 months. After a 2-week washout, patients received solifenacin 5 mg once daily or oxybutynin IR 5 mg tid for 8 weeks. For the current post-hoc analysis, adverse events were evaluated in subgroups of patients ≤ 65 years and >65 years, using a full logistic regression model, multinomial logit regression model and reduced model.

CLINICAL TRIAL REGISTRATION

NCT00431041.

RESULTS

The incidence and severity of dry mouth and other adverse events with solifenacin were similar between younger and older patients. In both age subgroups, solifenacin 5 mg/day was associated with fewer episodes and lower severity of dry mouth, and a lower discontinuation rate, compared with oxybutynin IR 15 mg/day.

CONCLUSIONS

Solifenacin 5 mg/day was better tolerated than oxybutynin IR 15 mg/day in younger (≤ 65 years) and older (> 65 years) subgroups. Solifenacin was equally well tolerated in both age subgroups. Limitations of the analysis were that the study was not preplanned to perform post-hoc subgroup analysis, patients knew that dry mouth was a primary outcome, and the study used fixed doses of each drug.

Canadian cost-effectiveness analysis of solifenacin compared to oxybutynin immediate-release in patients with overactive bladder

OBJECTIVE

To estimate the cost effectiveness of solifenacin 5 mg/day compared to oxybutynin immediate-release (IR) 15 mg/day in patients with overactive bladder, from the perspective of the Canadian healthcare (payer) system.

RESEARCH DESIGN AND METHODS

A Markov model was adapted to estimate the incremental cost per quality-adjusted life-year (QALY) of solifenacin and oxybutynin IR over a 1-year time horizon, based on efficacy and discontinuation data from the Canadian VECTOR (VEsicare in Comparison To Oxybutynin for oveRactive bladder patients) study. In the model, patients who discontinued treatment were offered tolterodine extended release 4 mg/day as second-line. Model robustness was tested using various sensitivity analyses. Utility values were derived from published literature; incontinence pads were included in a secondary analysis.

RESULTS

In the base-case analysis, total costs over 1 year were CAN$695 and CAN$550 in the solifenacin and oxybutynin IR groups, respectively. When including incontinence pad costs, there was an incremental saving of CAN$1,831 per patient with solifenacin. Solifenacin was associated with an incremental QALY gain of 0.01 over 1 year. In the base-case analysis without incontinence pads, the incremental cost-utility ratio for solifenacin was CAN$14,092. Probabilistic analyses showed no overlap in the 95% confidence intervals for total costs or QALYs with or without incontinence pads. Solifenacin was cost effective in >90% of cases, based on a willingness-to-pay threshold of CAN$50,000 per additional QALY, irrespective of whether pad costs were included in the model. The most influential variables were the discontinuation rates and the cost of incontinence pads. Limitations of the analysis relate mainly to the fact that data in the VECTOR study were collected using a direct questioning approach, which might have increased the reporting of dry mouth.

CONCLUSIONS

Solifenacin 5 mg/day was a cost-effective treatment compared with oxybutynin IR 15 mg/day.

TRIAL REGISTRATION

NCT00431041 (of the VECTOR study, upon which the analysis in this paper was based).

Multicenter randomized clinical trial comparing surgery and collagen injections for treatment of female stress urinary incontinence

OBJECTIVES

To compare, in a multicenter, randomized clinical trial, collagen injections versus surgery with regard to efficacy, quality of life, satisfaction, and complications.

METHODS

Of 133 women with stress urinary incontinence, 66 were randomized to collagen injection and 67 to surgery (6 needle bladder neck suspensions, 19 Burch, and 29 slings). After randomization, 15 women refused their allocated treatment. "Intent-to-treat" and "per protocol" analyses were applied. Women assigned to collagen injection could receive up to three injections before it was considered a failure. A "top-up" injection was allowed within 3 months after cure. Success as the primary outcome at 12 months was defined as a dry 24-hour pad test (2.5 g or less of urine) after having received only the allocated intervention.

RESULTS

The per protocol analysis showed that the success rate 12 months after collagen injections (53.1%) was much lower than that after surgery (72.2%). The difference was 19.1% (95% confidence interval -36.2% to -2%). The general and disease-specific quality-of-life scores measured by the Rand Medical Outcomes Study 36-item Health Survey and Incontinence Impact Questionnaire were similar in the two groups (P = 0.306). Women treated by surgery were, on average, more satisfied (79.6%) than those treated by collagen injection (67.2%), but the difference was not significant (P = 0.228). Finally, complications were less frequent and severe with collagen injection: 36 events in 23 subjects for collagen injection versus 84 events in 34 subjects for surgery (P = 0.03).

CONCLUSIONS

One year after intervention, the success rate of collagen injection as a treatment for stress urinary incontinence was about 19% lower than that after surgery. This has to be tempered by the similar changes in quality of life and satisfaction in both groups and that the number and severity of complications were much greater after surgery than after collagen injection. The results of this study indicate that collagen injections might be a worthwhile alternative to surgery for the treatment of stress urinary incontinence.

Urodynamic findings 3 months after radiotherapy in patients treated with conformal external beam radiotherapy for prostate carcinoma

OBJECTIVE

To quantify the effect of radiotherapy (RT) on urodynamic function 3 months after RT in patients with prostate cancer undergoing definitive external beam RT.

PATIENTS AND METHODS

Seventeen patients with clinically localized prostate cancer were accrued into a single-arm prospective study. Sixteen of the patients completed a scheduled multichannel video-urodynamic study at baseline and again 3 months after RT; the urodynamic variables were then compared to assess the nature and extent of urodynamic change caused by RT. Correlations were assessed between these quantitative changes and those in self-assessed qualitative urinary function measured by International Prostate Symptom Score (IPSS), Quality of Life assessment index (QoL) and urinary functional enquiry.

RESULTS

There were significant changes detected by the urodynamic study 3 months after RT in bladder volume at capacity (mean decrease 70 mL) and bladder volume at first sensation when supine (mean decrease 85 mL), and a lower postvoid residual volume (mean 50 mL). There was no significant change in the remaining urodynamic variables (including maximum flow rate and voided volume), nor in bladder compliance, bladder instability or bladder outlet obstruction. The self-assessed qualitative urological function measured by the IPSS, QoL and median urinary frequency/24 h showed no significant change after RT.

CONCLUSIONS

This is the first quantitative study to prospectively evaluate the effect of RT on urodynamics in patients with prostate cancer. Only a few urodynamic variables changed significantly 3 months after RT, while most, including self-assessed qualitative urinary function, did not. This finding corresponds well with the notion that most patients tolerate RT well and that acute RT-induced urinary symptoms resolve successfully, with the return of lower urinary tract function to baseline levels by 3 months after RT.

Current status of injectable agents for female stress urinary incontinence

The purpose of this review is to summarize the results of reports of injectable agents for the treatment of female urinary stress incontinence. Five agents were reviewed: collagen, Teflon, autologous fat, silicone microparticles, and silicone microballoons. Collagen was the most frequently reported agent and yielded short-term cure and improved rates of 74%-100%. This deteriorated to approximately 57% with longer term follow-up. Teflon has similarly lower longer term than short-term success rates, at 33%-76%. The reported local complications and the potential for particle migration have resulted in its lack of widespread acceptance. Autologous fat has yielded the lowest success rate. Longer term success in a small number of silicone microparticle articles was similar to the other injectables at approximately 60%. Early success with silicone microballoons was 70%. The technique is generally free of major morbidity. The indication for injectables is intrinsic sphincter deficiency but hypermobility is not a contraindication. Long-term durability, cost effectiveness, and some safety issues still have to be addressed by further clinical trials.

Female clear cell adenocarcinoma arising within a urethral diverticulum

Clear cell adenocarcinomas arising from female urethral diverticulae are rare. The optimal management of this clinical entity is uncertain. Two cases managed by a combination of surgery and XRT (radiotherapy) are presented. The common histopathological findings and treatment options are highlighted. Individualized patient management in a multi-disciplinary setting is recommended.

Ureteroscopic management of upper tract transitional cell carcinoma in patients with normal contralateral kidneys

PURPOSE

The standard treatment for upper tract transitional cell carcinoma in patients with a normal contralateral kidney is nephroureterectomy with a bladder cuff or segmental ureterectomy. We evaluate whether ureteroscopic tumor resection with vigilant surveillance is a safe alternative in select patients.

MATERIALS AND METHODS

Patients with isolated upper tract filling defects on an excretory urogram and a normal contralateral kidney were diagnosed ureteroscopically with papillary low intermediate grade appearing transitional cell carcinoma. Biopsies of the lesions were obtained, and the tumors were treated with laser ablation or electrofulguration in the same sitting. Patients with cytopathological results of high grade transitional cell carcinoma underwent nephroureterectomy. Surveillance consisted of ureteroscopy every 3 months until tumor-free and ureteroscopy every 6 months thereafter.

RESULTS

Between 1989 and 1998, 23 patients with normal creatinine (mean 1.0, range 0.7 to 1.6) underwent ureteroscopic resection of unilateral upper tract transitional cell carcinoma. On initial biopsy 22 tumors were grade 1 or 2 and 1 was grade 2 to 3. After the primary tumor was treated 8 (35%) patients remained tumor-free and 15 (65%) had multiple recurrences, which were treated ureteroscopically. Mean followup was 35 months (range 8 to 103 months). All 23 patients are alive without evidence of disease progression. At last followup 4 patients (17%) had persistent disease, 4 (17%) elected to undergo nephroureterectomy and 15 (65%) are free of ipsilateral disease for a mean duration of 17 months (range 6 to 77).

CONCLUSIONS

Ureteroscopic treatment of focal low intermediate grade superficial upper tract transitional cell carcinoma is a safe alternative to nephroureterectomy in select patients when vigilant ureteroscopic followup is used.

p53 nuclear accumulation is not associated with decreased disease-free survival in patients with node positive transitional cell carcinoma of the bladder

PURPOSE

Although the majority of patients with node positive transitional cell carcinoma of the bladder have disease progression, a definitive subset is cured by surgery only. Nuclear accumulation of p53 has been associated with disease progression in patients with superficial transitional cell carcinoma and decreased survival in those with muscle invasive disease. We determined whether p53 status would predict survival in a cohort with nodal metastasis.

MATERIALS AND METHODS

We explored the comprehensive database of all 199 radical cystectomies performed at our institution between July 1988 and September 1999. The 59 patients in this database with node positive pathology comprise our study. We performed immunohistochemical analysis of specimens using the MAB1801 antibody with greater than 20% lymph node and primary tumor nucleus staining deemed positive. Additional covariates measured included patient age, sex, pathological disease stage, adjuvant chemotherapy and nodal stage. Disease-free survival curves were generated for the various covariates and compared using the log rank test. The Cox proportional hazards technique was used to determine covariate adjusted p53 survival.

RESULTS

In the cohort overall median disease-free survival was only 21 months, although 18% of patients were disease-free at 5 years. There was evidence of p53 nuclear accumulation in 54% of cases and complete agreement of nodal with bladder p53 nuclear accumulation. No significant baseline differences were noted in the covariates with respect to p53 nuclear accumulation. For stratum specific disease-free survival univariate and multivariate analyses revealed that only pathological stages p0-p2b versus p3-p4 (hazards ratio 2.86, p = 0.03), and nodal stages N2 versus N1 and N3 versus N1 (hazards ratio 3.84, p = 0.01 and hazards ratio 13.3, p = 0.0002, respectively) were significantly associated with prolonged disease-free survival, while p53 nuclear accumulation was not.

CONCLUSIONS

Despite credible evidence for p53 nuclear accumulation prognostication in patients with in situ and invasive transitional cell carcinoma, this marker is not predictive of disease-free survival in node positive disease.

Early experience with small volume periurethral polytetrafluoroethylene for female stress urinary incontinence

PURPOSE

Injectable polytetrafluoroethylene paste has been used to treat female stress urinary incontinence. Since the substance is antigenically nonreactive we postulated that the reported morbidity may be due in part to the relatively large volumes injected. Therefore, we assessed the outcome of injecting small volumes of polytetrafluoroethylene with attention to the durability of success and morbidity.

MATERIALS AND METHODS

A total of 46 women with a median age of 73.8 years (range 26 to 88) with stress urinary incontinence were treated. The procedure was done on an outpatient basis using topical urethral lidocaine and periurethral lidocaine as anesthesia. A 20Fr urethroscope was used to inject polytetrafluoroethylene through an 18 gauge needle periurethrally. Patients were reinjected 1 to 3 months after initial injection if not cured (no incontinence or no pads). Continence was assessed by questionnaire from an interviewer not known to the patient. Subsequent top-up injections were given if required. Morbidity was monitored with clinical examination and imaging as required.

RESULTS

Of the patients 14 (30.4%) were dry, 19 (41.3%) were improved and 13 (28.3%) had treatment failure at a mean of 17.9, 15. 9 and 9.1 months, respectively, after last injection. For cured and improved patients (71.7%) an average of 2 treatments were needed, for a total mean volume of 5.4 cc polytetrafluoroethylene. Using a Kaplan-Meier survival curve the probability of the 14 patients remaining dry without additional polytetrafluoroethylene was 90% at 1 and 60% at 2 years. Outcome was not affected by radiological type of incontinence (that is with or without hypermobility), age, pretreatment bladder instability or previous interventions.

CONCLUSIONS

Periurethral injection of small volumes of polytetrafluoroethylene is effective and safe for treatment of female stress urinary incontinence. Early analysis shows that success is durable with minimal morbidity.

Patient perspective of long-term outcome of augmentation cystoplasty for neurogenic bladder

OBJECTIVES

Although the urologic outcomes of augmentation cystoplasty for neurogenic bladder dysfunction are well known, additional information about the patient perspective is needed. The aim of this study was to assess patient perspective using a standardized questionnaire.

METHODS

Fifty-nine patients, who had undergone augmentation enterocystoplasty as part of reconstruction mainly to correct hyperactive bladders and incontinence, were subjected to a questionnaire after a median of 76.1 postoperative months. The questionnaire addressed medications, catheterization, incontinence, bowel dysfunction, and satisfaction with urinary tract management. The urologic outcomes regarding upper and lower tract changes, complications, and reinterventions were documented as well.

RESULTS

The patients experienced a significant increase in bladder capacity and decrease in pressure at capacity (P < 0.0001). Normal upper tracts remained normal and there was either improvement or stabilization of hydronephrosis. Twenty-four patients (40.6%) had one or more complications, with 21 requiring reinterventions. Twenty-five percent of patients required the reintervention within the first 25 months, and the median time to reintervention was almost 10 years. Thirty-five patients took medications such as anticholinergics, antidiarrheals, or antibiotics. Fifty-six patients were treated with clean intermittent catheterization (CIC) at a mean interval of 4.6 hours. Seven patients had some difficulty with CIC. Thirty-nine patients (67%) were dry, and 17 had mild and 3 severe incontinence. Eleven patients (18.6%) reported bowel dysfunction, although 7 had it preoperatively. Almost all patients were very satisfied with their urologic management.

CONCLUSIONS

The high degree of patient satisfaction attests to the value of the procedure. The complication and reintervention rates underscore the importance of long-term follow-up.

Early experience with intraoperative cavernous nerve stimulation with penile tumescence monitoring to improve nerve sparing during radical prostatectomy

OBJECTIVES

To determine if intraoperative stimulation of the cavernous nerves while monitoring changes in penile tumescence to map the course of these nerves would result in an improvement in nerve sparing and erectile function after radical prostatectomy.

METHODS

Patients were eligible for this pilot study if they were undergoing a radical prostatectomy and were candidates for a nerve-sparing approach. Erectile function was assessed by patient self-reporting and questionnaire before surgery and by patient self-reporting periodically 12 months after surgery. A cavernous nerve stimulator and tumescence-monitoring device was used during radical prostatectomy to identify the course of the cavernous nerves and guide the surgeon in avoiding nerve damage. Patients were monitored for any evidence of complications and/or adverse events for 1 year from time of surgery.

RESULTS

Twenty-six patients were recruited to the trial. Nerve stimulation and tumescence monitoring was performed in 23 patients. Twenty-one of 23 patients demonstrated a tumescence response to intraoperative nerve stimulation. Nineteen of 21 patients reported erectile function preoperatively. Seventeen (89%) of 19 patients demonstrated a tumescence response during surgery. Sixteen (94%) of the 17 patients who demonstrated a response to nerve stimulation and for whom the surgery was guided by the tumescence response reported the ability to have erections after surgery. No side effects due to the use of the device were reported. Only 3 (12%) of 25 patients had positive margins confined to the lateral margin and/or apex whose modifications associated with nerve sparing could conceivably have altered margin status.

CONCLUSIONS

These clinical data suggest that an intraoperative tumescence response to cavernous nerve stimulation may guide the surgeon in preserving cavernous nerves and improving erectile function after radical prostatectomy.

Laparoscopic correction of stress urinary incontinence

The laparoscopic correction of stress urinary incontinence continues to be evaluated. Early results have been encouraging with cure/dry rates equivalent to those with traditional suspensions, but with shorter hospitalization and no significant morbidity. The approach continues to take longer in the operating room than traditional suspensions, although new innovations and refinements have shortened the time. We are still lacking long-term outcome data and well-constructed prospective randomized trials. Cost effectiveness studies are also not consistent.

Collagen injections for genuine stress urinary incontinence: patient selection and durability

The questions of patient selection parameters and durability of response in the use of collagen injections for genuine stress incontinence are addressed. A total of 181 women with a mean age of 64 years (range 26-94) underwent collagen injections for urethral incompetence. Treatment outcome was determined by a change in individual incontinence grades before and after injection. Of the 181 women 42 (23%) are cured, 94 (52%) are improved and 45 (25%) failed. Follow-up in the successful patients, either cured or improved, was a mean of 21 months (range 4-69) after their last collagen injection. No difference in outcome was seen in relation to patient age or pretreatment grade of incontinence. Of the 30 patients with bladder instability, 18 (60%) had a favorable outcome. No significant difference in outcome was seen in patients with or without hypermobility (P = 0.2889). Patients with type III incontinence required the largest amount of collagen for a successful outcome. The persistence of continence in 78 patients who were cured for at least 2 months were plotted on a Kaplan-Meier survival curve. The probability of remaining dry without additional collagen was 72% at 1 year, 57% at 2 years and 45% at 3 years. It was concluded that, collagen injection into the urethra is a safe and well-tolerated procedure. Pretreatment bladder instability may be an adverse factor. Patients with or without hypermobility had equal benefit. Long-term durability was seen. If deterioration occurred repeat collagen injections restored success. The current literature is reviewed and the use of collagen relative to other treatments is discussed.

Followup of intraurethral collagen for female stress urinary incontinence

PURPOSE

We studied patient selection parameters and durability of response of collagen injections for female stress incontinence.

MATERIALS AND METHODS

A total of 187 women 15 to 87 years old (mean age 63) underwent collagen injections for urethral incompetence. Treatment outcome was determined by a change in individual incontinence grades before and after injection.

RESULTS

Of the 187 women 43 (23%) were cured and 97 (52%) improved, while injection failed in 47 (25%). Mean followup in the successful (cured or improved) group was 22 months (range 4 to 69) after the last collagen injection. No difference in outcome was noted in relation to patient age or pretreatment grade of incontinence. Of the 31 patients with bladder instability 13 (42%) had a favorable outcome. No significant difference in outcome was noted in patients with or without hypermobility (p = 0.21235). Patients with type 3 incontinence required the largest amount of collagen for a successful outcome. Persistence of continence in 80 patients who were cured for at least 2 months was plotted on a Kaplan-Meier survival curve. The probability of remaining dry without additional collagen was 71, 58 and 46% at 1 to 3 years, respectively.

CONCLUSIONS

Intraurethral collagen is a safe and well tolerated procedure. Pretreatment bladder instability may be an adverse factor. Patients with or without hypermobility had equal benefit. Long-term durability was noted. If deterioration occurred, repeat collagen injections restored success.

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.

The artificial urinary sphincter for post-radical prostatectomy incontinence: impact on urinary symptoms and quality of life

PURPOSE

We addressed the impact of the artificial urinary sphincter on the health related quality of life and urinary symptoms in men with post-radical prostatectomy incontinence.

MATERIALS AND METHODS

A total of 30 men with an AMS800 artificial urinary sphincter following radical prostatectomy responded to a questionnaire dealing with the impact of the symptoms on activities of daily living and quality of life. We compared these results to those of 31 patients who underwent radical prostatectomy but did not require an artificial urinary sphincter.

RESULTS

Incontinence was minimal in both groups. Irritative symptoms were noted in the artificial urinary sphincter group, as well as some impairment in activities of daily living. No significant differences were noted with respect to quality of life.

CONCLUSIONS

The artificial urinary sphincter is an effective form of therapy for post-radical prostatectomy incontinence but irritative voiding symptoms occur, which tend to limit activities of daily living.

Laparoscopic Burch bladder neck suspension: early results

PURPOSE

The Burch suspension is an effective treatment for stress urinary incontinence due to hypermobility. To decrease the associated morbidity and hospital stay, we attempted the procedure laparoscopically in 46 women.

MATERIALS AND METHODS

All patients had stress incontinence with bladder neck hypermobility. Preoperative testing included cystoscopy, multichannel urodynamics with pressure-flow studies and measurement of Valsalva leak point pressure. Mean patient age was 49.5 years (range 26 to 70).

RESULTS

In 12 patients the laparoscopic approach could not be completed and an open operation was performed. Of the 34 laparoscopic Burch procedures 13 were performed transperitoneally and 21 extraperitoneally. Mean operative time was 196 minutes (range 130 to 300), mean blood loss 96.3 cc (range 50 to 400) and mean postoperative hospital stay 3.2 days (range 1 to 8). Five postoperative complications included hematoma/anemia in 2 patients, transient urinary retention in 1, enterocele in 1 and uterine prolapse in 1. Mean followup was 17.3 months (range 12 to 26). Of the 34 patients only 5 had persistent incontinence postoperatively (3 with stress and urge incontinence, 1 with stress incontinence only and 1 with urge incontinence only). Overall, 85% of the patients are totally dry. With experience the operative time and postoperative stay decreased. The extraperitoneal and transperitoneal approaches provide certain advantages.

CONCLUSIONS

The Burch suspension performed laparoscopically appears to have a favorable morbidity profile with a successful continence outcome. However, there is a steep learning curve to the procedure as manifested by the long operative time.

Penile prosthesis insertion with corporeal reconstruction with synthetic vascular graft material

Difficulty with penile prosthesis insertion may be encountered in patients with severe cavernous scarring or tunica albuginea deficiencies. Eleven patients who underwent penile prosthesis implantation required simultaneous corporeal reconstruction due to prior prosthesis infection and/or erosion in 6, priapism in 2 and Peyronie's disease in 1. One patient underwent prior neophallus construction with a tubularized abdominal wall flap for gender reassignment and 1 had congenitally deficient corporeal bodies. In 4 patients previous additional attempts at prosthesis replacement were unsuccessful. The reconstruction techniques included exposure of the corpora usually through a ventral midline incision and repair with synthetic vascular graft material. Accessory sub-coronal incisions were used when the disease was localized to the distal corpora. Six patients required reconstruction of more than half of the corporeal lengths bilaterally and in 5 smaller portions were repaired. Two patients received a semirigid and 9 an inflatable implant. Mean followup was 46 months (range 5 to 81). One patient required early reexploration for separation of the graft from the tunica and 2 required late surgical revision for distal tip divergence. Healing has been excellent and prosthesis function satisfactory in all patients. Infection, erosion and mechanical failure have not occurred. Penile prosthesis insertion with corporeal reconstruction using synthetic graft material is possible in these cases with acceptable morbidity rates and satisfactory erectile function.

Periurethral injection of collagen in the treatment of urinary stress incontinence: ultrasonographic appearance

OBJECTIVE

To describe the ultrasonographic appearance of collagen injected periurethrally to treat urinary stress incontinence.

PATIENTS AND METHODS

Transvesical and transvaginal ultrasonography (US) was performed 26 times in 23 patients 3 to 36 months after periurethral injection of collagen to treat symptomatic urinary stress incontinence. The patients ranged in age from 23 to 86 (median 54) years. The appearance, location and volume of the collagen were recorded. Clinical data were also obtained.

RESULTS

Transvesical US demonstrated the collagen in 17 of the patients, whereas transvaginal US demonstrated the collagen in all of them. The collagen collections appeared as circumscribed masses at the bladder base and showed various levels of echogenicity with both techniques. However, in patients with more than one deposit of collagen, the collections had similar echogenicity, and echogenicity increased over time in the two patients who underwent serial imaging. In 21 of the patients, the collagen collections were located posterior or lateral to the urethra, and these patients recorded complete or moderate resolution of incontinence. In two of the patients the collections were exophytic, projecting into the bladder lumen; these patients experienced little improvement in their continence.

CONCLUSIONS

US provides a rapid, noninvasive method of assessing collagen after periurethral injection. Transvaginal US is the best method of visualizing such collections.

Inverted papilloma of the upper urinary tract

Inverted papillomas of the upper urinary tract are rare lesions that have a male predominance. The associated symptoms are similar to those of other urothelial neoplasms. The tumors are considered benign and local excision has been advocated by many but long-term followup is lacking. We present a case of a locally excised inverted papilloma of the renal pelvis with a 3.5-year followup. While local excision appears to be ideal treatment, the difficulty with preoperative diagnosis and the reported coexistence of malignancy demand careful patient selection and close long-term followup. The biological potential of recurrence, multicentricity and malignancy is addressed.

Acute urinary retention in men: a comparison of voiding and nonvoiding patients after prostatectomy

Multiple parameters were examined preoperatively to determine if any could predict successful voiding after prostatectomy in male patients who present in acute urinary retention due to benign prostatic hypertrophy. A total of 50 men 50 to 85 years old (mean age 69.5 years) who presented with this clinical picture was investigated with multichannel urodynamic studies, and completed the American Urological Association (AUA) symptom score for benign prostatic hypertrophy preoperatively and postoperatively. All patients underwent prostatectomy. Mean retention volume was 1,172 cc (range 500 to 2,100). Mean preoperative and postoperative AUA symptom scores were 15.5 and 5.0, respectively. At 3 months postoperatively 45 patients (90%) were able to void without catheterization. At 16.6 months 5 patients still required clean intermittent catheterization to empty the bladder. Postoperatively, there was a statistically significant improvement in AUA symptom score, opening voiding pressure and peak flow rate. The AUA symptom score was not predictive of either impending acute retention or normal voiding after prostatectomy. In our patients no preoperative parameters were statistically different between those voiding and those on clean intermittent catheterization. However, poor sensation, large retention volumes, lack of instability and no voluntary detrusor contractions were more common in the nonvoiding men.

Urodynamic comparison of ileum vs. sigmoid in augmentation cystoplasty for neurogenic bladder dysfunction

We performed multichannel urodynamics before and after augmentation cystoplasty in 26 patients (11 females, 15 males) to determine which bowel segment is best to achieve a large volume and low pressure reservoir. All 26 patients had a neurogenic cause for their bladder dysfunction. Ileum was used in 14 patients and sigmoid was used in 12 patients. Detubularization was performed in all patients. Capacity improved significantly in both the ileum and the sigmoid group after surgery. When detubularized ileum was used, the maximum amplitude of uninhibited reservoir contractions was significantly improved or eliminated postoperatively. When sigmoid was used, uninhibited reservoir contractions did not significantly improve postoperatively and were, in fact, more common than preoperatively. Despite the detubularization, pressure waves were identified in 15 of the 26 patients postoperatively. There was significant improvement in end filling pressures at capacity (compliance) with both ileum and sigmoid postoperatively. However, end filling pressures were significantly higher in the sigmoid group. In conclusion, good capacity was achieved with both ileum and sigmoid postoperatively. However, ileum provided lower reservoir pressures and better compliance. We feel that urodynamically detubularized ileum is better suited than sigmoid for augmentation cystoplasty in patients with neurogenic bladder dysfunction.