Metal nanofoams via a facile microwave-assisted solvothermal process

A novel, facile, non-hazardous, low temperature/pressure microwave solvothermal method of producing pure copper, silver, and nickel metal nanofoams is presented.

Randomized multicenter clinical trial of myofascial physical therapy in women with interstitial cystitis/painful bladder syndrome and pelvic floor tenderness

PURPOSE

We determined the efficacy and safety of pelvic floor myofascial physical therapy compared to global therapeutic massage in women with newly symptomatic interstitial cystitis/painful bladder syndrome.

MATERIALS AND METHODS

A randomized controlled trial of 10 scheduled treatments of myofascial physical therapy vs global therapeutic massage was performed at 11 clinical centers in North America. We recruited women with interstitial cystitis/painful bladder syndrome with demonstrable pelvic floor tenderness on physical examination and a limitation of no more than 3 years' symptom duration. The primary outcome was the proportion of responders defined as moderately improved or markedly improved in overall symptoms compared to baseline on a 7-point global response assessment scale. Secondary outcomes included ratings for pain, urgency and frequency, the O'Leary-Sant IC Symptom and Problem Index, and reports of adverse events. We compared response rates between treatment arms using the exact conditional version of the Mantel-Haenszel test to control for clustering by clinical center. For secondary efficacy outcomes cross-sectional descriptive statistics and changes from baseline were calculated.

RESULTS

A total of 81 women randomized to the 2 treatment groups had similar symptoms at baseline. The global response assessment response rate was 26% in the global therapeutic massage group and 59% in the myofascial physical therapy group (p=0.0012). Pain, urgency and frequency ratings, and O'Leary-Sant IC Symptom and Problem Index decreased in both groups during followup, and were not significantly different between the groups. Pain was the most common adverse event, occurring at similar rates in both groups. No serious adverse events were reported.

CONCLUSIONS

A significantly higher proportion of women with interstitial cystitis/painful bladder syndrome responded to treatment with myofascial physical therapy than to global therapeutic massage. Myofascial physical therapy may be a beneficial therapy in women with this syndrome.

Tolterodine is equally effective in patients with mixed incontinence and those with urge incontinence alone

OBJECTIVE

To examine the efficacy of tolterodine, an antimuscarinic agent with a bladder-selective profile, in patients with mixed incontinence (MI, stress and urge) compared with patients with urge incontinence (UI) alone.

PATIENTS AND METHODS

The study included 239 patients with MI (urge predominating) and 755 with urge incontinence alone from a single-blind, multicentre trial of 1380 patients (80% female) with an overactive bladder. Those completing the trial were analysed 'per-protocol'. After a 7-day washout and a 3-day run-in to collect baseline information, patients were treated with tolterodine twice daily for 16 weeks. The two groups were compared for incontinence episodes/24 h, voiding frequency, nocturia episodes and pad usage after 16 weeks of treatment.

RESULTS

After 16 weeks the median changes from baseline for all voiding variables were statistically significant for the MI and the UI groups (P < 0.001), with no apparent significant between-group differences. The median percentage reduction in incontinence episodes from baseline was 67% for the MI and 75% for the UI groups (P = 0.39). 'Dry' rates for the MI and UI groups at the end of the study were 39% (66/171) and 44% (243/552), respectively, whilst 24% of patients in each group (MI 40/170; UI 130/551) achieved a voiding pattern of < 8 voids/24 h. 'Cure' rates for nocturia and the reduction in the number of patients not using pads used were also similar between the groups.

CONCLUSION

Tolterodine is as effective in reducing leakage and other symptoms of an overactive bladder in patients with MI as it is in patients with UI alone.

Initiation of nonselective alpha1-antagonist therapy and occurrence of hypotension-related adverse events among men with benign prostatic hyperplasia: a retrospective cohort study

BACKGROUND

Treatment of benign prostatic hyperplasia (BPH) with nonselective alpha1 antagonists such as terazosin, doxazosin, and prazosin results in blood pressure reduction due to vasodilation.

OBJECTIVE

Using claims data from a large Medigap plan, we examined the effect of initiating nonselective alpha1-antagonist therapy on the incidence of hypotension-related adverse events likely to be associated with vascular alpha-adrenoreceptor antagonism in patients with BPH.

METHODS

Medical and prescription claims data were obtained from the MEDSTAT Group for 53,824 men with a diagnosis code for BPH during the study period (January 1995-December 1997). We examined the rate of possible hypotension-related adverse events (diagnosis codes for hypotension, syncope, dizziness, fractures, and other injuries) per 10,000 person-days for men who began therapy with alpha1 antagonists and for a random sample of nonusers, stratified by prior use of other antihypertensive agents.

RESULTS

After adjusting for baseline differences in event rates, those who initiated alpha1-antagonist therapy (n = 1564) had a significantly greater increase in hypotension-related adverse-event rates in the 4 months after initiation (vs the 4 months before initiation) than randomly selected nonusers (n = 8641) (increase of 1.82 vs decrease of 0.02 events per 10,000 person-days among those not taking antihypertensive agents; increase of 0.94 vs 0.69 events per 10,000 person-days among those taking other antihypertensive agents; P < 0.01). This increase began earlier and lasted longer among patients taking other antihypertensive agents. Those who discontinued their alpha1 antagonist had a higher rate of hypotensive events at baseline than those who did not (5.09 vs 3.19 events per 10,000 person-days among those using other antihypertensive agents; 3.62 vs 2.27 events per 10,000 person-days among those not using other antihypertensive agents; P < 0.05).

CONCLUSIONS

Initiation of nonselective alpha1-antagonist therapy for the treatment of BPH increases the risk of a cluster of clinical events consistent with vascular alpha-adrenoreceptor antagonism. This effect is seen during a 4-month period around the initiation date. Prior initiation of other antihypertensive medication increases this effect. Urologists should consult with a patient's primary care physician about use of other antihypertensive agents before initiating nonselective alpha1-antagonist therapy for BPH.

Stress and symptoms in patients with interstitial cystitis: a life stress model

Objectives. Stress-related exacerbation of interstitial cystitis (IC) symptoms has frequently been reported. Previous research has found stress-related IC symptom exacerbation in an experimental model. However, this relationship has not been objectively examined with daily life stressors. We used a prospective daily symptom diary method to investigate the relationships among stress and bladder symptoms in patients with IC and age-matched healthy controls.Methods. Forty-five previously diagnosed female patients with IC completed a bladder symptom and stress diary nightly for 1 month; 31 female age-matched healthy controls completed a similar diary for 7 days. The symptom questions were modified from the Interstitial Cystitis Data Base study.Results. Patients reported greater mean daily stress, bladder pain, urgency, and daytime and nocturnal frequency than controls (all P values less than 0.001). Among all patients, a significant relationship between stress and urgency was observed. In addition, a significant relationship between stress and pain was observed among patients with moderate and severe disease. As the disease severity increased, more pronounced relationships between stress and the symptoms of urgency and pain were evidenced. Greater stress was associated with greater nocturnal frequency among patients with more severe disease. These stress-symptom relationships were not observed among the controls.Conclusions. Higher levels of stress were related to greater pain and urgency in patients with IC but not in the controls. In addition, the relationship of stress and these IC symptoms was stronger among patients with more severe disease. The results indicate that life stress is associated with greater IC symptoms, particularly among patients whose disease is not well controlled.

Comparison of cystoscopic and histological findings in patients with suspected interstitial cystitis

PURPOSE

Although the exact etiology of interstitial cystitis remains elusive, bladder inflammation appears to be common in many patients. The National Institutes of Health (NIH) have established diagnostic criteria for interstitial cystitis based on the presence of irritative voiding symptoms in the absence of other identifiable pathology. Cystoscopic examination with hydrodistention performed in patients under anesthesia is part of the NIH diagnostic criteria. We determine if the severity of cystoscopic findings correlated with histological evidence of inflammation in patients with suspected interstitial cystitis.

MATERIALS AND METHODS

A total of 69 patients who met NIH symptom criteria for interstitial cystitis and underwent cystoscopy, hydrodistention and bladder biopsy under anesthesia were reviewed. There were 2 investigators blinded to the histological data who independently reviewed operative reports. A urological pathologist blinded to the clinical data reviewed biopsies for inflammation severity. Cystoscopic and histological findings were then converted to a numeric scale. Numeric data were analyzed using the Pearson correlation coefficient.

RESULTS

Cystoscopic examination revealed no evidence of interstitial cystitis in 6 patients (9%), mild changes in 27 (39%), moderate changes in 23 (33%) and severe changes in 13 (19%). Histological examination revealed no inflammation in 21 patients (30%), mild inflammation in 28 (41%), moderate inflammation in 11 (16%) and severe inflammation in 9 (13%). Histological scores correlated poorly with total and scaled cystoscopic severity scores (r = 0.295 and 0.349, respectively).

CONCLUSIONS

Severity of cystoscopic findings observed during hydrodistention with anesthesia does not appear to correlate with the degree of inflammation identified histologically in patients with suspected interstitial cystitis.

Resolution of urge symptoms following sling cystourethropexy

PURPOSE

Persistence of urinary urge symptoms in women after pubovaginal sling cystourethropexy is a distressing problem. We assess the ability of preoperative video urodynamics to identify patients in whom urinary urge symptoms failed to resolve postoperatively.

MATERIALS AND METHODS

The records of 84 consecutive women who had undergone pubovaginal sling cystourethropexy were reviewed. Preoperative video urodynamics revealed stress urinary incontinence in all cases and concomitant detrusor instability in some. Cases of motor urge, defined as urge symptoms plus detrusor instability, were divided into low and high pressure categories. Patients with urge symptoms but no demonstrable detrusor instability on video urodynamics were diagnosed with sensory urge. Postoperatively complete urge resolution was defined as total absence of symptoms without pharmacological therapy. Mean followup was 26.7 months (range 2 to 62).

RESULTS

Of the 84 patients 41 with motor urge and 28 with sensory urge had preoperative urge symptoms. Complete resolution or improvement in urge symptoms occurred in 24 (58.5%) and 7 (17.1%) of the motor urge, and 11 (39.3%) and 9 (32.1%) of sensory urge cases, respectively. Of the 41 patients with motor urge 23 had low pressure instability, which completely resolved in 21 (91.3%) and improved in 2 (8.7%). Of the 18 remaining patients with high pressure motor urge only 5 (27. 8%) had complete resolution of urge and 5 (27.8%) had improvement.

CONCLUSIONS

Our results suggest that patients with low pressure motor urge are significantly more likely to experience resolution of urinary urge symptoms after pubovaginal sling cystourethropexy than those with high pressure motor urge or sensory urge.

Stress and symptomatology in patients with interstitial cystitis: a laboratory stress model

PURPOSE

Although patients with interstitial cystitis frequently report symptom exacerbation due to stress, to our knowledge this association has not been empirically examined. We evaluated the effects of a laboratory mental stress challenge on symptoms of urgency and pain in patients with interstitial cystitis and healthy controls.

MATERIALS AND METHODS

A total of 14 females with interstitial cystitis and 14 age matched controls participated in a laboratory session, including a 60-minute baseline measurement, 25 minutes of mental stress tasks and 75 minutes of recovery. Acute symptoms of pain and urgency were assessed at voiding 15 minutes before the stressor, and 25, 70 and 100 minutes after stressor onset. Chronic symptoms were evaluated by questions from the Interstitial Cystitis Data Base survey.

RESULTS

Patients reported significantly greater pain and urgency than controls at all 4 voidings (p <0.005). Pain increased in patients from the prestressor point to 25 minutes after stressor onset (p <0.005), remained elevated at 70, and decreased between 70 and 100. At 100 minutes patient pain remained significantly elevated above baseline (p = 0.018). Patient urgency was significantly elevated over baseline by 70 minutes after stressor onset (p <0.001) and significantly decreased between 70 and 100 minutes (p <0.002). Controls had no symptom changes with stress.

CONCLUSIONS

These findings indicate that an acute stressor evokes increased symptoms of pain and urgency in patients with interstitial cystitis but not in controls. Findings are consistent with sympathetic effects on inflammatory processes in interstitial cystitis. However, further evaluation of the mechanisms underlying stress related interstitial cystitis symptom exacerbation is needed to provide a more comprehensive understanding of these phenomena.

Spinal cord neuromodulation for voiding dysfunction

A clear understanding of the pathophysiology and neurophysiologic effect of neuromodulation is lacking. Apparently there is a balance of efferent and afferent negative and positive feedback loops that are augmented by external electrical stimulation. This effect may be dramatic even in patients who have have not benefited from virtually every other form of treatment.

Fascia lata sling cystourethropexy for the management of female urinary incontinence

Pubovaginal sling cystourethropexy has rapidly become one of the primary surgical treatment options for women with urinary incontinence. The procedure has evolved over time with regard to clinical indications, patient selection criteria and surgical techniques. This article reviews the historical development of pubovaginal sling cystourethropexy, including recent technical advances. The selection of graft materials is considered and the utility of fascia lata emphasized. Clinical results and potential complications of the procedure are also reviewed.

Alterations in constituent urinary proteins in response to bladder outlet obstruction in rats

PURPOSE

Benign prostatic hyperplasia, resulting in bladder outflow obstruction, induces well recognized clinical symptoms and morphologic bladder changes. Despite these phenomenon, relatively little is known with regard to the precise molecular events occurring in the bladder as a consequence of obstruction. In an effort to screen for alterations in bladder gene expression induced by obstruction, and/or alterations in uroepithelial integrity, this study compared pre- and post-obstructive constituent urinary proteins in an animal model.

MATERIALS AND METHODS

Outlet obstruction was created using a previously established model system. Experimental animals were surgically obstructed for either 2 or 7 days, at which time the urine was aspirated and the bladders removed and weighed. Urinary proteins were separated using 2-D PAGE. Following comparison of sham versus experimental animals, microsequencing was performed on proteins that were down regulated.

RESULTS

Duplicate experiments confirmed the presence of outflow obstruction. Statistically significant increases (p <0.01) in bladder weights were seen at 2 and 7 days in the obstructed groups as compared with both sham and control groups. 2-D PAGE demonstrated a down regulation of three urinary proteins post-obstruction. Microsequencing identified these proteins as prostatic steroid-binding protein C3 precursor (pI=5.5, MW=15000), glandular kallikrein 9 (S3) precursor (pI=6.2, MW=19000), and glandular kallikrein 8 (P1) precursor (pI=6.2, MW=33000).

CONCLUSIONS

Bladder outflow obstruction alters constituent urinary protein composition in an animal model system. The precise etiology of these alterations remains to be defined.

Transurethral collagen injection for treatment of postprostatectomy urinary incontinence in men

OBJECTIVES

Transurethral injection of glutaraldehyde cross-linked bovine collagen has recently been advocated as a potentially useful treatment modality for management of urinary incontinence. The reported clinical experience with urethral collagen injection in adult males has been limited.

METHODS

This study summarizes the current literature and reviews the clinical results of collagen injection in a group of 25 men with incontinence after either transurethral or radical prostatectomy.

RESULTS

The overall results in this series were disappointing. Only 2 patients (8%) achieved significant improvement with this treatment. Eight patients (32%) experienced minimal improvement in symptoms, and 15 (60%) remained incontinent with no improvement in symptoms after collagen injection. The number of injection procedures and volume of collagen material implanted did not correlate with clinical outcome. Five patients (20%) have subsequently required placement of an artificial urinary sphincter to control their incontinence.

CONCLUSIONS

We conclude that transurethral injection of glutaraldehyde cross-linked bovine collagen has a limited role in the management of urinary incontinence in adult men after prostatectomy.

Impaired bone growth after ileal augmentation cystoplasty

PURPOSE

We evaluated how ileal augmentation cystoplasty predisposes growing animals to hyperchloremic acidosis and abnormal skeletal development.

MATERIALS AND METHODS

Weanling female Wistar rats weighing 35 to 50 gm. underwent ileal augmentation cystoplasty or sham operation consisting of a similar ileal resection and closure (ileoileostomy). Both groups were stressed with 1% ammonium chloride loading. Serial bone densitometry measurements, weight and blood gas studies were performed in an 8-week growth period. Femur bone ashing and mineral analysis, arterial blood gas studies and serum bone mineral determinations (calcium, magnesium and phosphorus) were obtained at study conclusion.

RESULTS

Augmented and control animals had similar serum calcium, phosphorus and magnesium concentrations. In augmented animals metabolic acidosis developed with respiratory compensation and decreased mean serum bicarbonate plus or minus standard deviation compared to controls (18.34 +/- 3.23 versus 21.76 +/- 2.46 mEq./l., p <0.003). Growth curves of both groups were similar, although augmented animals had shorter femur lengths than controls (p <0.04). Bone density results were mixed. Whole body bone density was decreased (p <0.05), while bone ash and mineral content (except phosphorus) were not. When rats with augmentation cystoplasty given 1% ammonium chloride were fed an equal molar diet of sodium bicarbonate, metabolic acidosis and bone mineral density normalized to control values.

CONCLUSIONS

Acid challenged weanling rats that underwent ileal augmentation cystoplasty demonstrated decreased bone mineral density and growth compared to controls. These changes were prevented by bicarbonate replacement.

Comparative cost analysis of collagen injection and fascia lata sling cystourethropexy for the treatment of type III incontinence in women [ssee comments]

PURPOSE

We examined the cost of 2 common forms of surgical treatment of genuine stress urinary incontinence due to intrinsic sphincter deficiency, that is sling cystourethropexy and periurethral collagen injection.

MATERIALS AND METHODS

Between May 1994 and July 1995, 14 women with intrinsic sphincter deficiency underwent sling cystourethropexies. A total of 14 matched patients with intrinsic sphincter deficiency underwent endoscopic collagen injection during the same period.

RESULTS

The total cost per treatment of fascia lata sling cystourethropexy ($10,382) was 2.1 times greater than that for collagen injection ($4,996, p < 0.001). At an average followup of 14.9 months for fascia lata cystourethropexy and 21.3 months for collagen injection, 71.4% of patients in the former and 26.7% in the latter groups were completely continent (p = 0.05). One or no pads were used daily by 85 and 40% of the patients, respectively.

CONCLUSIONS

Fascia lata sling cystourethropexy may be a more cost-effective surgical treatment than periurethral endoscopic collagen injection for treating genuine stress urinary incontinence in women with intrinsic sphincter deficiency when the greater success rate of the former procedure is considered.

Treatment of stress urinary incontinence in women with urethral hypermobility and intrinsic sphincter deficiency

PURPOSE

We compared 2 treatment modalities (sling cystourethropexy and periurethral collagen injection) in patients with intrinsic sphincter deficiency alone or with urethral hypermobility (combined stress urinary incontinence).

MATERIALS AND METHODS

We retrospectively reviewed a series of 50 consecutive patients treated surgically for intrinsic sphincter deficiency during a 2-year period. All patients were evaluated by history and physical examination to assess urethral hypermobility and urodynamic testing. Intrinsic sphincter deficiency was assessed by abdominal leak point pressure and video urodynamics. Of the 50 patients 28 underwent a pubovaginal sling operation and 22 received a periurethral injection of collagen.

RESULTS

Of the patients studied 40% had combined stress urinary incontinence. A pubovaginal sling procedure resulted in a cure rate of 81% in this group, compared to 25% for periurethral injection of collagen.

CONCLUSIONS

A subgroup of women exists with combined stress urinary incontinence due to urethral hypermobility and intrinsic sphincter deficiency. When treated with sling cystourethropexy women with combined stress urinary incontinence do as well or better than those with intrinsic sphincter deficiency alone and those treated with periurethral collagen injection do worse.

Design and development of an electromechanical ultrasound probe holder for urodynamics testing

A prevalent difficulty in urodynamics studies employing ultrasonography is associated with the manual application of the imaging transducer to the perineum. We have developed an electromechanically operated device for remote positioning of an ultra-sound probe during voiding studies of the lower urinary tract. The mechanical arm holds the probe inside a funnel that is mounted underneath a modified portable commode on which the patient is seated. External manually operated mechanical slides are used to translate the probe along the three primary axes for initial lateral and vertical positioning. Backwards/forwards and left/right pivoting of the transducer is then accomplished via linear stepper motors that are operated with a hand-held controller. A preliminary evaluation has shown that the device is easy to use, safe, and allows excellent visualization of the bladder outlet and proximal urethra in both male and female patients. The capability to remotely adjust the imaging angle allows the patient to void in a more private setting behind a drawn curtain, thereby minimizing the psychological distress associated with this test and facilitating the acquisition of more physiological test results.

A change in practice: current urologic practice in response to reports concerning vasectomy and prostate cancer

OBJECTIVE

To examine the practice patterns of urologists performing vasectomy in response to studies reporting an increased risk of prostate cancer in vasectomized men.

DESIGN

A mailed survey.

SETTING

A university medical institution.

PARTICIPANTS

One thousand five hundred randomly selected United States urologists under the age of 65 years.

MAIN OUTCOME MEASURE

Urologists reported practice patterns of vasectomy in response to studies showing possible link between vasectomy and prostate cancer.

RESULTS

A response rate of 51% (759/1,500) was obtained. Although > 90% state that these studies have had little or no effect upon their practice of vasectomy, 27% screen vasectomized men earlier for prostate cancer, and 20% would be reluctant to recommend a vasectomy to a man with a strong family history of prostate cancer.

CONCLUSIONS

Over one fourth of urologists who screen for prostate cancer have altered their screening patterns even though they responded that the studies have not affected their practice patterns.

Laparoscopic urethral sling for treatment of intrinsic sphincter deficiency

The surgical treatment of intrinsic sphincter deficiency, or Type III genuine stress urinary incontinence, has traditionally been accomplished by sling cystourethropexy, the placement of an artificial urinary sphincter, or periurethral injection. We developed a laparoscopic approach for the performance of a sling cystourethropexy as an alternative to the open approach and herein describe our experience. We have found that a laparoscopic sling cystourethropexy is feasible, but at the present time, we have been unable to demonstrate any significant advantages to the patient in terms of decreased cost or convalescence compared with the open vaginal sling cystourethropexy.

Spine update. Urological management in patients with spinal cord injuries

In the past, urologic complications contributed greatly to spinal cord injury mortality. With improved evaluation and treatment, this is no longer the case. Treatment should be guided by urodynamic data gathered after the resolution of spinal shock symptoms. Goals of treatment are to facilitate voiding, reduce incontinence, and prevent renal damage. Indwelling catheters are almost never indicated for long-term treatment of the neurogenic bladder. Commonly used treatments include intermittent catheterization, condom catheter drainage with sphincter ablation, and pharmaceutical manipulation. Electrical stimulation of sacral nerve roots shows promise for future therapy.

Efficacy of pelvic floor muscle exercises in women with stress, urge, and mixed urinary incontinence

OBJECTIVES

Our purpose was (1) to evaluate the efficacy on an intent-to-treat basis of a 3-month course of pelvic floor muscle exercises as first-line therapy for urinary incontinence in consecutive women seen in a tertiary care center with stress, urge, and mixed urinary incontinence and (2) to evaluate whether a specially designed audiotape improves compliance and efficacy of the exercises.

STUDY DESIGN

A prospective randomized trial wa conducted with 71 women seen for treatment of urinary incontinence in two tertiary care center referral clinics (in the departments of gynecology and urology). The primary outcome measure was the number of incontinent episodes, as documented with a 3-day voiding diary. Statistical analysis included t tests and Wilcoxon signed-ranks test, as appropriate. A value of p < or = 0.05 was considered significant.

RESULTS

Forty-four percent of all enrollees had a > or = 50% improvement in the number of incontinent episodes per day. This increased to 56% of enrolles who completed the treatment course. For all enrollees the mean number of incontinent episodes per day decreased from 2.6 to 1.7 for genuine stress incontinence, from 3.5 to 2.3 for detrusor instability, and from 3.9 to 3.2 for mixed incontinence. For enrollees who completed the 3-month course the mean number of incontinent episodes per day decreased from 2.5 to 1.4 for genuine stress incontinence, from 2.8 to 0.5 for detrusor instability, and from 3.0 to 1.7 for mixed incontinence. Six months after completing the course of exercises approximately one third of all enrollees reported that they continued to note good or excellent improvement and desired no further treatment. There was no difference in outcome measures and no difference in compliance between the women who exercised with the aid of the audiotape and those who exercised according to our usual office routine (p > 0.05).

CONCLUSIONS

One third of all participants remained improved to the patient's satisfaction 6 months after completion of a risk-free, inexpensive, simply provided therapy. Our audiotape did not improve our success rate or decrease the dropout rate. In this study the exercises were equally effective for all three urodynamic diagnoses. Inexpensive methods that could be used by primary care providers to improve the success rate of this therapy merits further attention.

Laparoscopic urethral sling for the treatment of intrinsic urethral weakness (type III stress urinary incontinence)

The treatment of intrinsic urethral weakness (type III stress urinary incontinence) has traditionally been accomplished by the performance of a sling cystourethropexy, the placement of an artificial urinary sphincter, or periurethral injection. Herein we describe our experience using laparoscopy to perform a sling cystourethropexy.

Survival of patients with localized prostate cancer treated with percutaneous transperineal placement of radioactive gold seeds: stages A2, B, and C

Between 1984 and 1991, a total of 177 patients with adenocarcinoma of the prostate were treated with transcutaneous, transperineal radioactive gold seeds. Of these 177 patients, 20 were determined to have pelvic lymph node involvement and were excluded from this review. The remaining 157 patients received a median radioactivity dose of 164 mCi with a median follow-up of 48 months. Cancer-specific survival at 5 years was 100% for stage A2 and B1, 90% for stage B2, and 76% for stage C cancer. Covariates of grade, total radioactivity administered, age of the patient, and number of seeds implanted did not influence disease-free survival in a statistically significant manner. Significant complications were observed in two patients. The survival rates of patients treated with 198Au seed implantation for localized cancer are equivalent or better when compared to historical data of patients treated with 125I implantation, external beam radiotherapy, combination radioactive gold seed implantation and external irradiation, and radical prostatectomy. In addition, these comparable survival rates using interstitial 198Au seeds may be achieved with less morbidity.

Laparoscopic partial nephrectomy: initial experience and comparison to the open surgical approach

During an 18-month period, 6 laparoscopic partial nephrectomies were attempted, 4 of which were successful. The surgical technique was modified and improved between cases aided by new laparoscopic instrumentation, such as the argon beam coagulator and the 7.5 MHz. ultrasonic sector scanning system. In a retrospective comparison between laparoscopic and open partial nephrectomy, estimated blood loss was 525 ml. for the former versus 708 ml. for the latter procedure. However, operating time was more than 2 hours longer with the laparoscopic approach. The major advantages of the laparoscopic procedure appear to be a more rapid return to full diet, less postoperative pain and less requirement for parenteral narcotics. Despite the small size of this series and limited followup data, convalescence may be shortened by 4 weeks after laparoscopic partial nephrectomy. Patients with benign diseases of the kidney, especially with a duplicated collecting system, who require partial nephrectomy may be considered candidates for the laparoscopic approach. The advantages to the patient, however, may be offset by the technical demands on the surgeon.

Urethral reconstruction after pelvic fracture with urethral disruption: the gold standard

Traumatic injuries with disruption of the posterior urethra frequently occur in patients who sustain pelvic fracture. Several endoscopic and open reconstructive techniques have been proposed for management of such urethral injuries. Treatment objectives include restoration of physiological urethral voiding with preservation of urinary continence and sexual function. This article summarizes the current recommendations for evaluation and treatment of patients with traumatic posterior urethral injuries. The various reconstructive techniques are reviewed and selection criteria and clinical outcomes are evaluated.

Laparoscopic approaches to the treatment of intrinsic urethral weakness (type III stress urinary incontinence)

The treatment of intrinsic urethral weakness (Type III stress urinary incontinence) has traditionally been accomplished by the performance of a sling cystourethropexy or the placement of an artificial urinary sphincter. As experience with operative laparoscopy continues to increase, the possibility of performing these procedures from a laparoscopic approach becomes realistic. We report our experience with the laparoscopic performance of a sling cystourethropexy and placement of an artificial urinary sphincter in the canine model. On the basis of initial results, we believe these techniques are feasible in human subjects.

Compartment syndrome: an unusual complication of the lithotomy position

The compartment syndrome is a rare complication of surgery in the lithotomy position, but one that may result in neurovascular damage and permanent disability. Herein, we present a case of bilateral three-compartment syndrome following urethroplasty in the dorsolithotomy position, with review of the literature and discussion of the causes and possible means to prevent this complication.

Testicular cancer in blacks. A multicenter experience

BACKGROUND

The rarity of testis tumor in black patients has made the study of a large series difficult. Much of the epidemiologic and clinical information regarding this neoplasm in this population is in dispute, including data on incidence, prognosis, histologic distribution, age and stage at presentation, and side distribution.

METHODS

A retrospective review of 66 blacks with testicular tumors from seven military medical centers was performed.

RESULTS

Similar results were found for blacks with testis tumor to those of the general testis cancer population regarding prognosis, side distribution, and age of onset for nonseminoma and interstitial tumors. There is a slight increase in the expected number of interstitial tumors in blacks, but the distribution between seminoma and nonseminoma is similar to the general population. The mean age of presentation for seminoma in blacks was younger than that of the general testis cancer population. For testis tumor treated at the same institution, there was an increased delay of diagnosis in blacks compared with whites. The number of new cases of testicular cancer between 1979 and 1991 at one major center was increased for whites but not for blacks. The availability of cisplatin-based combination chemotherapy has resulted in an improved prognosis for blacks, as has already been demonstrated for white populations.

CONCLUSIONS

Testis tumor in blacks behaves similarly to testis tumor in the general population except that in blacks there are more interstitial tumors and the mean age of presentation for seminoma is younger. Further, there is an increased delay in diagnosis for blacks compared with whites, but the incidence of this tumor in this population does not appear to be increasing. Cisplatin-based chemotherapy has significantly improved survival in this population.

Direct vision internal urethrotomy using topical anesthesia

A consecutive series of 18 patients underwent attempted direct vision internal urethrotomy (DVIU) under topical lidocaine anesthesia. The procedure was completed successfully in 15 of 18 (83%) patients. In these patients 12 of 15 (80%) reported either minimal or no discomfort. Direct vision internal urethrotomy using topical lidocaine anesthesia is a safe and cost effective procedure.

Lidocaine as topical anesthesia for bladder mappings and cold-cup biopsies

We describe the use of lidocaine as a topical anesthetic for 35 patients undergoing random bladder biopsies (bladder mappings) and cold-cup resection of small bladder lesions. Serum lidocaine levels were measured 7 to 10 minutes after instillation of the anesthetic using fluorescent polarization immunoassay. Adequate pain control was noted in 33 of 35 patients (94%), with negligible serum lidocaine levels noted in all 35. One patient had a 2 cm. tumor on the anterior wall of the bladder making resection with topical anesthesia suboptimal and 1 patient required 1 mg. supplemental intravenous midazolam hydrochloride to complete the procedure. We conclude that topical lidocaine is a safe, inexpensive and effective mode of anesthesia for bladder mappings and cold-cup biopsies of small bladder lesions. However, it may be inadequate for lesions large enough to require resection rather than cold-cup biopsy and those at poorly accessible regions of the bladder.

Randomized clinical trial comparing balloon dilatation to transurethral resection of prostate for benign prostatic hyperplasia

To evaluate the effectiveness and clinical outcome of patients treated by balloon dilatation of the prostate (BDP) compared with transurethral resection of the prostate (TURP) we performed a prospective, randomized clinical trial. Fifty-one men were randomized to either BDP or TURP. Both groups demonstrated a significant decrease in symptom score from preoperative levels (TURP 13.6 to 6.0 [p < 0.05]; BDP 14.1 to 8.1 [p < 0.01] at 1 year). The TURP group improved peak urinary flows; while, after initial improvement, the balloon group returned to pre-procedure levels. At twelve months 14 of 19 BDP patients (74%) and 14 of 18 TURP patients (78%) considered themselves improved. BDP results in symptomatic improvement; however, the effect may not persist. Objective improvement after BDP does not always occur. The morbidity of BDP is low and compares favourably to that of TURP. Thus BDP does not appear to be as effective as TURP and may offer only temporary relief of symptoms.

Ogilvie's syndrome: a potential complication of vaginal surgery

Ogilvie's syndrome is a well described disorder of the gastrointestinal tract and is characterized by marked dilatation of the distal colon without mechanical obstruction. There are numerous proposed etiologies for this syndrome, which include an association with certain medical conditions, medications and major abdominal surgery. The occurrence of Ogilvie's syndrome, however, is not widely reported following vaginal operations. We present 3 cases in which procedures on the bladder neck performed through the vagina resulted in the development of postoperative Ogilvie's syndrome. Early diagnosis and treatment of this syndrome are important to avoid significant morbidity and mortality.

Anomalies associated with myelodysplasia

The records of 181 patients with myelodysplasia were reviewed. The prevalence of associated genitourinary anomalies as well as cardiac, facial, anal, and tethered cord were determined. The prevalence of congenital malformations associated with myelodysplasia were less in this series than in previous reports.

Management of the bladder outlet in patients requiring enterocystoplasty

We reviewed 30 patients who required augmentation enterocystoplasty and a procedure to modify the bladder outlet for the treatment of intractable incontinence. Of the 30 patients 16 were treated with simultaneous cystoplasty and an outlet procedure, 6 initially underwent an outlet procedure followed by cystoplasty and in 8 cystoplasty was performed first with a subsequent operation to modify the bladder outlet. Continence was achieved in 29 patients. The current methods for evaluation of the bladder and its outlet are reviewed, focusing on the predictive value of preoperative testing to determine which patients require cystoplasty and an outlet modifying procedure.

Evaluation and management of incontinence after implantation of the artificial urinary sphincter

Despite the fact that the AS-800 artificial urinary sphincter represents a significant advance in the treatment of urinary incontinence, for many reasons, incontinence persists or recurs in a small percentage of cases. This is often a challenging problem to manage; however, a logical and sequential approach (as outlined in the algorithm in Figure 2) will aid in successful diagnosis and treatment.

Salvage posterior urethroplasty after failed initial repair of pelvic fracture membranous urethral defects

Experience with 20 salvage urethroplasties in patients with pelvic fracture membranous urethral defects who failed previous delayed urethroplasty is presented. A total of 15 patients was successfully managed by 1-stage procedures, 14 by bulboprostatic reanastomosis and 1 by a tubed pedicled island of skin. Substitution urethroplasty with a staged perineoscrotal skin tube inlay was performed in 5 patients in whom an anastomosis could not be achieved either due to an excessively long urethral defect or inelasticity of the anterior urethra precluding its elongation for an anastomosis free of tension. A successful result was achieved in 19 of the 20 patients (95%). The rationale for procedure selection is discussed.

Voiding dysfunction following cystourethropexy: its evaluation and management

We report on 15 women who underwent cystourethropexy for anatomical stress incontinence and who subsequently had dysfunctional voiding symptoms. All 15 women underwent retropubic takedown of the prior repair and substitution with an obturator shelf repair. All 13 women who had symptoms of bladder instability experienced resolution of these symptoms. Of 7 patients who were in urinary retention and required clean intermittent catheterization only 1 continued to require clean intermittent catheterization to facilitate bladder emptying after obturator shelf substitution. In this series a successful outcome was achieved in 14 of 15 patients (93%).

New technique for endourologic treatment of cystine nephrolithiasis

Cystine renal calculi are fragmented using a unique combination of ultrasonic and electrohydraulic lithotripsy. This endourologic application of a mining principle can be used to fragment any hard urinary stones.

Cocaine and lidocaine as topical urethral anesthetics

To evaluate the efficacy of topical cocaine combined with lidocaine as a urethral anesthetic, a double-blind, randomized, prospective study was performed comparing lidocaine combined with cocaine or placebo in male outpatient cystoscopy. Evaluations were based on a scale of 1 to 10, with 1 representing no discomfort and 10 extreme discomfort as judged by the patient, and 1 representing the best tolerance and 10 extreme intolerance as judged by the physician. Patients who received lidocaine plus cocaine reported a mean score of 3.33 for over-all discomfort of cystoscopy. This was not significantly different than for lidocaine alone. This finding indicates a lack of a summation effect in combining topical anesthetics. Patients undergoing repeat examinations were no more comfortable than those undergoing initial cystoscopy but older patients tolerated the procedure significantly better than younger patients.

Ectopic prostate tissue at the bladder dome

A 71-year-old white man with asymptomatic microscopic hematuria had a sessile tumor at the dome of the bladder containing benign prostatic glandular tissue. Benign prostatic polyps occur commonly in the prostatic urethra and bladder neck as vestigial remains of embryonic prostatic elements. Ectopic prostatic tissue elsewhere is rare and has not been described previously arising at the bladder dome. The origin of prostate glands in this unlikely location is unclear. The clinical course of ectopic prostatic polyps at any location is benign, although local recurrence has been reported.