A Prospective Study of Bladder Function Following Endometriosis Surgery With Up to Eight years Follow-up

STUDY OBJECTIVE

To assess long-term urinary function for women having laparoscopic surgery for endometriosis.

DESIGN

Institutional Review Board-approved nested cohort study within a larger randomized controlled trial assessing urinary function following any benign laparoscopy for gynecological presentations.

SETTING

Two tertiary-level university-affiliated hospitals.

PATIENTS

Women with histologically confirmed endometriosis within the randomized controlled trial between April 2012 and November 2019, where baseline urinary function was determined.

INTERVENTIONS

Women with histologically confirmed endometriosis were contacted between February and October 2020, and urinary function was re-assessed.

MEASUREMENTS AND MAIN RESULTS

Urinary function was assessed using validated questionnaires across the domains of filling, voiding, incontinence, and quality of life determined distant from surgery. Higher scores correlated with a greater severity of symptoms. From 518/711 (72.9%) women with histologically confirmed endometriosis, 289/518 (55.8%) consented to the nested study. At a mean of 50 months (range 12-103 months) post-operatively, 35 participants (12.1%) had sought treatment for bladder symptoms, and 81 participants (28.0%) reported at least one urinary tract infection since their index surgery. There was a significant worsening of symptoms for filling, voiding, incontinence, and quality of life pre-operative to post-operatively (2.27 vs 3.32, 0.93 vs 2.02, 1.06 vs 2.32, 0.83 vs 2.13 respectively, p <.001). There was no statistically significant difference in urinary questionnaire scores in participants with and without uterovesical endometriosis. There was no statistically significant difference in any parameter when comparing any revised American Society of Reproductive Medicine (rASM) stage of endometriosis. Participants who had post-operative urinary retention reported a higher mean voiding score than those who did not (3.24 vs 1.94, p = .017), while participants with post-operative urinary tract infection reported a higher mean frequency score than those who did not (5.17 vs 3.24, p = .016).

CONCLUSION

This study suggests a decline in urinary function over time following laparoscopic surgery for endometriosis that is not dependent on the severity or location of the disease.

Secondary stone formation 8 weeks after percutaneous nephrolithotomy treatment: A case report

INTRODUCTION

This work reports a patient with recurrent renal calculi subjected to three surgeries in half a year to be in the same position, and the high-throughput sequencing data showed different species in the renal pus and urine samples, which suggested that partial renal infection or stone formation can be judged by the bacteria in urine.

PATIENT CONCERNS

The female patient aged 43 years was referred to the authors' department on April 13, 2020, due to left waist pain and fever for 3 days.

DIAGNOSIS

Kidney stones and hydronephrosis were determined by a urinary system computed tomography scan.

INTERVENTIONS

On April 20, 2020 and June 15, 2020, the patient was successfully treated with left percutaneous nephrolithotomy twice under general anesthesia. An investigation on the health and eating habits of the patient within 6 months was completed at the last admission. The components of the second renal calculus sample were analyzed with an infrared spectrum analyzer. The third renal stone (renal pus, triplicates) was subjected to microbial metagenome sequencing, and urine samples before and after surgery were subjected to 16S RNA sequencing by SEQHEALTH (Wuhan, China).

OUTCOMES

After percutaneous nephrolithotomy, the left kidney stones were basically cleared, stone analysis revealed that the main components were calcium oxalate monohydrate, silica, and a small amount of calcium oxalate dehydrate. Although the urine samples exhibited differences, the renal pus and urine sample shared a single species.

CONCLUSION

It is not clear that the prospects of partial renal infection or stone formation can be judged by the bacteria in urine.

Safety of retrograde pyelography for infected ureteral stones

INTRODUCTION

Initial management of obstructing ureteral stones with concomitant urinary tract infection (UTI) includes prompt renal decompression and antibiotics. Some urologists theorize that performing retrograde pyelography (RGP) at the time of ureteral stent placement may cause pyelovenous backflow of bacteria thereby worsening clinical outcomes. We compared outcomes in patients with infected ureteral stones who underwent RGP versus no RGP prior to stent placement.

MATERIALS AND METHODS

A retrospective chart review was conducted involving patients who presented between 2015 and 2017 with an obstructing ureteral stone and associated UTI. Computed tomography scans were evaluated for stone size and location. Operative reports were reviewed to determine whether the patient underwent RGP at time of ureteral stent placement. Demographics, perioperative information, intensive care unit (ICU) admission rate, and length of stay (LOS) were compared.

RESULTS

Seventy-two patients were identified and stratified by severity of condition at presentation, including UTI without sepsis (n = 18), sepsis (n = 32), severe sepsis (n = 11), and septic shock (n = 11). Forty-three patients underwent RGP at the time of stent placement, and 29 did not. Between both patient cohorts, statistical analysis revealed no significant difference in postoperative ICU admission rate (p = 0.35) or LOS for patients with UTI without sepsis (p = 0.17), sepsis (p = 0.45), severe sepsis (p = 0.66), and septic shock (p = 0.25).

CONCLUSION

The use of RGP prior to ureteral stent placement for an obstructing ureteral stone with concomitant UTI was not associated with unfavorable clinical outcomes in our retrospective series. While these findings support the safety of RGP in this setting, prospective trials are warranted.

Laparoscopic heminephrectomy for duplex system: observed difference in outcomes between upper and lower pole resections

INTRODUCTION

Renal duplication is a relatively common congenital abnormality of the urinary tract, but symptomatic duplex kidney is a rare presentation in adults. Traditionally, the treatment of choice for poorly functioning moiety has been heminephrectomy. There is extensive literature detailing the outcomes of minimally invasive upper pole heminephrectomy, but comparatively little published regarding lower pole resection, especially in adult patients. We present a series of 13 patients who underwent minimally invasive heminephrectomy for duplex kidney.

MATERIALS AND METHODS

Over a 6 year period (2011-2017) 13 patients at a single center underwent laparoscopic heminephrectomy for symptomatic duplex kidney with a poorly functioning moiety. A retrospective review of case notes and imaging was undertaken.

RESULTS

Eight and 5 patients underwent upper and lower pole heminephrectomies, respectively. Laparoscopic transperitoneal approach was utilized in all cases. Median length of stay was 2 days (range 1 to 16 days). In the upper pole cohort, one patient had a postoperative infection requiring IV antibiotics. In the lower pole cohort by contrast, there were three major complications (60%). Conversion to complete nephrectomy was necessary in one case; one patient had urinary leakage requiring selective embolization and one patient required a second operation to resect remnant calyces. Furthermore, two patients (40%) developed late recurrence of symptoms.

CONCLUSIONS

Symptomatic duplex kidney is a rare presentation in adults. In our experience, heminephrectomy for non-functioning renal unit is safe and reproducible in experienced hands with no major complications and resolution of symptoms in the majority of patients. We have, however, observed a higher complication rate in those undergoing resection of a lower pole moiety. Alternative management such as uretero-ureterostomy should be considered in these cases.

Congenital Posterior Urethral Fistulae: Literature Review and Case Report

Congenital posterior urethral-perineal fistula is an abnormal communication extending from the posterior urethra to the perineal skin. We present the case of an 11-year-old boy who had recurrent febrile urinary tract infections and abnormal dribbling of urine from the perineum. Fistulogram showed a paraescrotal fistula tract, which was then surgically excised. During the 10 months of follow-up, the patient remained asymptomatic without recurrence of urinary pathology.

[Nephrectomies in poor or non-functioning kidneys. Is it the right thing to do?]

AIM OF THE STUDY

To review our management and outcomes of nephrectomies performed in patients with non-functioning kidneys.

METHODS

Retrospective analysis of the patients who underwent nephrectomy surgery in our hospital between 2010 and 2014. Data was collected from the patient charts paying special attention to the clinical resolution of the symptoms that motivated surgery.

MAIN RESULTS

A total of 18 nephrectomies were performed. Median age was of 6,5 years (range: 11 months to 15 years). Surgery was indicated by recurrent urinary tract infections (UTI) in 7 cases, renovascular hypertension (RHT) in 5, pain in 2, increasing size in 2 and parents' preference due to poor compliance with follow up in 2 patients. 16 nephrectomies were performed laparoscopically and 2 were open procedures. Median hospital length of stay was 48 hours. Complication rate was 5.55% both for the intraoperatively (1 case of bleeding) and post operatively (1 case of subcutaneous emphysema). Signs and symptoms were successfully resolved in all cases except for 3, 2 patients had an UTI and 1 persistent RHT.

CONCLUSIONS

Nephrectomy is a safe surgical procedure in children with a low rate of complications. An appropriate selection of the cases and a thorough preoperative multidisciplinary assessment are essential aspects to obtain good clinical results and to avoid post-operative complications.

[TACTICS OF TREATMENT OF PATIENTS FOR ONCOLOGICAL DISEASES IN IATROGENIC INJURY OF UPPER URINARY WAYS]

Results of examination and treatment of 119 patients for oncological diseases were analyzed, in whom iatrogenic injury of ureter (IIU) have occurred. Remission of oncological diseases plastic operations were performed in 48 (40.3%) patients, reconstructive - in 23 (19.3%), restoration - in 3 (2.5%); while a progress - palliative nephrostomy in 41 (34.5%) patients. In 4 (3.4%) patients dynamical observation was conducted. The method of operative treatment was selected, taking into account efficacy of treatment of oncological diseases; mechanism of IIU; level of obstruction and irreversibility of changes in wall of ureter; character of injury (one-sided, bilateral, injury of ureter of a single kidney); anatomo-functional changes of upper and lower urinary ways; the patient state severity.

The role of cystectomy for non-malignant bladder conditions: a review

INTRODUCTION

Few studies have adequately addressed the indications, efficacy, and quality-of-life for cystectomy performed for non-malignant bladder conditions. Patients with debilitating non-malignant bladder conditions who have failed all previous conservative therapies may undergo various forms of cystectomy, including partial, simple or radical cystectomy. We provide a review of the current literature and recommendations for cystectomy for various non-malignant bladder conditions.

MATERIALS AND METHODS

A systematic review of MEDLINE was conducted to find prospective and retrospective studies using the keywords "cystectomy", "benign", and `non-malignant`. Articles were reviewed and triaged, background articles were added as supplements, leaving a final review of 67 papers.

RESULTS

Data from the final review suggests that common benign indications for cystectomy are interstitial cystitis/painful bladder syndrome (IC/PBS), neurogenic bladder, hemorrhagic/radiation cystitis, infectious diseases of the bladder and miscellaneous conditions of the bladder such as endometriosis and total refractory incontinence. The most common perioperative complications include urinary tract and wound infections. Efficacy of cystectomy in patients with IC/PBS is greater than 80%, while efficacy in patients with neurogenic bladder is greater than 90%. Finally, improved urinary quality-of-life has been demonstrated in patients with neurogenic bladder post-cystectomy.

CONCLUSION

Cystectomy for non-malignant conditions can be considered for patients who have failed previous conservative therapy. The limited data in existence suggests fertility can be adequately preserved after cystectomy in younger males. The data regarding the forms of urinary diversion suggests no significant advantage between any of the major forms of urinary diversion. Finally, while newer pharmacologics and technological advances are widely used in the treatment of various benign urological conditions, their role in preventing or treating refractory benign bladder conditions have not been fully characterized.

Effectiveness of early ureteric stenting for urosepsis associated with urinary tract calculi

OBJECTIVE

Patients with urosepsis associated with urinary tract calculi occasionally require drainage, primarily via ureteric stenting. Such patients require longer hospitalization. However, the indications for early ureteric stenting for this condition have not been clearly defined. To compare the length of stay (LOS) in the hospital between patients treated with earlier ureteric stenting versus those with delayed ureteric stenting.

METHODS

Design: Retrospective cohort study. Setting: An acute care teaching hospital in Japan.

MEASUREMENT

Length of hospital stay in days. Patients Patients with urosepsis associated with urinary tract calculi.

RESULTS

Among a total of 30 patients (mean age, 72; 13 men), the mean number of days from emergency room admission to ureteric stenting was 3.5 days (range, 1-14 days), and the overall mean LOS was 36 days (range, 8-102 days). The early stenting group (mean LOS, 21 days) had a significantly shorter LOS than the delayed stenting group (mean LOS, 50 days), with an adjusted beta coefficient of -26 days [95% confidence interval (CI), -46, -6].

CONCLUSION

In patients with urosepsis associated with urinary tract calculi, performing early stenting within two days of admission may reduce the LOS in the hospital.

"It is important to know that before, there was no lawalawa." Working to stop female genital mutilation in Tanzania

This article is about efforts to unearth the facts about a myth in Tanzania about lawalawa, and the use of female genital mutilation (FGM) by some Tanzanian ethnic groups to cure lawalawa. The term lawalawa, used to describe certain vaginal and urinary tract infections, appeared soon after 1968, following the ban on FGM in the Arusha Declaration, and is still used today. When working with these ethnic groups on the subject of eliminating FGM, one always hears about lawalawa. Today, the arguments for using FGM to cure lawalawa are used not only in relation to small children, but also adolescent girls and boys. Lawalawa is not always limited to vaginal and urinary tract infections, but sometimes also when girls or boys have a fever for other reasons. This article is based on information from the continuous work against FGM in 45 villages by the Singida and Dodoma chapters of the Inter-African Committee on Traditional Practices, Tanzania, from 2003 through 2012. The lesson we have learned is that the only way of eliminating FGM is to accept lawalawa as a fact and to give information and counselling. Only in this way, and not by force, will it be possible to break the connection between lawalawa and FGM.

[Infectious complications of stress urinary incontinence treatment with TVT procedure]

We present case report of 51-year-old female patient admitted to surgery ward because of presence of pyogenic discharge in perianal region since 7 months. Eighteen months earlierthe patient underwent stress urinary incontinence procedure with use of TVT synthetic implant. Diagnosis of wast, bilateral, composite vagino-perianal fistule was made. After carrying out four operations with two stage sling removal final postfistule wound healing was obtained.

Catheter-induced urethral erosion

Indwelling bladder catheters are often placed when a patient requires voiding assistance. Long-term use of these catheters has been associated with significant morbidity This case presentation describes a complete erosion of the glans, urethra, and penile skin, up to the penoscrotal junction, as an outcome from long-term use of an indwelling bladder catheter. Appropriate nursing interventions can prevent this devastating health care outcome.

The inguinal approach to extravesical ureteral reimplantation is safe, effective, and efficient

INTRODUCTION

Minimally invasive surgery implies a percutaneous or endoscopic approach rather than an incision, regardless of size. However, open approaches to various procedures using a mini-incision should assume the same appellation. We report our experience with extravesical ureteral reimplant (EVR) performed through an inguinal mini-incision.

MATERIALS AND METHODS

Patient characteristics of age, gender, and reflux grade were obtained, and outcomes of recurrent urinary tract infection, time of surgery, time of hospitalization and radiographic resolution were assessed. The technique involved a 2 cm incision made in the lowest inguinal skin crease, standard hernia exposure, opening of the floor of the inguinal canal to isolate the ureter, detrussorhaphy.

RESULTS

30 girls and 15 boys with a mean age of 64 months (range 20-180), and mean followup of 18 months (range 3-36) underwent unilateral inguinal mini-incision EVR. Reflux grades represented were 7, 13, 18, 5, and 2 for Grades I through V respectively. Common sheath reimplantations were performed in twelve duplicated systems, and tapering performed in three patients. The average time of surgery was 75 min. All but 2 patients were discharged within 24 h; postoperative imaging was normal in all cases. Three patients had febrile UTIs following discontinuation of prophylactic antibiotics.

CONCLUSION

The inguinal approach to EVR is safe, effective, efficient, and well-tolerated. Through several maneuvers learned as the experience with EVR grew, we present a realizable approach to minimally invasive ureteral reimplantation with application in most pediatric urologic practice.

[Should morphology of the upper pole in renal duplication with preserved function and associated ureterocele be taken into account during treatment planning?]

INTRODUCTION

The aim of this study was to assess structural changes of the upper pole in renal duplication with coexisting ureterocele with regard to primary and/or secondary lesions. These changes might be of importance in treatment planning.

MATERIAL AND METHODS

The material of this study consisted of clinical documentation and results of histopathology of 23 upper poles removed due to renal duplication with coexisting ureterocele. The qualification criterion was preserved function of the upper pole seen with 99mTc-DTPA (99mTechnetium diethylenetriaminepentaacetic acid)/99mTc-DMSA (99mTechnetium dimercaptosuccinic acid). Resection of the upper pole was indicated in patients with recurrent urinary tract infections and/or persistent vesicoureteral reflux to the lower pole following endoscopic surgery of the ureterocele and/or low function of the upper pole. Morphological lesions were classified as primary (dysplasia) or secondary lesions. The patients were operated at the Department of Pediatric and Oncologic Surgery, PMU, in 1990-2008.

RESULTS

The study group consisted of 17 girls and 6 boys aged from 4 months to 9 years (mean 40 months). Recurrent urinary tract infections noted in 16 (70%) children were the most frequent indication for surgery. The preoperative mean function of the renal poles assessed with DTPA/DMSA represented 6% of the differential renal function. Dysplasia was identified in eight resected renal poles (34%) with coexisting secondary lesions in three of them. Secondary lesions only were seen in 15 poles (66%). There was no correlation between age and incidence of dysplasia during follow-up (Pearson's correlation coefficient r = 0.031).

CONCLUSIONS

Secondary lesions are a quite frequent finding in resected upper poles. As 66% of the renal poles studied with histopathology revealed secondary lesions only, we believe that renal sparing treatment is justified in cases of urinary duplication with coexisting ureterocele.

Laparoscopic treatment of appendicovesical fistula

A 23-year-old man had a history of intermittent episodes of urinary tract infection with associated low abdominal pain for 15 years. Persistent bacteriuria even with prolonged antibiotics was the reason why he was referred to our hospital. Laboratory tests were normal except pyuria and growth of Escherichia coli in the urinary samples. Cystoscopy revealed a small slit-like opening on the right lateral wall of bladder dome. We found some air within the bladder and a suspicious communicating tract between the appendix and bladder on a CT scan. With a strong impression of appendicovesical fistula, a laparoscopy was performed to confirm a diagnosis and to remove the appendicovesical fistula resulting in a satisfactory result without any complication.

Treatment of renal transplant failure

INTRODUCTION

Among graft failures beyond months, we performed progressive reduction and complete withdrawal of immunosuppressive drugs and steroids over a period of 6 months.

PATIENTS AND METHODS

We analyzed the treatment and complications associated with all late allograft failures in 34 patients (8.19%) out of 415 patients transplanted from November 1996 to November 2006.

RESULTS

In 21 patients (61.8%), the progressive reduction of immunosuppressive treatment was effective and well tolerated; however, in 13 patients (38.2%) there was rejection of the allograft at 10.74 +/- 8.95 months (0.77-34.80) after the failure. With the reintroduction of these drugs, the rejection was controlled in seven patients, but in the other six we had to embolize the allograft, which had to be repeated in one case. Embolization was well tolerated, but in one case there was migration of one coil to the femoral artery. One patient treated with drug withdrawal experienced emphysematous pyelonephritis after repeated urinary infections, requiring a nephrectomy. Thirteen (38.2%) of the patients with late failures have been admitted for a second transplant; five of them showed HLA sensitization.

CONCLUSIONS

Conservative treatment with progressive withdrawal of immunosuppression was effective and well tolerated in two-thirds of the patients with late renal allograft failure, but one-third of the patients rejected the graft and needed allograft embolization. Infection of the graft and HLA sensitization can complicate the course of these patients.

[Theoretical considerations and comments on the physiopathology in renovascular hypertension]

The researches performed during the last four decades did not elucidate completely the pathogenic mechanism of the renovascular hypertension. The present knowledge considers that the origins of renovascular hypertension are the imbalance between the renal hypotensive system located in the medullar renal site (antihypertensive and hypotensive substances) and the renal hypertensive system (renin-angiotensin-aldosterone) located cortically. As an additional mechanism in producing hypertension is involved the disorder of hydro electrolytic metabolism, as a result of decreased excretory function, inducing an increase of plasmatic natrium level, of volemia and interstitial liquid.

Cytomegalovirus ureteritis: an unreported cause of hematuria in an immunocompetent individual

A middle-aged woman presented with painless hematuria and passage of large clots. Two weeks earlier, she had pyrexia with upper respiratory tract symptoms. Imaging studies revealed no lesions of the urinary tract. Cystoscopy showed clots and oozing of blood from the left ureteric orifice. Urine cytology and mucosal biopsies were normal. Left nephroureterectomy was done as an emergency procedure; the hematuria stopped following the procedure. Histopathology revealed cytomegalovirus inclusion bodies in the mucosa of the excised ureter. This unusual presentation of hematuria has not been reported previously.

Reconstruction of the urethra by use of an inverse tubed bipedicle flap in a dog with hypospadias

CASE DESCRIPTION

A 1-year-old castrated male German Shepherd Dog was evaluated because of a history of hematuria and stranguria secondary to recurrent urinary tract infections.

CLINICAL FINDINGS

Physical examination revealed hypospadias with penile and preputial aplasia. The urethral orifice was just ventral to the ventral aspect of the anocutaneous junction. Ascending urinary tract infections, secondary to fecal contamination of the urethral orifice, were the presumed source of recurrent bouts of cystitis that developed despite periodic antimicrobial treatment.

TREATMENT AND OUTCOME

A 1-cm-diameter urethral extension was constructed from the urethral mucosal remnant located along the midline of the perineum (urethral trough). Two parallel 4-cm incisions (3 cm apart) were made lateral to that urethral trough. The borders were sutured to form an inverted, epithelium-lined tube (bipedicled flap) attached to the dorsal urethral orifice. The lateral skin margins were sutured over the reconstructed urethral extension, completing the procedure. Postoperative swelling necessitated temporary catheterization of the urinary bladder. After closure of a small fistula from the reconstructed urethral segment, the dog subsequently had only 2 episodes of cystitis during a 3-year period. To minimize skin irritation secondary to urine exposure, the dog's owner regularly trimmed the hair around the new urethral orifice.

CLINICAL RELEVANCE

In dogs, correction of perineal (subanal) hypospadias via urethral reconstruction should be considered among treatment options. By use of an inverse tubed urethral extension, direct fecal contamination to the lower urinary tract may be effectively eliminated, dramatically reducing the incidence of ascending urinary tract infections in dogs with hypospadias.

Infective endocarditis of aortic valve during pregnancy: a case report

Infective endocarditis during pregnancy is uncommon but very serious. A 31-year-old woman in the 36th week of second pregnancy was admitted to a hospital because of fever, weakness, chest pain, painful skin over her right leg and dyspnea. Transthoracic echocardiography showed aortic valve vegetation and severe aortic regurgitation. Transesophageal echocardiography revealed a 18 mmx6 mm mobile vegetation, attached to the right coronary cusp. Emergency cesarean section followed with a delivery of a healthy baby. Cardiopulmonary bypass with subsequent aortic replacement with bioprosthesis was initiated immediately after cesarean section. Early echocardiographic examination and 6 months after surgery revealed normal function of aortic valve bioprosthesis and normal LV function. Clinical recognition and early echocardiographic diagnosis followed urgent simultaneous cesarean section and aortic valve replacement was lifesaving for both mother and fetus.

Bladder augmentation and/or continent urinary diversion: 10-year experience

OBJECTIVE

We evaluated the success and the long-term complications associated with augmentation cystoplasty and/or continent urinary diversion in children with urinary incontinence due to neurogenic or malformed bladder.

MATERIALS AND METHODS

The records of 23 patients (12 females, 11 males) who underwent such procedures between 1994 and 2004 were reviewed retrospectively. The most common type of augmentation cystoplasty was ileocystoplasty. The most common type of conduit for the urinary continent diversion was appendicovesicostomy. Combined bladder neck closure was not performed systematically. Neocystoureterostomy was done in 14 refluxing ureters.

RESULTS

Of the 21 patients who underwent augmentation cystoplasty, only one was incontinent after the procedure and required reconstruction of the bladder neck using the Young-Dees procedure. The most common complications were stomal stenosis and bladder stone formation.

CONCLUSION

Augmentation cystoplasty and continent urinary diversion procedures can increase the functional capacity of the small bladder and allow the majority of patients to achieve continence while preserving renal function. Combined bladder neck closure is not necessary to obtain urinary continence; on the contrary, it eliminates a useful pop-off mechanism. Neocystouretrostomy is not required for every refluxing ureter unless it can be performed on the original bladder. Bladder stones and stomal stenosis are the most significant long-term complications in these patients.

Hydatid cyst of urinary tract: 11 cases at a single center

INTRODUCTION

We retrospectively reviewed clinical records of 11 patients with hydatid cyst of the urinary tract admitted to our institution from 1998 to 2005.

MATERIALS AND METHODS

Hospital and follow-up records of 11 patients with hydatid cyst of the urinary tract were reviewed and data on the patients' symptoms and signs at presentation, radiological findings, diagnostic tests, pathologic findings, and surgical outcomes were reviewed.

RESULTS

The chief complaint was flank pain in 7 patients (63.6%). Hydaturia was not seen in any of our patients. Ten patients had renal involvement and 1 had a retrovesical hydatid cyst. Eosinophilia was detected in 2 of 11 patients who were tested. A positive indirect hemagglutination test was seen in 4 of 7 patients and a positive Casoni test in 1 of 2. Intravenous urography revealed caliceal distortion in 6 patients (54.5%), caliectasis in 3 (27.3%), and nonfunctioning kidney in 2 (18.2%). Ultrasonography showed a complex cyst in all of the patients. Computed tomography demonstrated multivesicular cystic structure in 4 patients (36.4%), complex cyst in 4 (36.4%), and a simple cyst in 3 (27.3%). Definite diagnosis was made only after surgical operation. We performed nephrectomy in 2 patients (18.2%), partial nephrectomy in 2 (18.2%), cystectomy plus marsupialization in 5 (45.4%), and retrovesical surgery in 1 (9.1%). One patient refused surgical treatment. There was no perioperative major complication.

CONCLUSION

Renal hydatidosis is a rare entity and the main challenge is preoperative diagnosis. Radiological and serologic studies, although indicative, cannot confirm the diagnosis, and only pathologic examination after surgical removal can confirm echinococcal infection.

Management bei postoperativ diagnostizierter intravesikaler TVT-Bandlage anhand zweier Kasuistiken

Recurrent urinary tract infections and symptoms of a hyperactive bladder in women having undergone a TVT (tension-free vaginal tape) procedure may be due to intravesical position of the tape. Urogenital ultrasound can provide early preliminary diagnostic evidence, which can then be confirmed by subsequent urethrocystoscopy. Minimally invasive revision can be achieved by transurethral resection of the intravesical TVT portions. Tape portions near the wall can be removed after stretching of the tape with grasping forceps inserted through a suprapubically placed trocar. This simple procedure can spare the patient a more extensive repeat operation for removal of the intravesical TVT that may even require a combined abdominovaginal approach.

Intravesical hydatid cyst

A case of intravesical hydatid cyst is reported. The cyst was completely evacuated cystoscopically with intravesical instillation of a scolicidal agent (hydrogen peroxide) to destroy scolices and daughter cysts. The postoperative course was uneventful, and follow-up did not show evidence of recurrence. Because this is the first case, to our knowledge, to be reported, little is known about the nonoperative management of such hydatid localization. A recommendation is made, however, to adopt this minimally invasive procedure.

[The results of surgery on HIV carriers with urinary system disease]

OBJECTIVE

To approach characteristics of performing operation on HIV carriers with urinary system diseases.

METHODS

To summarize author's experiences of surgery on 41 HIV carriers suffering urinary system diseases abroad from April 1996 to May 2004.

RESULTS

The 41 HIV carriers received HAART and were performed with corresponding operations, followed up from 4 to 30 months post-operatively. The 31 carriers have recovered well up to date, while 4 carriers died of AIDS. Among them, 2 patients with penis cancer who received a partial peotomy and a patient with renal tuberculosis receiving left nephrectomy were died of AIDS within 4-8 months after operations whose CD4+ T lymphocyte number was below 0.2 x 10(9)/L.

CONCLUSION

Prior to operation, HIV carriers should receive HAART ordinarily to control copy of the virus. The CD4+ T lymphocyte number is important for selecting a proper time for operation and deciding the further after surgery. We also take note to CD4+ T lymphocyte number to monitor progress of the AIDS. For those HIV carriers, endourologic surgery and laparoscopy should be taken so far as possible. Meanwhile, medical stuffs must pay more attention to preventing occupational infection during surgery.

Corynebacterium urealyticum urinary tract infection in dogs and cats: 7 cases (1996-2003)

OBJECTIVE

To identify clinical features of Corynebacterium urealyticum urinary tract infection in dogs and cats and antimicrobial susceptibility patterns of C urealyticum isolates.

DESIGN

Retrospective study.

ANIMALS

5 dogs and 2 cats.

PROCEDURE

Medical records of dogs and cats for which C urealyticum was isolated from urine samples were reviewed. Isolates from clinical cases, along with previously lyophilized unsubtyped isolates of Corynebacterium spp collected between 1977 and 1995, were examined and, if subtyped as C urealyticum, tested for antimicrobial susceptibility.

RESULTS

Signalment of infected animals was variable. Prior micturition disorders were common, and all animals had signs of lower urinary tract disease at the time C urealyticum infection was diagnosed. Median urine pH was 8.0; WBCs and bacteria were variably seen in urine sediment. In vitro antimicrobial susceptibility testing of 14 C urealyticum isolates revealed that all were susceptible or had intermediate susceptibility to chloramphenicol, tetracycline, and vancomycin and most were susceptible to enrofloxacin. Thickening of the bladder wall and accumulation of sediment were common ultrasonographic findings. Contrast radiography or cystoscopy revealed findings consistent with encrusting cystitis in 3 dogs. Infection resolved in 2 dogs following surgical debridement of bladder plaques and antimicrobial administration. In 2 other dogs and 1 cat treated with antimicrobials, infection with C urealyticum resolved, but urinary tract infection with a different bacterial species developed.

CONCLUSIONS AND CLINICAL RELEVANCE

Results suggest that preexisting urinary tract disorders are common in dogs and cats with C urealyticum infection. Treatment with appropriate antimicrobials in combination with surgical debridement might eliminate C urealyticum infection.

Spontaneous external drainage of renal abscess through persistent nephrostomy tract eleven years after percutaneous nephrolithotomy

A unique case of spontaneous external drainage of a renal abscess through a persistent nephrostomy tract is reported in a patient with a history of two subsequent percutaneous nephrolithotomies 11 years earlier. Nephrostomy tracts can open up even after several years to provide an exit path for infected urine or renal abscess drainage.

Nephrektomie bei akuter unkomplizierter Pyelonephritis

BACKGROUND

Which complications can develop from uncomplicated pyelonephritis that may require nephrectomy?

METHODS

From January 1999 to June 2003 we carried out nephrectomy in ten cases due to abscess formation after acute, uncomplicated pyelonephritis. The medical files were evaluated retrospectively.

RESULTS

Nine women and one man were involved. The mean age was 36.2 years. Leading symptoms: flank pain, fever and chills. The mean symptom duration before admission was 14.6 days. Urinary tract infections were caused by Escherichia coli (six), E. coli and Enterococcus (once) and Klebsiella pneumoniae (once). Two cultures were sterile. Indications for nephrectomy were urosepsis (7 cases), anuria (once), increasing abscess formation under antibiotic therapy (once), drastic deterioration of general condition (once).

CONCLUSIONS

Uncomplicated pyelonephritis is easy to treat under outpatient conditions with adequate oral antibiotic therapy. Close control must be ensured and clear recovery of symptoms should occur within 48 h. In the case of long duration of symptoms (>6-7 days) or lack of improvement of symptoms under calculated therapy in the first 2 days, inpatient therapy should be initiated because of the high risk of infectious complications. According to our experience, the following patient group is especially at risk: female, symptom duration of at least approximately 1 week, pre-treatment and transfer from another departments.

Severe ciprofloxacin-associated pseudomembranous colitis in an eight-year-old child

Clostridium difficile is the principal cause of antibiotic-associated diarrhea and pseudomembranous enterocolitis in children. A case of severe pseudomembranous colitis developing in an 8-year-old child who had received oral ciprofloxacin therapy as part of an investigational protocol is presented. The safety and efficacy of fluoroquinolones in children has not yet been established. Use of these antibiotics in children outside investigational protocols ("off-label" use) as oral antipseudomonas agents is discouraged.

Contrast-enhanced Voiding US for Grading of Reflux in Adult Patients Prior to Antireflux Ureteral Implantation

PURPOSE

To prospectively assess contrast material-enhanced voiding ultrasonography (US) for grading of vesicoureteral reflux (VUR) and to compare results with those of voiding cystourethrography (VCUG) in adult patients undergoing antireflux ureteral implantation.

MATERIALS AND METHODS

Thirty-seven consecutive adult patients who had undergone renal transplantation with Politano-Leadbetter (18 patients) or Lich-Gregoire (19 patients) technique were included on the basis of previous urinary tract infections (UTIs) and time elapsed after renal transplantation. Exclusion criterion was current UTI. US was performed by one of two sonologists with injection of saline and microbubble suspension and was recorded on videotape. Sonologists assigned VUR diagnosis in consensus after videotape review. VCUG was performed by one of two radiologists immediately after US. Radiologists were blinded to US findings and assigned VCUG diagnoses in consensus. Contingency table was used to compare US and VCUG. Agreement between US and VCUG was determined with kappa statistics.

RESULTS

With VCUG, VUR was diagnosed in 15 patients and not diagnosed in 22 patients. US and VCUG results were in agreement in 14 patients with VUR and 21 patients without VUR. US sensitivity and specificity for detection of VUR were 93% (14 true-positive results in 15 abnormal cases) and 95% (21 true-negative results in 22 normal cases), respectively. Agreement between US and VCUG was 95% (kappa = 0.89, P <.001). In 11 of 14 patients, VUR grades were in agreement for US and VCUG. In three of 14 patients, US indicated a higher grade than did VCUG. VUR was diagnosed in seven of 18 Politano-Leadbetter cases and eight of 19 Lich-Gregoire cases.

CONCLUSION

A high rate of agreement was seen between voiding US and VCUG.

Urinary diversion in infants with primary high-grade vesicoureteric reflux, urinary sepsis and renal function impairment

INTRODUCTION

General consensus on the optimal treatment of septic infants with primary high-grade vesicoureteric reflux (VUR) and renal function impairment has not been reached. Our study aims at evaluating the role of temporary urinary diversion.

MATERIALS AND METHODS

Twenty male infants, affected by sepsis and primary high-grade VUR, underwent urinary diversion in 1996-2001 because of estimated risk of renal function deterioration, due to non-compliance with the antibiotic treatment. Plasmatic creatinine clearance, ultrasonography, micturition cystography and scintigraphy were evaluated.

RESULTS

Creatinine clearance was abnormal in 13 infants on admission, in 10 after urinary diversion and in 6 after second surgery. Renal damage (focal or diffuse) was evident in 16 patients, without modifications after surgery. No patient developed urinary tract infections (UTI). Vesicostomy was done in 12 cases, ureterostomy in 8. Nephrectomy was performed in 3 cases with poor renal function, and ureteroneocystostomy in 17.

CONCLUSIONS

Urinary diversion in septic infants with high-grade VUR can represent an alternative approach to the conservative or surgical treatment in selected patients presenting risk of renal function impairment. This procedure allowed an easy management of UTI without worsening of renal function while waiting for a better anatomical status to perform reconstructive surgery.

Management of urinary tract infections

Urinary tract infection (UTI) is common in childhood. It may result in long-term complications due to renal scaring. Younger children are at higher risk of renal scarring. The diagnosis of UTI is based on urine culture. The bacterial count for diagnosis of UTI depends on the method of urine collection. Urinalysis is useful for making a presumptive diagnosis of UTI and allows initiation of empirical treatment in high-risk patients, after urine culture has been obtained. The treatment of UTI is guided by the severity of illness and age of the patient. Following a UTI, investigation should be performed to identify an underlying urinary tract anomaly. Recurrence of UTI occurs in 30-50% children. Important predisposing factors include VUR, urinary tract obstruction, voiding dysfunction and constipation. Vesicoureteric reflux (VUR) is seen in 30-50% children with UTI. The cornerstone of management of VUR is long-term antibiotic prophylaxis, which has been found to be as effective as surgical reimplantation.

The effect of dysfunctional voiding on the costs of treating vesicoureteral reflux: a computer model

PURPOSE

We created a computer model for evaluating the effect of dysfunctional voiding on the costs of managing vesicoureteral reflux in children.

MATERIALS AND METHODS

The literature on vesicoureteral reflux was reviewed to create a set of assumptions regarding the epidemiology, likelihood of resolution, need for operative intervention, risk of infection and appropriate regimen for nonoperative surveillance. Recent literature describing the effect of dysfunctional voiding on the clinical course of vesicoureteral reflux was included in the model to compare the costs of treating vesicoureteral reflux in children with and without dysfunctional voiding. A 5-year management period was considered.

RESULTS

Dysfunctional voiding in children with vesicoureteral reflux increased the cost of treatment per patient by 51.2%. The cost per patient increased with increasing grade in those with and without dysfunctional voiding. The difference in costs in the 2 groups increased from 18.7% for grade 1 reflux to 62.1% for grade 5. Sensitivity analysis was performed, in which the risk of urinary tract infection, rate of surgical resolution, incidence of dysfunctional voiding and discount rate varied. The cost in children with dysfunctional voiding remained higher in all scenarios studied, showing the robustness of the model.

CONCLUSIONS

Dysfunctional voiding substantially increases the costs of treating children with vesicoureteral reflux due to the higher rate of urinary tract infection in children with dysfunctional voiding. Methods that would decrease the rate of urinary tract infection in children with dysfunctional voiding and vesicoureteral reflux would lead to a significant saving of health care dollars.

Ureteroneocystostomy in children with posterior urethral valves: indications and outcome

PURPOSE

Ureteroneocystostomy in children with posterior urethral valves represents a surgical challenge. We reviewed our experience with this procedure to assess its indications and outcome.

MATERIALS AND METHODS

Between 1996 and January 2000, 106 children with posterior urethral valves were treated of whom 20 (19%) underwent ureteroneocystostomy at a mean age plus or minus SD of 5 +/- 2.6 years. Indications for surgery were recurrent urinary infections despite adequate valve ablation in 14 patients of whom 7 had persistent reflux in 12 renal units and 7 had obstruction in 11 ureterovesical junctions. The remaining 6 patients were initially treated with high loop diversion and obstruction was confirmed in 9 ureterovesical junctions by the Whitaker test. Bladder function was assessed by videourodynamics before surgery. Transureteroureterostomy was performed in 7 ureters, and 25 ureters were tailored and reimplanted using the combined intravesical and extravesical approach, including a psoas hitch in 18 (72%).

RESULTS

Mean followup plus or minus SD was 2.3 +/- 1 years. Obstruction and reflux occurred in 1 (4%) and 9 (36%) ureteroneocystostomies, respectively. Obstruction was successfully managed by repeat surgery. Patients with reflux were maintained on chemoprophylaxis. No patient required repeat surgery and reflux did not resolve spontaneously in any. Reflux occurred in all ureteroneocystostomies without a psoas hitch (100%) and in 2 with a hitch (10%) (p <0.004). Dilatation of the upper tracts persisted in all patients. In 2 patients end stage renal disease developed. The remaining 18 patients had serial sterile urine cultures and with a mean serum creatinine plus or minus SD of 0.8 +/- 0.3 mg.%.

CONCLUSIONS

Ureteroneocystostomy is indicated for patients with persistent obstruction after high diversion or those with persistent reflux or obstruction and recurrent infections despite adequate valve ablation and a stable bladder. However, the procedure is associated with a high rate of postoperative reflux. Psoas hitch has a significant role in prevention of reflux.

Influence of vestibulovaginal stenosis, pelvic bladder, and recessed vulva on response to treatment for clinical signs of lower urinary tract disease in dogs: 38 cases (1990-1999)

OBJECTIVE

To determine influence of vestibulovaginal stenosis, pelvic bladder, and recessed vulva on response to treatment for clinical signs of lower urinary tract disease in dogs.

DESIGN

Retrospective study.

ANIMALS

38 spayed female dogs.

PROCEDURE

Medical records and client follow-up were reviewed for dogs evaluated via excretory urography because of clinical signs of lower urinary tract disease. Clinical signs, results of radiography, and response to surgical or medical treatment were analyzed.

RESULTS

Clinical signs included urinary tract infection (n = 24), urinary incontinence (20), vaginitis (11), pollakiuria or stranguria (10), and perivulvar dermatitis (4). Vaginocystourethrographic findings included vestibulovaginal stenosis (n = 28), pelvic bladder (17), and ureteritis or pyelonephritis (4). Ten dogs had a vestibulovaginal ratio of < 0.20 (severe stenosis), 9 dogs had a ratio of 0.20 to 0.25 (moderate stenosis), 9 dogs had a ratio of 0.26 to 0.35 (mild stenosis), and 10 dogs had a ratio of > 0.35 (anatomically normal). Lower urinary tract infection, incontinence, and pelvic bladder were not associated with response to treatment for recessed vulva. Vestibulovaginal stenosis with a ratio < 0.20 was significantly associated negatively with response to treatment. Dogs without severe vestibulovaginal stenosis that received vulvoplasty for a recessed vulva responded well to treatment.

CONCLUSIONS AND CLINICAL RELEVANCE

Vestibulovaginal stenosis is likely an important factor in dogs with vestibulovaginal ratio < 0.20. Vaginectomy or resection and anastomosis should be considered in dogs with severe vestibulovaginal stenosis and signs of lower urinary tract disease.

[Prolapse operation--also of help in urinary tract infections?]

Pelvic support defects are frequently associated with chronic and recurrent urinary tract infections. This is due to common etiological factors (hormone-related atrophy, neurogenic diseases, metabolic disorders) and to direct mechanical effects exerted by the descensus on the urethra function (kinking that occurs with miction disorders and an increase in the residual urine with large cystoceles or stress incontinence and urgency with large urethroceles). The therapy should begin conservatively and address all possible etiological factors. Fundamentals of conservative therapy include estrogens, pelvic floor training, pessaries, drinking and micturition training and therapy and prevention of ascending infections [1]. When conservative therapy does not achieve either a cure or a satisfactory degree of improvement within a few months, surgical treatment should usually be recommended. In this case, modern surgical methods are preferred which seek to achieve both an anatomical as well as a functional restoration, i.e. continence, a good degree of bladder emptying and defecation as well as painless coitus.

Fate of the retained ureteral stump after upper pole heminephrectomy in duplex kidneys

PURPOSE

We review the long-term outcome of retained ureteral stumps in children undergoing heminephrectomy for nonfunctioning upper pole moieties in duplex kidneys.

MATERIALS AND METHODS

The medical records of 50 patients who underwent 50 upper pole heminephrectomies for a nonfunctioning upper pole moiety of a duplex kidney between January 1990 and December 2000 were reviewed retrospectively.

RESULTS

Median patient age at heminephrectomy was 2.5 years (range 3 weeks to 16.5 years) and median followup was 6 years (range 1 to 11). Indications for heminephrectomy in the 50 renal units were obstructive ureterocele in 25 (50%) cases, ectopic ureter in 15 (30%), obstructive megaloureter in 5 (10%) and reflux nephropathy in 5 (10%). A total of 48 (96%) of the corresponding ureters were taken down as low as possible and transfixed through the heminephrectomy incision. Residual stump excision was required in 5 (10%) of the 50 units for recurrent urinary tract infection due to vesicoureteral reflux.

CONCLUSIONS

Our long-term followup suggests that the majority of patients with residual ureteral stumps after upper pole heminephrectomy do not require stump resection.

Long-term outcome of the retained ureteral stump after lower pole heminephrectomy in duplex kidneys

OBJECTIVES

Duplication of the ureter and renal pelvis is the most common upper urinary tract anomaly in childhood. The anatomical and functional divisions between upper and lower moieties of duplex kidney are extremely variable. The underlying pathological condition associated with a lower moiety is usually massive vesicoureteral reflux (VUR) to the lower collecting system and only rare obstruction. The non-functioning upper moiety is usually associated with obstructive ectopic ureter (with or without ureterocele). Most lower pole heminephrectomies are carried out for non-functioning lower moieties. In most cases, the lower defunctionalised segment of the ureter is left in situ. Complete ureterectomy is usually performed if presence of VUR into the lower end of the corresponding ureter is shown. There is little information on the long-term outcome of residual ureteral 'stumps'. The purpose of our study was to review the long-term outcome of retained ureteral stumps in children undergoing heminephrectomy for non-functioning lower pole moieties in duplex kidneys.

MATERIALS AND METHODS

The medical records of 19 patients who underwent 20 lower pole heminephrectomies for a non-functioning lower pole moiety of a duplex kidney between January 1990 and December 2000 were reviewed retrospectively. Median age at heminephrectomy was 4.5 years (range: 1 month to 12 years). Indications for heminephrectomy in the 20 renal units was reflux nephropathy in 16 (80%) and obstructive nephropathy in 4 (20%). All corresponding ureters were taken down as low as possible and transfixed through the heminephrectomy incision. Median follow-up was 8.5 years (range: 1-11 years).

RESULTS

Eight (40%) showed VUR into the stump after lower pole heminephrectomy. Two of these underwent subureteral endoscopic correction of VUR with polytetrafluoroethylene paste and resection of the stump was carried out in remaining two patients for recurrent urinary tract infections (UTI). Remaining four of the eight patients demonstrated spontaneous resolution of VUR during follow-up.

CONCLUSIONS

Our data suggest that the vast majority of patients with residual ureteral stumps after lower pole heminephrectomy do not require stump resection at long-term follow-up.

Clinical management of hydatid disease of the urinary tract

This study reviews urinary hydatid disease in seven males and three females (mean age, 32.1 +/- 17.7 years; range, 7-67 years). Cysts were located in the kidney in six cases (one also involved the liver), the paravesical and retrovesical region in two cases (one coexisted with a bladder tumour), the adrenal gland (one case) and in the right parapelvic region (one case). Investigations included urinalysis, eosinophil count, Casoni skin test, indirect haemagglutination test (IHA), abdominal ultrasonography, intravenous urography and computed tomography (CT). All patients underwent surgery and were followed for an average of 5.6 years. Lumbar or abdominal pain was the most common symptom. Eosinophilia was seen in five patients (50%), IHA positivity occurred in four patients (40%) and the Casoni skin test was positive in four patients (40%). Abdominal CT was the most useful diagnostic method of radiological investigation (100%). No complications or recurrences were seen on follow-up. Urinary hydatid disease is uncommon and is likely to cause considerable diagnostic difficulties, and should therefore be considered in the differential diagnosis of space-occupying lesions of the urinary tract.

Episioplasty for the treatment of perivulvar dermatitis or recurrent urinary tract infections in dogs with excessive perivulvar skin folds: 31 cases (1983-2000)

OBJECTIVE

To evaluate the effectiveness of episioplasty for the treatment of perivulvar dermatitis or chronic or recurrent urinary tract infections (UTI) believed to be secondary to excessive perivulvar skin folds in dogs and to document whether a causal relationship exists between the presence of chronic or recurrent UTI and excessive perivulvar skin folds in female dogs.

DESIGN

Retrospective study.

ANIMALS

31 female dogs.

PROCEDURE

Medical records of dogs with vulvar dermatitis (group 1; n = 15) or UTI (group 2; 16) were reviewed for history, signalment, physical examination findings, hematologic findings, results of urine or vaginal bacteriologic culture, and results of additional diagnostic procedures.

RESULTS

14 of 15 dogs in group 1 had complete resolution of perivulvar dermatitis and associated clinical signs following episioplasty. One dog had a relapse of clinical signs and vulvar dermatitis 2 years after surgery in association with a 9-kg (1 9.8-1b) weight gain. Sixteen of 16 dogs in group 2 had complete resolution of clinical signs of UTI following episioplasty. Urine samples were obtained via cystocentesis no earlier than 1 month after surgery to confirm resolution of UTI in 13 of 16 of dogs in group 2. Mild-to-moderate incisional swelling was the only surgical complication reported for either group, with the exception of 1 dog in group 2 that had wound dehiscence. All owners were satisfied with surgical outcomes.

CONCLUSIONS AND CLINICAL RELEVANCE

All owners reported complete resolution of clinical signs for both groups of dogs. Episioplasty is an effective low morbidity treatment for perivulvar dermatitis and chronic UTI associated with excessive perivulvar skin folds.

The treatment of post-urethrotomy incontinence in pediatric and adolescent females

PURPOSE

Until 1986 many urologists performed currently outdated, redundant internal urethrotomy as standard therapy for recurrent urinary tract infection in girls. We describe the results of therapy in patients who became incontinent due to previous internal urethrotomy.

MATERIALS AND METHODS

Between 1986 and 1995, 21 female patients with post-Otis urethrotomy incontinence have presented at our department with combined dysfunctional voiding, recurrent urinary tract infection and various types of urinary incontinence partially based on bladder instability and often provoked by abdominal straining. All cases were diagnosed by repeat video urodynamics and ultrasound of the open bladder neck. Endoscopy provided proof of scarring in the bladder neck and urethra. All patients except 1 underwent conservative treatment for at least 2 years, consisting of pharmacological therapy, physical therapy and biofeedback training. Surgical therapy to cure incontinence was performed in 14 cases, including a conventional Burch-type colposuspension in 5, modified needle colposuspension in 4 and complete endoscopic excision of the urethral scars followed by open reconstruction of the bladder neck and urethra in an abdominoperineal procedure in 5.

RESULTS

Conservative treatment has been completely successful in 7 patients. Primary open or needle colposuspension was unsuccessful in 6 of 9 cases, including several requiring further surgery to achieve dryness. The results of excising urethral scars with bladder neck and urethral reconstruction were good in 4 of 5 patients at a followup of at least 4 years.

CONCLUSIONS

When previous internal urethrotomy appears to be an important factor in the evaluation of incontinence, conservative therapy is the treatment of choice. Conservative therapy should consist of biofeedback reeducation of the voiding pattern and physical therapy. When surgery is needed, excision of the urethral scars with reconstruction of the bladder neck and urethra plus colposuspension is superior to colposuspension only.