Recurrent urinary conduit bleeding in a patient with portal hypertension: management with a transjugular intrahepatic portosystemic shunt.

OBJECTIVE: To determine if a transjugular intrahepatic portosystemic shunt can control recurrent urinary conduit bleeding in a patient with portal hypertension. METHODS: Following transjugular catheterization of the right hepatic vein, a long curve Colapinto needle was advanced through the liver parenchyma into the portal vein near its bifurcation. After a guide wire exchange, a catheter was advanced into the portal system and venogram was obtained. Following another guide wire exchange, a balloon angioplasty catheter was used to create the shunt by dilating the parenchymal tract between the hepatic and portal veins. A self-expandable stent was used to ensure patency of the shunt. RESULTS: After shunt placement, bleeding from the ileal conduit and stroma decreased significantly. A duplex ultrasound at five-month follow-up demonstrated the shunt to be completely patent. CONCLUSIONS: Based on this limited experience, it appears that the transjugular, intrahepatic, portosystemic shunt is an acceptable method to control massive, recurrent urinary conduit bleeding in patients with portal hypertension.

Local recurrence of renal cell carcinoma causing duodenal-inferior vena caval fistula: case report and review of the literature.

We report the first case of a duodenal-inferior vena caval (IVC) fistula resulting from locally recurrent renal cell carcinoma (RCC). A 45-year-old man presented with gross hematuria and underwent a right radical nephrectomy to treat a solid renal mass. Histologic evaluation showed RCC, Stage pT3aN0M0. The patient presented 21 months later in hemorrhagic shock, with upper gastrointestinal bleeding. He underwent an exploratory laparotomy and Whipple procedure for a mass in the second portion of the duodenum extending to the inferior vena cava with a secondary duodenal-IVC fistula. We describe this case and review the previously published reports of duodenal-IVC fistulae.

Fracture of penis: diagnosis and management.

Fracture of the penis is a rupture of the rigid corporeal body. Nine consecutive patients with this malady were managed by an operative repair, which included degloving of the penis, evacuation of the hematoma, and closure of the corporeal tear. Postoperatively all patients reported excellent rigidity of a straight penis. We conclude that operative management of a fractured corporeal body is safe and effective.

Intraoperative ultrasound: determination of the presence and extent of vena caval tumor thrombus.

OBJECTIVES: To report and discuss five cases of renal cell carcinoma (RCC) in which preoperative imaging studies were equivocal with regard to the presence and extent of vena caval tumor thrombus or in which dynamic intraoperative imaging of the vena cava was advantageous. METHODS: We reviewed the cases of five patients who had conflicting preoperative imaging studies and reviewed the literature applying to this clinical situation. RESULTS: Two patients whose preoperative magnetic resonance imaging studies suggested inferior vena caval tumor thrombus were shown, on intraoperative color Doppler ultrasound, not to have tumor thrombus but rather turbulent flow within the vena cava mimicking thrombus. In two patients intraoperative ultrasound (IOUS) was used to image the position of the tumor thrombus as it was manipulated to allow for safe vena caval clamp placement. In one patient we used real-time imaging to visualize thrombus extraction from the heart. CONCLUSIONS: Intraoperative ultrasound real-time imaging is beneficial in two specific situations: in those cases in which the presence of renal vein or inferior vena cava involvement is equivocal based on preoperative imaging techniques and when there is a need to identify intraoperatively the limits of a known tumor thrombus to allow subsequent safe placement of a caval clamp.

One hundred consecutive laparoscopic pelvic lymph node dissections: comparing complications of the first 50 cases to the second 50 cases.

OBJECTIVES: To report the outcome of our first 100 consecutive laparoscopic pelvic lymph node dissections (LPLND) and compare the early complication rate of the first 50 cases (14%) to the second 50 cases (4%). METHODS: We reviewed 100 patients who underwent LPLND: Ninety-six patients had carcinoma of the prostate and underwent LPLND prior to radical prostatectomy or definitive radiation therapy. Four patients had histologically proved penile (2) or bladder carcinoma (2) and underwent LPLND to assess their pelvic lymph nodes. RESULTS: We encountered 7 major and minor complications in our first 50 cases, and 2 minor complications in our second 50 cases. The overall complication rate was 9% (9 of 100). CONCLUSIONS: We believe that modification of our operative technique and changes in patient management resulted in a lower complication rate in the second 50 patients. We conclude that although LPLND has a significant learning curve, it is a viable surgical staging option for patients with urologic pelvic malignancies.

Perfusion sphincterometry for objective evaluation of postprostatectomy intrinsic sphincter deficiency.

OBJECTIVES: Male urinary incontinence secondary to intrinsic sphincter deficiency (ISD) is a possible complication of transurethral resection of the prostate (TURP) or radical prostatectomy (RP). For objective assessment of urinary sphincteric competence, we used perfusion sphincterometry (PS) to measure the retrograde urethral perfusion pressure (RUPP). METHODS: A retrospective and prospective analysis of 60 neurologically normal patients of varying continence status was performed. The subjects were divided into three groups: continent patients with no previous prostate surgery (group 1), continent patients after prostatectomy (group 2), and incontinent patients after prostatectomy (group 3). All patients underwent PS with the technique described. All incontinent patients (group 3) had a filling cystometrogram (CMG) to rule out detrusor instability. RESULTS: Continent patients with no prior prostate surgery (group 1) had a mean RUPP of 101 +/- 16 cm H2O; continent postprostatectomy patients (group 2) had a mean RUPP of 77 +/- 14 cm H2O; and incontinent postprostatectomy patients (group 3) had a mean RUPP of 36 +/- 11 cm H2O. The differences were statistically significant (P <0.001). There was no statistically significant difference in RUPP when the patients in groups 2 and 3 were stratified into TURP and RP groups. CONCLUSIONS: PS is a simple and accurate technique for objective evaluation of lower sphincter competence. Patients with stress incontinence after prostatectomy have a statistically significant decrease in RUPP compared with continent controls. In combination with cystourethroscopy and filling CMG, PS can be useful in the evaluation of postprostatectomy incontinence.

Surgical procedures for uncomplicated ("routine") female stress incontinence.

Routine incontinence in the woman is defined as stress urinary incontinence associated with a hypermobile urethra and bladder neck that has not been subjected to an operative procedure. Although urgency and occasional urgency incontinence may accompany the symptoms of stress incontinence, they are not a significant component of the patient's complaints. Regardless of technique, the goal common to all procedures designed to cure stress urinary incontinence is to immobilize and support the hypermobile urethra. The support provided by the operation creates a foundation on which the urethra can be compressed shut during abdominal straining. The operation of choice is determined by its ability to provide this strong foundation over a long period of time. Although numerous reports have been published outlining the results of bladder neck suspension, most authors have not utilized objective long-term follow-up when assessing cure rates. We prefer either the Burch colpourethropexy or the modified Pereyra needle bladder neck suspension because the vaginal wall is firmly supportive without interfering with the delicate mechanisms of the urethra.

Transvaginal needle bladder neck suspension.

Like the transabdominal bladder neck suspension, the aim of the transvaginal needle suspension of the bladder neck is to suspend the bladder neck and urethra in a fixed retropubic position. Because the transvaginal technique does not require the splitting of the abdominal wall fascia, postoperative discomfort and convalescence may be lessened. Different techniques of transvaginal needle bladder neck suspension, including suspension of the bladder neck with a fascial sling, are discussed in detail.

Genitourinary fistulae. Vaginal approach for repair of vesicovaginal fistulae.

Controversy still remains concerning the timing of repair, the type of approach, and the technical guidelines most likely to prevent recurrence of both radiated and nonradiated vesicovaginal fistulae. The authors advocate the transvaginal approach because it avoids a cystotomy and involves minimal blood loss and consequently is followed by less postoperative discomfort and a shorter hospital stay. Included in this discussion are the techniques and results of the transvaginal approach for simple vesicovaginal fistulae as well as for complex cases and radiation fistulae.

The pathophysiology of stress incontinence.

The factors contributing to stress incontinence of urine are reviewed and categorized with respect to their effects on coaptation and compression of the urethra. Intrinsic urethral dysfunction and poor anatomic support are discussed from both a functional and a pathophysiologic approach.

Renal angiomyolipoma: optimal treatment based on size and symptoms.

The natural history of renal angiomyolipoma is not well delineated. Current management options include observation, embolization, and partial or total nephrectomy. Recommendations for treatment are usually based on the patient's symptoms or the size of the lesion. In an effort to help define the optimal treatment of renal angiomyolipomas, we reviewed our experience over the last 10 years with these tumors. We performed a retrospective study of 37 patients (48 renal units) diagnosed with renal angiomyolipoma over a ten year period at our medical center (mean follow-up 40 months, range 1 month-12 years). Lesions were classified as small (< 4 cm), medium (4-8 cm) or large (> 8 cm) based on the single largest lesion in each kidney. The relationship between the size, symptoms and treatment was reviewed. Patients were also analyzed with regard to the diagnosis of tuberous sclerosis. Our findings indicate renal angiomyolipomas less than 4 cm (21/37 patients) tend to be asymptomatic and generally do not require intervention. Angiomyolipomas greater than 8 cm were responsible for significant morbidity and generally require treatment (5/6). Patients with tuberous sclerosis made up one half (3/6) of the large lesions. Medium-sized lesions had a less predictable natural history, with 54% (7/13) requiring intervention to treat hemorrhagic complications. Small asymptomatic lesions (< 4 cm) tend to remain stable but should be periodically evaluated. Medium-sized lesions (4-8 cm) have the most variable behavior. These lesions should be followed closely with serial imaging studies, and if significant changes in size or symptoms are noted, or the patient is at risk for flank trauma, elective intervention should be initiated promptly to increase the chances of renal salvage. Large asymptomatic angiomyolipomas (> 8 cm) will most likely become symptomatic and should be treated electively prior to the development of symptoms and potential complications.

The use of rotated vascularized pedicle flaps for complex transvaginal procedures.

We report the use of relatively simple rotated vascularized pedicle flaps to assist in the closure of complex vaginal procedures. The Martius, labial and buttock flaps are described, and should be included in the armamentarium of the urological surgeon.

Management of persistent or recurrent urinary incontinence after placement of artificial urinary sphincter.

A rational systematic approach is presented in the evaluation of 14 men with persistent or recurrent urinary incontinence after placement of the AMS800 artificial urinary sphincter. Mechanical malfunctions, including device leaks and control assembly malfunctions, may often be discovered with physical examination and radiographic evaluations. Nonmechanical malfunctions, such as cuff erosion, inadequate cuff compression and functional urethral atrophy, can be diagnosed with perfusion sphincterometry, urethroscopy and a filling cystometrogram, all combined in 1 simplified technique. With the presented algorithm the over-all success rate after 1 revision was 82%. Mechanical malfunctions appear to have a better revision rate of success than nonmechanical malfunctions (100% versus 71.5%, respectively).

Nondelayed transvaginal repair of high lying vesicovaginal fistula.

The management of vesicovaginal fistula still remains controversial in regard to the timing of repair and type of approach. A total of 16 patients underwent transvaginal repair of simple nonradiated vesicovaginal fistulas. In 7 patients the repairs were less than 3 months after the injury, while in 9 the delay was greater than 3 months. A total of 14 patients had high lying lesions (fistulas above the trigone) and 2 had low lying lesions (fistulas below the trigone). Of the 16 patients 15 (94%) stopped leaking after a transvaginal repair. All 7 patients with high lying lesions who underwent operative repair less than 3 months after injury were dry. We advocate early nondelayed repair of high and low lying simple nonradiated vesicovaginal fistulas using the transvaginal approach. The customary waiting period of 3 to 6 months before repair may not be warranted.

Experiences with the artificial urinary sphincter in the irradiated patient.

The AMS800 artificial urinary sphincter was placed in 16 men who underwent previous pelvic irradiation for adenocarcinoma of the prostate. A total of 13 patients had undergone external beam irradiation and 3 had had iridium seed implants. The sphincteric cuff was placed in the bulbar urethra in all patients, with a pressure regulating balloon of 51 to 60 or 61 to 70 cm. water. Overall social continence rate was 87%. Total complication rate was 25% with a rate of erosion and/or infection of 12.5%. We advocate that with meticulous technique, use of a low pressure balloon and delayed primary cuff activation, the artificial urinary sphincter can be placed with a reasonable success rate in post-irradiated men with urinary incontinence.

[Treatment of urinary stress incontinence by transvaginal suspension of the bladder neck. Peyreyra-Raz technic]. / Traitement de l'incontinence urinaire d'effort par suspension transvaginale du col vésical. Procédé de Peyreyra-Raz.

Results are reported of the use of the technique of suspension of paravaginal tissue from either side of the neck of the bladder to treat female stress incontinence. Conducted almost exclusively through the vaginal route, an inversed incision in U allows dissection of the total retropubic space and pre-urethral bladder neck adhesions from any previous surgery, and the passage of a solidly implanted non-absorbable thread from one side of the suprapubic incision involving skin and subcutaneous tissue is made down to the aponeurosis alone. A special long needle is then passed from above downwards from the lateral extremity of the suprapubic incision to the vaginal incision and the two ends of the non-absorbable thread clamped. One of the advantages of the retropubic dissection is the guidance of this needle without the risk of perforation of the bladder or urethra. The ends of the thread are brought from the vaginal incision to the lateral angles of the hypogastric wound and tied together or over a small square of Teflon. The tension of the thread is such that it will just allow ascension of the posterior lip of the neck. This ascension, as well as the absence of any vesico-urethral perforation, and the permeability of the ureteral meatuses is verified by endoscopy. The very wide safety margin inherent in this procedure is shown by the 96% of perfect results in patients not previously operated upon, and the 94% of successes in those operated upon previously on one or several occasions without practically any complications. These findings suggest that this technique should occupy a place of choice in the treatment of urinary stress incontinence in women.

[Vaginal approach to non-irradiated vesicovaginal fistula]. / La voie d'abord vaginale des fistules vésico-vaginales non irradiées.

We herein report our experience in the transvaginal repair of 30 consecutive cases of non-radiated Vesicovaginal Fistulae. The new principles applied include: early surgery as soon as the fistula is recognized, no excision of the fistulous tract to avoid retraction and bleeding of the margins as well as to provide protection of the ureteric orifices, closure of the intact fistula in two layers, rotation and advancement of the vaginal flap to cover the fistula avoiding overlapping of suture lines, and finally assurance of adequate bladder decompression with both a suprapubic tube and an urethral catheter. In the followup period of 6 to 72 months, we experienced a 94% success rate at primary repair with only two failures which are now dry after subsequent trans-vaginal closure. In spite of size, location or proximity to the ureteric orifices, the vaginal approach has proved to be amenable in all cases with minimal discomfort for the patient, a shorter hospital stay and equal or even better results than the more extensive abdominal approach.

Phytochemicals potentiate interleukin-2 generated lymphokine-activated killer cell cytotoxicity against murine renal cell carcinoma.

The success of adoptive immunotherapy using recombinant interleukin-2 (rIL-2) and lymphokine-activated killer (LAK) cells in several cancers has been hampered by severe toxicity associated with high doses of rIL-2. Methods that reduce the dosage of rIL-2 without loss of clinical efficacy are needed. In this study we determined the in vitro effect of a phytochemical immune modulator, Astragalus membranaceus (AM), and two fractions isolated by high-performance liquid chromatography on the cytotoxicity of rIL-2-generated LAK cells against a murine renal cell carcinoma. Our results indicated a 10-fold potentiation of rIL-2-generated LAK cell cytotoxicity manifested by tumor cell lysis of 88% in the group with 100 U/ml of rIL-2 plus AM versus 86% in the group with 1,000 U/ml of rIL-2 alone. Potentiation was obtained with the purified fractions as well. A significantly reduced number of LAK cells was required to achieve the tumor cytotoxicity after LAK cell generation with rIL-2 plus the phytochemicals as compared with rIL-2 alone. Our data indicate that AM is an effective immune modulator, capable of potentiating in vitro the antitumor activity of rIL-2-generated LAK cells.

Transvaginal closure of the bladder neck and placement of a suprapubic catheter for destroyed urethra after long-term indwelling catheterization.

We report on 6 women with continuous urinary incontinence as a late complication of an indwelling urethral catheter for neurogenic bladder. Pressure necrosis by the balloon resulted in progressive destruction of the entire urethra, with subsequent incontinence despite the catheter. Surgical attempts at bladder neck closure to correct the incontinence generally have been unsuccessful. Instead of supravesical urinary diversion, we performed transvaginal closure of the bladder neck and percutaneous placement of a permanent suprapubic tube cystostomy. All 6 patients remained dry after closure and none has shown upper urinary tract deterioration at followup for as long as 5 years.

Urethral replacement using ileum with an intussuscepted ileal valve for continence.

Numerous techniques for replacing the urethra have been previously described, but attempts to provide continence have rarely been satisfactory. Urethral replacement using ileum with an ileal intussuscepted valve for continence has been successfully performed in ten female dogs. Eight of them were available for a 1 to 6-month followup. This neo-urethra has provided good continence and can be easily catheterized. The clinical usefulness of this technique in the treatment of total urethral loss in humans needs to be further explored.