Local anesthesia for urologic procedures.

The ability to perform a variety of urologic procedures (urethrotomy, prostate surgery, penile prosthesis insertion, and bladder neck suspension) under local anesthesia in an outpatient setting is a significant advance in patient care. The surgical techniques are described that will allow the urologist to incorporate these procedures into practice.

Bone fixation technique for transvaginal needle suspension.

Bone fixation of the suprapubic suspension sutures has been used in conjunction with transvaginal needle suspension in 115 women with genuine stress urinary incontinence over the last two years with excellent results being obtained. Utilizing the pubic tubercle as the fixation point for the suspension sutures (rather than the anterior abdominal wall) has decreased postoperative discomfort and obviated the need for any synthetic material.

Mechanical complications associated with mentor inflatable penile prosthesis.

The Mentor inflatable penile prosthesis was developed in an attempt to decrease the mechanical failure rate of the various prostheses' components. We herein report on the reliability of the device in 46 men implanted with the Mentor device from December 1982 to June 1987. Prior to manufacturer device modification in 1985, mechanical failure mainly attributable to input tubing cracks occurred in 10 of 30 implantations. Since device improvement in April 1985, the mechanical failure rate has decreased to 4 percent. The Mentor inflatable penile prosthesis has been a mechanically reliable device since design improvement in 1985.

Role of urologist in diagnosis of multiple sclerosis.

This report presents 7 patients with confirmed cases of multiple sclerosis (MS) in whom the diagnosis of MS was first suspected by the urologist. Review of these 7 cases identifies three factors that increased the suspicion of MS at the time of urologic evaluation: a history of neurologic symptoms, abnormalities on a brief neurologic examination, and abnormal basic urodynamic evaluation. Urologists attuned to the possible diagnosis of MS in patients who present with symptoms of voiding dysfunction can facilitate the proper diagnosis with a basic office evaluation.

Giant vesical calculi in the female.

We herein report a case of giant vesical calculi in the female bladder. To the best of our knowledge, these calculi represent the largest group of vesical calculi ever removed from the female bladder. The etiologic factors that contribute to bladder calculus formation in the female are discussed.

Partial nephrectomy: Mayo Clinic experience 1957--1977.

Three hundred and six partial nephrectomies were performed at Mayo Clinic between 1957 and 1977. Operative and postoperative risks were analyzed according to the indication for surgery, type of partial nephrectomy performed, and other factors. The results demonstrate that partial nephrectomy performed by modern techniques is safe, with acceptable operative time, operative blood loss, and postoperative hospital stay. Complications encountered also were investigated. One death occurred, 8 delayed nephrectomies were required, in 2 patients delayed renal hemorrhage developed, 10 had urinary fistulas or urinomas, and in 16 patients wound infections developed. Study of the techniques used in those cases with postoperative complications suggests several approaches to reduce still further the morbidity of partial nephrectomy.

Cost-effective treatment of female stress urinary incontinence: modified Pereyra bladder neck suspension.

We herein report on the cost effectiveness of the modified Pereyra bladder neck suspension (MPBNS) compared with the Marshall-Marchetti-Krantz (MMK) retropubic suspension procedure. A total of 82 cases was reviewed retrospectively. The MPBNS was found to provide a 41 per cent cost savings with significantly shorter duration of intravenous fluid administration, shorter duration of postoperative indwelling catheter drainage, shorter operative time, and significantly shorter postoperative hospitalization. Early postoperative intermittent catheterization was a major factor in facilitating early discharge after MPBNS.

Delayed bladder dysfunction after abdominoperineal resection: an indicator of local recurrence.

It is generally not appreciated that the delayed onset of voiding dysfunction after abdominoperineal resection for rectal carcinoma may be the first sign of local pelvic recurrence. We herein present a series of 5 patients who were referred for urodynamic evaluation of voiding dysfunction beginning nine to twenty-four months after the original operative procedure. Urodynamic evaluation revealed low bladder wall compliance in 4 patients, and detrusor hyperreflexia in 1 patient. Computerized tomography scans confirmed the local tumor recurrence in all cases. The delayed onset of voiding complaints after abdominoperineal resection should prompt a high index of suspicion that a local tumor recurrence may be present.

Urodynamic findings in interstitial cystitis.

The urodynamic findings in 41 women with proven interstitial cystitis were reviewed. All subjects had pain during bladder filling with sensory instability and limited functional capacity. Despite an average symptom duration of 5.7 years, all women had normal bladder wall compliance during cystometry. Fourteen of 41 women had additional significant urodynamic findings.

Feasibility of outpatient percutaneous bladder neck suspension under local anesthesia.

OBJECTIVES: To demonstrate the feasibility of outpatient percutaneous bladder neck suspension (BNS) under local anesthesia to treat stress urinary incontinence (SUI) in females. METHODS: Since October 1994, 40 women with SUI (mean age 59.6+/-12.0 years) underwent outpatient percutaneous BNS with "Z" suture anchoring of the anterior vaginal wall and pubocervical fascia. The suspension sutures were secured to percutaneously placed bone anchors. The procedure was performed under local anesthesia. Pain during surgery was evaluated with an analogue scale graded from 0 (no pain) to 5 (severe pain). RESULTS: In 98% of the BNS, the procedure was successfully performed with the patient under local anesthesia. Conversion to general anesthesia was necessary for only 1 patient due to knee pain in the lithotomy position. No major complications were observed. Patients rated their perioperative pain as 1.0+/-0.6 (that is, minimal pain). Patients required pain medications for a mean of 2.4+/-1.3 days postoperatively. Mean duration of recovery (defined by a return to normal activities) was 2.2+/-1.0 weeks; 92% of the patients were continent postoperatively, and no recurrence of urethral hypermobility was observed. CONCLUSIONS: Our results demonstrate the feasibility of outpatient percutaneous BNS performed in patients under local anesthesia without significant morbidity. Continued follow-up will be necessary to determine the long-term efficacy of this procedure.

Modified Pereyra bladder neck suspension after previously failed anti-incontinence surgery. Surgical technique and results with long-term follow-up.

Fifty-four female patients with persistent or recurrent stress urinary incontinence who underwent between 1 and 9 previously unsuccessful operative procedures were treated with transvaginal mobilization of the urethra and anterior vaginal wall with subsequent modified Pereyra bladder neck suspension. The important points of this technique are reviewed. With minimum follow-up of twenty-four months, a 94 per cent cure rate was achieved with minimal morbidity in this difficult group of patients.

New dual-channel microtip transducer catheter for urethral pressure profile and cystometry.

Urethral pressure profilometry performed with a dual-channel microtipped transducer catheter and its use in the clinical investigation of female urinary stress incontinence and bladder hyperreflexia are described. A technique for performing filling and voiding cystometry in conjunction with dual-channel profilometry also is discussed.

Bladder leiomyoma.

We herein present a case of leiomyoma of the urinary bladder discovered during evaluation for stress urinary incontinence. The histologic findings of this benign tumor and its urologic implications are reviewed.

Ectopically draining dysplastic kidney associated with genuine stress urinary incontinence: unusual combined cause of incontinence.

A thirty-two-year-old Samoan woman was referred for evaluation of "unstable bladder" and a history of continuous life-long urinary incontinence. A comprehensive radiographic and urodynamic evaluation demonstrated the unusual combination of a vaginal ectopic ureter draining a dysplastic kidney and genuine stress urinary incontinence. Appropriate treatment based on the recognition of both abnormalities resulted in restoration of continence.

Outpatient visual laser-assisted prostatectomy under local anesthesia.

OBJECTIVE: Visual laser-assisted prostatectomy (VLAP) with a noncontact right-angle delivery system recently has been introduced as a new treatment option for symptomatic outlet obstruction secondary to benign prostatic hyperplasia. The right-angle laser technology has numerous potential advantages over traditional transurethral resection of the prostate. These advantages include the feasibility of performing the VLAP procedure under local anesthesia without bleeding. We summarize our experience with VLAP performed with local anesthesia administered with periprostatic block. METHODS: This technique was employed in 46 men with symptomatic BPH as an outpatient procedure. All men were evaluated prior to surgery with flow rates, residual volume determinations, and AUA-6 symptom score analyses. Follow-up occurred at three and six months and included repeat measures of flow rates, residual volumes, and symptom scores. RESULTS: Mean AUA symptom scores and uroflow parameters significantly improved with six months' follow-up. No significant complications were encountered. CONCLUSIONS: VLAP under local anesthesia as an outpatient procedure is a promising treatment alternative for men with symptomatic benign prostatic hyperplasia.

Mechanism of continence after modified Pereyra bladder neck suspension. Prospective urodynamic study.

Twenty females with genuine stress urinary incontinence who underwent modified Pereyra bladder neck suspension were urodynamically studied pre- and postoperatively in an attempt to determine the mechanism by which continence was restored. Detailed analysis demonstrated no significant change comparing the pre- and postoperative cystometry findings, uroflow parameters, maximal voiding pressure, urethral resistance, maximal urethral closure pressure, or functional urethral length. The only significant change identified as a result of the surgical procedure was an alteration of proximal urethral pressure transmission during stress from negative to positive gradients. It is concluded that the modified Pereyra bladder neck suspension restores continence by restoring proper urethral support with restoration of positive pressure transmission to the proximal urethra without causing outflow obstruction, changing functional length, or altering maximal urethral closure pressure.

Intravesical oxybutynin chloride: experience with 42 patients.

To evaluate the efficacy of intravesical oxybutynin chloride, 42 patients who were incontinent secondary to uninhibited detrusor contractions and had failed oral anticholinergic therapy were begun on intravesical oxybutynin chloride. Indications for intravesical therapy were detrusor hyperreflexia (N = 20), detrusor instability (N = 19), and bowel/bladder overactivity after augmentation cystoplasty (N = 3). A 5-mg tablet dissolved in 30 cc of sterile water was instilled into the bladder two to three times daily via clean self intermittent catheterization. With a mean follow-up of 18.4 months, no patient reported side effects as a result of the intravesical therapy. Nine patients (21%) dropped out of the study due to inability to tolerate the catheterization or difficulty retaining the solution in the bladder. Eighteen of the 33 patients (55%) who followed the protocol experienced elimination or significant improvement of their incontinence. The results of the current study confirm the safety and usefulness of intravesical oxybutynin in treating uninhibited detrusor contractions in a difficult patient population.

Symptom analysis of patients undergoing modified Pereyra bladder neck suspension for stress urinary incontinence. Pre- and postoperative findings.

The results of a physician-directed follow-up of 145 women undergoing the modified Pereyra bladder neck suspension from March 1980 to February 1986 are presented. Median follow-up was 3.5 years (2.0-7.7); 70 percent of patients had follow-up between three and four years postoperatively. All patients had preoperative demonstration of stress incontinence as well as urodynamic evaluation. Fifty-one percent of patients reported no stress incontinence and 76 percent reported that their sense of urinary control was better, or much better at the time of follow-up. Improvement was seen in all grades of stress incontinence. Age, weight, parity, and history of prior anti-incontinence surgery had no significant impact on success rates. Although preoperative urgency symptoms were more common among failure (28% vs 15%), this association was not statistically significant. However, persistent or de novo urgency symptoms postoperatively were highly associated with postoperative incontinence (p less than 0.005). The onset of recurrent incontinence was experienced more than two years postoperatively in 23 percent of the incontinent group.

Role of the four-corner bladder neck suspension to correct stress incontinence with a mild to moderate cystocele.

OBJECTIVES: Women undergoing four-corner bladder neck suspension were evaluated for subjective and objective results of the procedure. Patients were evaluated for continence, prolapse, and symptomatic status postoperatively. METHODS: Forty-seven women underwent four-corner bladder neck suspension for moderate cystocele with (44) or without (3) stress urinary incontinence. Mean and median follow-up were 37 months (range 15 to 80). To assess results of the four-corner bladder neck suspension, two sets of outcome measures were used (subjective questionnaire, including patient satisfaction, and objective physical examination, with standing voiding cystourethrogram) to compare pre- and postoperative data. RESULTS: At the time of follow-up, 25 patients (53%) reported no incontinence, 14 (30%) reported one incontinent episode per week, and 8 (17%) reported daily loss of urine. Twenty-seven (57%) had grade I or grade II cystoceles on follow-up examination and voiding cystourethrogram; however, only 12 (26%) experienced recurrent prolapse symptomatology. Overall patient acceptance of the procedure was high (70%). CONCLUSIONS: The four-corner bladder neck suspension is an effective option in the management of moderate cystocele.

Prospective multicenter ProLase II clinical trial of neodymium:yttrium-aluminum-garnet laser prostatectomy.

OBJECTIVES: To assess the clinical efficacy of neodymium:yttrium-aluminum-garnet (YAG) laser coagulation prostatectomy using a broad-angle, divergent-beam, side-firing fiber. METHODS: Eighty adult men with voiding symptoms caused by benign prostatic hyperplasia were enrolled in a prospective multicenter study of free-beam neodymium:YAG laser prostatectomy performed with the ProLase II side-firing delivery fiber. Voiding outcomes were assessed at 3, 6, and 12 months postoperatively. RESULTS: At 1-year follow-up, peak urinary flow rates were increased by 105%, postvoid residual urine volumes had decreased by 38%, and the AUA symptom index had decreased by 60%. Serious treatment-related complications occurred in 3 of 80 patients (3.8%). The reoperation rate through 1-year follow-up was 2.7%. CONCLUSIONS: Neodymium:YAG laser prostatectomy performed with the ProLase II delivery fiber has proven safe and efficacious with durable results through 1 year in the relief of symptomatic bladder outlet obstruction due to benign prostatic hyperplasia.