Artificial bladder replacement: a new design concept [see comment].

An effectively functioning artificial bladder would be useful after cystectomy because of the ease of insertion and the availability to all patients. In this report, we describe a new design concept based on negative pressure drainage of the kidneys and active voiding, and we present the results of testing this device. Although previous prosthetic bladders have had difficulties with renal failure from hydronephrosis, infection from retention of urine, and encrustation of the luminal surface, the current artificial complete bladder system addresses these problems.

Obstructive anuria and dermatomyositis: a unique association.

This case is the first reported presentation of obstructive anuria due to extrinsic ureteral compression in a patient with dermatomyositis. Further evaluation revealed disseminated sigmoid colon adenocarcinoma. Conservative treatment of ureteral obstruction by internal double-J stents achieved appropriate palliation.

Should we treat localized prostate cancer? An opinion.

Localized prostate cancer is a progressive disease if left untreated. However, cancer-specific mortality is low in patients with moderately and well-differentiated prostate cancer treated with observation and delayed hormonal therapy, being 13% at 10 years and 20% to 30% at 15 years. By and large, radiation therapy does not appear to improve survival in these patients. With modern surgical techniques, mortality from prostate cancer is lowered by 23% to 65% in patients with moderately or well-differentiated tumors. However, the impact on relative cancer-specific survival is modest, since the mortality rate in untreated patients is low. The survival of conservatively managed patients with poorly differentiated prostate cancer is dismal: here radiation therapy or surgery significantly improves outcome. The QOL of patients with localized prostate cancer is significantly affected by the occurrence of distant metastasis. Metastatic rates are high in patients who are followed with observation and delayed endocrine treatment (19% to 85%). We were unable to deduce the effects of radiation therapy on grade-specific metastatic rates at 10 and 15 years. The only surgical series that addresses the issue shows a 50% to 80% reduction in metastatic rates. This results in an improvement in metastasis-free survival of 19% to 300%. The reduction in metastatic rates with surgery holds true for patients with poorly, moderately, or well-differentiated tumors. However, a significant proportion of the surgical patients were treated with adjuvant endocrine therapy, and it is impossible to identify the benefit from surgery and the benefit from adjuvant therapy. Radical prostatectomy improves survival in men who are 65 years or younger with moderately or well-differentiated adenocarcinoma of the prostate, and in men 75 years or younger who have poorly differentiated adenocarcinoma of the prostate. Its efficacy in reducing cancer-specific mortality in patients who have a survival expectancy of less than 15 years (older than 65 years) and moderately or well-differentiated adenocarcinoma of the prostate is less clear. Radical prostatectomy, with or without adjuvant hormonal therapy, decreases metastatic rates in men with a life expectancy of 10 years or more (age 75 years or younger) irrespective of tumor grade and, thus, should improve the QOL expectancy in these men. Nevertheless, between 20% and 60% of patients undergoing radical prostatectomy have biochemical recurrence, as defined by a detectable PSA, at 10 years of follow-up. This is worrisome and may portend clinical failure with longer follow-up.(ABSTRACT TRUNCATED AT 400 WORDS)

Mayo Clinic experience with the AS800 artificial urinary sphincter for urinary incontinence after transurethral resection of prostate or open prostatectomy.

The model AS800 artificial urinary sphincter was implanted in 56 patients with urinary incontinence after transurethral resection of the prostate and in 8 patients after open prostatectomy. Their ages ranged from fifty-three to eighty-seven years (mean, 70 years). At presentation, 92 percent had total incontinence and 8 percent had distressing stress incontinence. Fifteen patients (23%) had had previous radiation therapy. Bulbous urethral cuffs were used in 60 (94%) patients and vesical neck cuffs in 4 (6%). Follow-up questionnaires were mailed to assess satisfaction rate and degree of continence. Continence was significantly improved in 90 percent, and 87 percent of the patients were satisfied with their sphincters. Surgical revisions were required in 14 patients (22%). Cuff compression was inadequate in 9 patients, and erosion led to revision in 3 patients. At follow-up, 3 patients had had at least one component of the AS800 removed (complete device in 2 and cuff in 1).

Experience with AS 800 artificial sphincter in pediatric and young adult patients.

Congenital or acquired sphincteric urinary incontinence in children and young adults is a severe social and physical burden. As a therapeutic option, we implanted 61 AS 800 artificial sphincters in 59 patients (46 males and 13 females). The mean age of the patients was 17.5 years (range, 6 to 34 years), and mean follow-up was forty-three months (range, 5 to 84 months). In addition to artificial sphincter implantation, intestinal cystoplasty was required in 22 patients to obviate problems of increased detrusor contractility or decreased detrusor compliance, or both. Continence was good in 47 patients (80%) and fair in 8 (14%). Four patients (7%) were awaiting sphincter modification or cystoplasty, or both. Careful and prolonged follow-up is mandatory in all patients managed in this fashion to preclude the deleterious effects of subtle changes in detrusor or ureteral function on the integrity of the upper urinary tracts.

Detection of leakage in inflatable genitourinary devices.

OBJECTIVES: Improved manufacturing techniques and stronger materials have significantly reduced but not eliminated the incidence of hydraulic leakage in the inflatable genitourinary devices. This study was designed to test the efficacy of pressure dissipation and volume loss as potential tests for the detection of site-specific hydraulic leakage in the inflatable penile prosthesis (IPP) and the artificial sphincter (AS) and compare their efficacy with the current standard--the ohmmeter technique. METHODS: Five IPPs and ASs were dismantled to achieve five reservoirs and cuff-pump assemblies. Each component was inspected visually and then tested for volume, pressure, and electrical resistance over 5 minutes. Next a needle puncture was deliberately made in these components, and the experiment was repeated. The in vivo pseudocapsule was simulated by an elastic covering, made from antiembolic hose. RESULTS: The techniques of pressure, volume, and ohmmeter testing were not able to detect current leakage in all the components, with the pseudocapsule in place. CONCLUSIONS: None of the currently available tests qualify for the label of "gold standard" in accurately detecting hydraulic leakage. We currently recommend testing the device's integrity by visual inspection in vivo, starting with the reservoirs. If a leakage is detected, the reservoir alone is replaced. If no leakage is found, we recommend that the entire unit be removed and replaced. If the malfunctioning device is more than 2 years old, we suggest that it be entirely replaced.

Revision surgery for penile implants.

Over the last two decades, penile implants have been associated with a 81-97% patient satisfaction. Complications and revisions are inevitable sequelae of penile implant surgery. Between 1982 and 1992, a total of 47 patients were presented to us with complications related to penile implants who required surgical correction. Forty-two of 47 patients elected to do so. All 42 who opted for corrective surgery have functioning implants with 38 characterizing the result as good and four reporting them as fair. The corrective surgeries included corporal reconstruction with Goretex graft in five patients and use of rear tip extender for posterior crural repair in one patient. There was no increase in the incidence of infection or mechanical malfunction.

Misoprostol induces relaxation of human corpus cavernosum smooth muscle: comparison to prostaglandin E1.

Prostaglandin E1 (PGE1) relaxes trabecular smooth muscle by interacting with specific G-protein coupled receptors on human corpus cavernosum smooth muscle and increasing intracellular synthesis of cAMP. Misoprostol (Cytotec), is an oral prostaglandin E analogue. The purpose of this study was to compare the functional activity of misoprostol with PGE1 in human corpus cavernosum and cultured human corpus cavernosum smooth muscle cells. Misoprostol, misoprostol free acid or PGE1 induced dose-dependent relaxations in strips of human corpus cavernosum. At concentrations greater than 10(-6) M, tissue recontraction was observed with all three agents. This was abrogated by pretreatment with the thromboxane A2 receptor antagonist SQ29,548. From these observations, we conclude that misoprostol is activated by human corpus cavernosum in situ and relaxes phenylephrine-precontrated tissue strips in vitro. This relaxation response is mediated by the increased cAMP synthesis by these agents.

The artificial sphincter (AS-800). Experience in children and young adults.

From reviewing our experience in the application of the AS-800 sphincter for the management of incontinence in children, we conclude that implantation is indicated after conservative and less invasive therapy has been attempted. The bladder neck is the site of choice for cuff placement in children. Primary deactivation and moderate or low reservoir pressures (61 to 70 and 71 to 80 cm H2O) are indicated, especially in patients with previous bladder neck surgery or an inadvertent bladder neck injury. Excess residual urine should be evacuated by clean intermittent catheterization. The AS-800 is mechanically reliable (9 mechanical failures in 45 sphincters). When the sphincter is implanted in a select group of patients, upper tract function is maintained in a stable state. Detubularized augmentation cytoplasty must be used to supplement the sphincter in patients with low-compliance, low-capacity, and nonresponsive hyperreflexic bladders. In all patients, long and careful follow-up is necessary to identify late changes in bladder function and consequent upper tract damage. An overall satisfactory result (fair to good) was obtained in 88 per cent of patients during an average follow-up period of 35 months, and 0.6 modifying procedure per patient was done in the sphincters.

Urinary incontinence in adults.

Abnormalities of the micturition cycle are responsible for a large number of visits to the urologist. Some of these abnormalities produce annoying symptoms; others may lead to hazardous and disabling changes in the urinary tract. Urinary incontinence in adults results from an abnormality of one or more of the factors involved in the two phases of the micturition cycle: filling-storage and emptying. Proper management requires judicious selection among the pharmacologic and surgical alternatives.

Ureteral tailoring in situ: a practical approach to persistent reflux in the dilated reimplanted ureter.

PURPOSE: We evaluated a new simplified technique for secondary surgical correction of persistent reflux in a reimplanted dilated ureter. MATERIALS AND METHODS: Four patients a median of 3 years old with recurrent vesicoureteral reflux after initial reimplantation of ureters greater than 9 mm. in diameter underwent in situ excisional ureteral tailoring. RESULTS: Followup ranged from 15 to 27 months (mean 22). Within 3 months postoperatively ultrasound confirmed no ureteral obstruction, and at 3 to 6 months voiding cystourethrography revealed no vesicoureteral reflux in any case. CONCLUSIONS: Our study highlights the surgical details and safety of this technique for preserving the vascularity of the reconstructed ureter and avoiding injury to the contralateral ureter.

Application of the AS-800 artificial sphincter for intractable urinary incontinence in females.

Intractable incontinence is a challenging problem, especially in females who have been operated upon frequently for the correction of this problem. Twenty-four such females (age 11 to 78 years) received an artificial sphincter (AS-800). The mean follow-up time was 41 months (range of eight to 66 months). Detubularized augmentation cystoplasty was performed upon six patients, simultaneously with sphincter implantation in three patients and in two stages in the others. Seventeen patients reported "good" continence, and three reported continence as "fair, improved." The four failures occurred in patients in whom the sphincter had been extracted because of erosion and infection of the bladder neck cuff. A total of 12 revisions were necessary, nine during the first two years after sphincter implantation (0.5 revisions per patient). Two patients who had successful pregnancies underwent deactivation of the sphincter in the third trimester. Strict attention to surgical principles, postoperative care and careful selection of patients have made the AS-800 artificial sphincter a reliable option in treating intractable sphincteric incontinence in females.

Combined implantation of artificial sphincter and penile prosthesis.

Concurrent sphincteric incontinence and organic impotence are not uncommon; they can be caused by many congenital and acquired conditions. In the past simultaneous implantation of the artificial sphincter and penile prosthesis was met with skepticism. Of 65 patients who had concurrent implantation of the artificial sphincter and various categories of penile prosthesis 60 were followed for a mean of 35.74 months (range 8 to 55 months). Continence was graded as good or satisfactory in 95 per cent of the patients and poor in 5 per cent. The penile implants were functional in 98 per cent of the patients. Of the 60 patients 33 required 59 corrections, for an average of 0.98 correction per patient. These results indicate that staged or concurrent implantation of dual prostheses is feasible technically, functionally and cosmetically, and without increased risk for surgical or mechanical problems.

Mayo Clinic experience with use of the AMS800 artificial urinary sphincter for urinary incontinence following radical prostatectomy.

The model AMS800 artificial urinary sphincter was implanted in 117 patients with urinary incontinence resulting from radical prostatectomy. The indication for implantation was total incontinence in 107 patients and stress incontinence in 10. All patients had bulbous urethral cuff insertion and 20 had previous pelvic irradiation. Followup questionnaire indicated a 90% significantly improved continence rate and a 90% satisfaction rate among patients. There were 64 surgical revisions required in 37 patients: inadequate cuff compression in 21 (33%), tubing kinks in 10 (16%), urethral cuff erosion in 8 (13%), scrotal hematoma in 6 (9%), control assembly malfunction in 4 (6%) and cuff leaks in 4 (6%). Of the 20 patients with previous pelvic radiation 2 (10%) had at least 1 erosion, compared to 5 of 97 (5%) in the nonirradiated group. At followup 5 patients did not have at least 1 component of the AMS800 device indwelling (2 cuffs and 3 entire devices had been removed).

The genitourinary spheroidal membrane: an experimental study of a new percutaneously inserted prosthetic device for the control of urinary incontinence.

The genitourinary spheroidal membrane, composed of silicone rubber, has been developed along with a mechanical delivery instrument that allows transcutaneous insertion of the prosthetic sphere in the periurethral tissues to enhance outlet resistance in incontinent patients. An experimental study was undertaken in six female mongrel dogs to evaluate the safety and efficacy of this concept. The leak-point pressure increased from five to 38 cm. H2O (mean increase, 16.8 cm. H2O). This increase is statistically significant (p less than 0.024, two-sided t test). During the 90-day experiment, there was no migration of the spheres, minimal local inflammatory response, and no granuloma formation or inflammatory response in various organs studied. Although the leak-point pressure was increased in all of the dogs, none developed difficulty voiding. We conclude that the design concept is sound and safe, the delivery system is reliable, and it is possible to place the spheroidal membrane into an anatomic location that will increase outlet resistance.

Renal colic during pregnancy: a case for conservative treatment.

PURPOSE: We defined the merits of early evaluation and conservative treatment of pregnant patients admitted with renal colic. MATERIALS AND METHODS: We retrospectively evaluated 72 pregnancies in 70 patients who were hospitalized with the diagnosis of renal colic between 1984 and 1995. Urinalysis was performed in every case. Ultrasound was the primary diagnostic test in 65 patients. The patients were followed for 2 weeks to 3 months after delivery (mean 21 days). RESULTS: Mean patient age at presentation was 27.4 years. The majority of patients were multiparous (47 of 70) and presented in the third trimester (44 of 70). Microscopic urinalysis was not helpful in identifying stone disease in pregnant patients. The sensitivity of ultrasound for the diagnosis of renal calculi was 95.2%. Watchful conservative nonsurgical treatment resulted in spontaneous passage of stones in 64.3% of cases. Of the 19 pregnancies in which intervention was necessary cystoscopy and Double-J* silicone stent placement were done in 15, and ureteroscopy and stone basketing were done in 4. Two patients, who presented with pyelonephritis and premature ruptured membranes had fetal loss. Long-term antibiotic prophylaxis was maintained in all stented and bacteriuric patients. CONCLUSIONS: Renal colic in pregnant patients can be complicated by pyelonephritis and premature labor, especially if misdiagnosed or inadequately treated. Ultrasound is a safe and sensitive diagnostic test. Approximately two-thirds of renal calculi will pass spontaneously. For those who require intervention, placement of a Double-J stent is a safe and effective option.

W-stapled ileal neo-bladder formed entirely with absorbable staples.

Orthotopic bladder replacement after total cystoprostatectomy for bladder cancer has gained broader use. Continent diversion has historically increased the complexity of the surgical procedure, often discouraging its adoption by many urologists. Absorbable staples on a GIA* instrument became available in 1992 and have been incorporated into reservoir formation in this preliminary study. A novel W-shaped ileal reservoir entirely fashioned from absorbable staples using the GIA and TA instruments has been developed and used in 15 patients undergoing cystoprostatectomy. The advantages of this technique are its simplicity and the speed with which the reservoir can be fashioned. In the first 15 patients operative time to construct the reservoir ranged from 12 to 21 minutes. Functional aspects of urodynamic studies and continence appear comparable to those of other ileal reservoirs. These preliminary data justify comparative trials on an expanded scale.