Female bladder neck incision.

Bladder neck resection or incision in the female is not a new urologic procedure; however, it has not been widely accepted because of poor results and complications. From January to December, 1986, ten such operations have been performed on females with obstructive uropathy. All had previous anti-incontinence procedures and postoperative obstruction developed. Bladder neck incisions rather than resections have been performed with encouraging results. Urologic presentation, urodynamic investigations, and details of the surgery are presented. Bladder neck incision is a valuable adjunct in the management of bladder neck obstruction in the female.

Vasovasostomy--is the microscope necessary?

Many techniques for vasovasostomy have been described, with each author suggesting his technique as the most effective procedure. Theoretical considerations such as leakage of sperm, obstruction, and narrowing of anastomosis suggest that a stentless technique with exact approximation of mucosal edges results in improved success rates. Careful macroscopic surgery with loupes, fine suture material, and experience on the part of the surgeon will give good results and pregnancy rates of 50 per cent. The value of microsurgery, however, becomes obvious when the anastomosis is performed in the convoluted portion of the vas and the epididymis. The microscope allows more mobility in allowing one to determine if the patient had a block proximal to the vasectomy site and then bypass these blocks. The success of vasovasostomy depends greatly on the surgeon's experience with the actual surgical technique. Although technique is of paramount importance, there are factors other than technique that determine the pregnancy rate. Factors important in the success of vasovasostomy, macro- and microscopic techniques, basic concepts, principles and techniques of the various procedures, and the merits and limitations of each procedure, will be discussed.

Unusual case of urethral duplication.

We present a case of unique penile malformation, a child with common prostatic urethra with two normal, double urethras parallel to one another with a bifid glans penis. This case emphasizes how abnormal embryology can contribute to our knowledge of normal development.

Female bladder neck reconstruction. Anatomic and physiologic approach.

Postoperative scarring of the bladder neck and urethra after failed anti-incontinence surgery in the female can seriously disrupt the normal mechanisms of bladder storage and emptying. We have analyzed and treated this problem in 10 selected female patients. A "wrap-flap" technique with omental support has been applied to reconstitute the normal anatomy and physiology of the bladder neck. Excellent results were obtained in all patients, with up to fifty-four months of follow-up. We recommend this procedure prior to the implantation of prosthetic material, with its inherent difficulties.

Disseminated intravascular coagulation in carcinoma of prostate: role of estrogen therapy.

Advanced carcinoma of the prostate may present as disseminated intravascular coagulation and its sequelae. It is postulated that the slow release of thromboplastic material from tumor cells eventually overcomes normal homeostatic mechanisms. High-dose intravenous diethylstilbestrol diphosphate successfully reversed this coagulopathy in 2 cases of metastatic carcinoma of the prostate.

Transurethral electrovaporization of the prostate versus transurethral prostatic resection: a comparison of postoperative hemorrhage.

OBJECTIVES: To determine the acute and delayed hemorrhage rate of transurethral electrovaporization of the prostate (TEVP) versus standard transurethral resection of the prostate (TURP). METHODS: A retrospective review of 524 consecutive patients who underwent TURP and 302 consecutive patients who underwent TEVP was conducted. The indications for both procedures were identical and based on history, physical examination, American Urological Association symptom score, and uroflowmetry. Parameters of evaluation included the incidence of both initial and delayed hemorrhages, the time until a delayed bleed occurred, blood transfusion rates, and the average length of stay in hospital after a bleed. RESULTS: The overall hemorrhage rate for TURP and TEVP was 4.8% and 4.0%, respectively. In the TURP group, there was a 1.1% incidence of acute bleeds and 3.6% incidence of delayed bleeds. For the TEVP group, 0.3% had an acute hemorrhage, and 3.6% were readmitted for clot retention. The average length of time from original discharge to readmission was 12.9 days for the TURP group with a mean repeat stay of 5.7 days. For the TEVP group, the average interval to readmission was 15.4 days with a stay of 3.1 days. CONCLUSIONS: The overall rate of hemorrhage for the TEVP group was slightly lower than for the TURP group due to fewer acute bleeds. However, the incidence of delayed bleeds and clot retention between the two was identical at 3.6%. Because of improved hemostasis intraoperatively with similar functional results in the long term as shown by other investigators, we foresee TEVP continuing as a viable alternative to TURP.

Urinary retention in sexually abused women.

Urinary retention is generally believed to be the result of neurogenic or non-neurogenic problems. In men, it is often caused by benign prostatic hypertrophy which can be treated by transurethral surgery.1 In women, however, studies have shown that urinary retention is usually caused by detrusor dysfunction rather than obstruction. Surgery on the urethra or bladder neck is, therefore, inappropriate and ineffective. Once the cause of retention has been determined (i.e whether neurogenic or non-neurogenic in origin), appropriate treatment can be decided upon. The most common neurogenic problems are diabetes mellitus, multiple sclerosis and spinal cord pathologies.(1) Patients with non-neurogenic etiology associated with urinary retention are often found to have psychosocial problems that inhibit detrusor activity causing psychogenic retention.1-4 Studies have found that woman with a history of psychosis, depression and stress/anxiety have a higher incidence of urinary retention than woman with no history of such conditions. Psychological problems involving the loss of loved one, recent marriage break-up, abortion, pelvic surgery, etc. have been found to contribute to the incidence of urinary retention. There is another group of women who may or may not exhibit psychological problems associated with psychogenic urinary retention, but who may develop the same physical manifestations. These women have been sexually abused and have not fully resolved or realized the trauma of the assault. This paper looks at four cases or urinary retention in sexually abused woman, the treatments used and the results and conclusions obtained.

Quadriplegia: urological complications.

Unlike the general public, quadriplegics are prone to various urological complications as a direct/indirect result of spinal cord lesions. These complications include neurogenic bladder, urinary tract infections, renal and bladder calculi, obstructive uropathy, renal failure, and bladder neoplasms. A significant portion of upper urinary tract disease, including pyelonephritis, hypernephrosis, and calculi are usually secondary to neurogenic bladder related to detrusor sphincter dysfunction. These complications will be discussed in some detail in the following report.

Vasovasostomy-microscopy versus macroscopic techniques.

Many different surgical techniques of vasovasostomy can be successful. Many factors, both technical and nontechnical, play a role in determining pregnancy. Theoretical considerations such as leakage of sperm, obstruction and narrowing of the anastomosis, suggest that a stentless technique with exact approximation of mucosal edges will result in a better success rate. Careful macroscopic surgery with the use of fine suture material, and experience on the part of the surgeon, will give good results and pregnancy rates of up to 50%. Microsurgery becomes quite important when the anastomosis is performed in the convoluted portion of the vas and epididymis. The microscope allows more mobility in permitting one to determine if the patient has a block proximal to the vasectomy site, and then bypass these blocks. Conventional macroscopic techniques do not allow for this freedom of choice. Factors other than technique are also important and are discussed.

PIP: Technique in the performance of vasovasostomy is of great importance, but the following factors still may determine pregnancy rates: the timing of reversal surgery from previous vasectomy, the presence of sperm granuloma, epididymal obstruction, and sperm antibody. The macroscopic and the microscopic techniques of vasovasostomy are reviewed and compared. A macroscopic technique with the use of stents has been the classical approach. Utilizing a nylon stent, a pregnancy rate of 55% has been reported. A problem is that obstruction can occur at the site of exit of the stent through the wall of the vas deferens, rather than at the anastomosis site itself. To avoid this, internal absorbable stents have been used with early good results. Many have advocated omitting stents in macroscopic vasovasostomy. Initially popularized in 1975, a pregnancy rate of 76% suggested the superiority of the microscopic technique. The vas is mobilized superiorly and inferiorly until the defeat is isolated. Proximal exploration is continued until fluid is encountered coming out of the cut end of the vas. If no sperm are found in this fluid, progress is made in a stepwise fashion along the vas and into the epididymis. A study comparing macro and microscopic techniques has suggested that both techniques have merits worth considering. Macroscopic surgery with externalized nonabsorbable stents gives potency rates of 85%-85% with the pregnancy rates ranging from 39%-55%. Although large series have not been reported, it appears that the use of loupe magnification and possibly the use of absorbable stents would be a theoretical and a practical advantage and lead to better results. Microscopic surgery gives potency rates ranging from 75%-98% with pregnancy rates from 72%-76%, but the microscopic procedure requires a mastering of microsurgery and training in the laboratory. The surgeon's experience in performing the technique used appears to be 1 of the most important factors in determining the technical success rate of vasovasostomy.

Surgical management of Peyronie's disease.

Various forms of treatment have been advocated for Peyronie's disease but none has been entirely satisfactory. Recent reports in the literature indicate that surgical management consisting of excision and dermal grafting may not be the perfect cure suggested in the original report of Devine and Horton. The authors therefore review their experience in the use of the Devine-Horton technique emphasizing factors thought to be important for success. These include careful selection of patients for operation (patients should be potent, have undergone at least 6 months of conservative treatment, have non-inflammatory painless disease and a resectable localized fibrotic plaque), use of a circumferential incision to allow adequate operative exposure and use of a dermal graft 25% larger than the defect.

An effective treatment for functional urinary incoordination.

Twenty women diagnosed with functional urinary incoordination were randomly assigned to one of two treatment groups: biofeedback or progressive muscle relaxation. Ten subjects who were placed on a waiting list prior to treatment allocation served as a comparison group. The biofeedback intervention focused specifically on retraining of pelvic floor musculature (PFM). Patients were assessed pretreatment, posttreatment, and at 2-month follow-up. Outcome measures included self-reported symptomatology, psychological functioning, psychophysiological assessment of the PFM, and urologist ratings of problem severity and treatment efficacy. Both treatment approaches proved effective in improving symptomatology and psychological state. Subjects on the waiting list demonstrated no change in urological difficulties. No differences were found between the two treatment groups on any of the outcome measures. Theoretical and practical implications of the results are discussed.

Carcinoma in the defunctionalized urinary tract.

Carcinoma developing in the lower urinary tract diverted from the urinary stream, although uncommon, does occur and must be sought carefully in the presence of intractable pyocystis. Our experience with this condition is presented with emphasis on early diagnosis and treatment.

A psychophysiological evaluation of female urethral syndrome: evidence for a muscular abnormality.

This is a preliminary investigation into a recently defined urological disorder occurring in a subgroup of women with "urethral syndrome" suggestive of pelvic floor muscular (PFM) dysfunction. Symptoms include straining to void, urgency, frequency, hesitation, incontinence and/or retention, and subpubic pain. Finding neither bladder nor urological abnormalities, urologists may consider these women emotionally unstable without organic cause for their symptoms. However, their distress may be a consequence rather than a cause of their voiding problems. Sixteen female urological patients were matched with 16 asymptomatic controls to investigate PFM functioning, psychological status, and symptomatology. Results showed heterogeneity of symptomatology and little elevation of depression or anxiety when comparing patients with controls. Hypotheses of muscular abnormality were confirmed. Patients evidence poor control over testing and relaxing PFM, elevations of PFM activity under various conditions, and chronic pain as a prominent symptom. Treatment approaches specifically designed to address PFM dysfunction are discussed.

Pathogenesis of urinary infection in patients with acute spinal cord injury on intermittent catheterization.

In a small pilot study urinary tract infection in patients with acute spinal injury was preceded by the establishment of Enterobacteriaceae on the introitus, glans and urethra. Those patients who retain the normal flora do not become infected. The first infection most commonly is by Escherichia coli with universal antibiotic sensitivities. Female patients with a history of urinary infections and male patients with a history of bacterial prostatitis are at risk for suffering recurrent infections. Saline or chlorhexidine gluconate pre-catheter preparation does not appear to relate to a continual status free of infection.

An assessment of the use of intravesical potassium in the diagnosis of interstitial cystitis.

PURPOSE: We evaluated the use of intravesical potassium in the diagnosis of interstitial cystitis. MATERIALS AND METHODS: A blinded test assessment on 39 consecutive subjects attending our urology clinic for the evaluation of symptoms consistent with interstitial cystitis was performed. The pain response to intravesical potassium and water as a control was measured. The response rate was compared to the results of cystoscopy using standard outcome measures associated with diagnostic test assessment. RESULTS: The probability of having interstitial cystitis given a positive intravesical potassium test was 66%. This finding added no new useful information and would not be helpful with clinical decisions as the probability of having interstitial cystitis in this population was already 56% before the test. Similarly, if the test was negative then 46% or nearly half of the subjects were still likely to have interstitial cystitis. Therefore, a negative test would have no ability to rule out disease nor would it be useful in making clinical decisions about how to proceed with evaluation or therapy. Test characteristics were considered poor with a sensitivity of 69.5% and a specificity of 50%. Likelihood ratios (positive 1.39, negative 0.61) also indicated poor inclusion and exclusion capabilities. CONCLUSIONS: The general use of intravesical potassium as a diagnostic test for interstitial cystitis is not validated. The diagnosis of interstitial cystitis must depend on the clinical presentation and endoscopic findings based on National Institutes of Health criteria.

The correlation of multichannel urodynamic pressure-flow studies and American Urological Association symptom index in the evaluation of benign prostatic hyperplasia.

PURPOSE: We correlated multichannel pressure-flow urodynamics and the American Urological Association (AUA) symptom index in the evaluation of benign prostatic hyperplasia. MATERIALS AND METHODS: We evaluated 121 consecutive, symptomatic patients older than 55 years with the AUA symptom score and multichannel pressure-flow urodynamic studies. Testing was performed during a single session and the data obtained from 103 patients were plotted on the Schäfer nomogram for assessment of outflow obstruction. Linear regression statistical analysis was used to determine correlations. RESULTS: There was no significant correlation between uroflowmetry and Schäfer curves (r = 0.173 to 0.326), uroflowmetry and AUA symptom scores (r = 0.134 to 0.153) and, most importantly, AUA symptom scores and Schäfer curves (r = 0.025 to 0.137). CONCLUSIONS: We conclude that these modalities measure independent variables, and should not be linked in the evaluation and treatment decision of the patient with prostatism.

Translabial sonography of vaginal fibroids: report of 2 cases and review of the literature.

OBJECTIVE: To determine the role of translabial sonography in the diagnosis of vaginal fibroids. METHODS: Two women with vaginal masses of undetermined origin were examined by various imaging procedures, including translabial sonography. RESULTS: Initial examinations, which included transabdominal sonography, cystoscopy, and cystourethrography, yielded inconclusive findings. Translabial sonography, however, suggested isolated vaginal leiomyomas in both patients, and in both the diagnosis was confirmed histologically after surgery. CONCLUSIONS: Translabial sonography should be considered as an adjunct to transabdominal and transvaginal sonography for patients with suspected vaginal fibroids.