Phase I/II examination of transurethral ethanol ablation of the prostate for the treatment of symptomatic benign prostatic hyperplasia.

PURPOSE: We assessed the safety of transurethral ethanol ablation of the prostate as a treatment for men with symptomatic benign prostatic hyperplasia and determined the efficacy of this procedure. MATERIALS AND METHODS: We performed a multicenter randomized trial on 79 men, 50 to 79 years old, who had drug refractory voiding symptoms (International Prostate Symptom Score greater than 12) and prostate volumes of 30 to 80 cc. Ethanol was injected transurethrally into the prostate with a curved cystoscopic needle in men randomly assigned to 1 of 3 doses: 15%, 25% or 40% of prostate volume by transrectal ultrasound. Followup evaluations were performed 1, 3 and 6 months later. Postoperative cystoscopy was performed on all patients to evaluate ablation extent and extraprostatic effects. Transrectal ultrasound volume determinations were obtained before and 6 months after transurethral ethanol ablation of the prostate. RESULTS: Adverse events were generally mild or moderate, and included hematuria (42.9%), irritative voiding symptoms (40.3%), pain/discomfort (25.6%) and urinary retention (22.1%). No serious adverse events were reported. Statistically significant improvements were seen in International Prostate Symptom Score, quality of life, maximum flow rate and prostate volume reduction (p<0.05). Improvements were consistently observed across the 3 groups without an apparent dose effect. CONCLUSIONS: In this randomized clinical trial transurethral ethanol ablation of the prostate was safe and effective at 6-month followup. No serious adverse events were encountered. Although ethanol can safely ablate prostatic tissue, further studies will be necessary before widespread clinical application.

Does laparoscopic ureterolithotomy replace shock-wave lithotripsy or ureteroscopy for ureteral stones?

Ureteral stones are a major cause of morbidity and anxiety among urologic patients. Before the 1980s, ureteral stones were managed by open ureterolithotomy. Since then, second- and third-generation shock-wave lithotriptors, small-caliber ureteroscopes, and laparoscopic procedures have evolved as options for the treatment of ureteral calculi. Each technique is highly effective when implemented for the appropriate indication. Stone size, location, composition, and surgeon's and patient's preferences each play a major role in the decision-making process. Currently, ureteroscopy and shock-wave lithotripsy are regarded by many as the first-line treatment modalities for the management of ureteral stones, and the exact role of laparoscopic ureterolithotomy remains poorly defined. The present review addresses the most recent literature, and highlights the advantages and disadvantages of each surgical option.

Imaging of the lower urinary tract in adults.

Imaging of the lower urinary tract is an integral part of everyday urologic practice. Clinical application of less commonly used techniques is discussed to expand their usefulness in an ambulatory setting.

Do prostatic stents solve the problem of retention after transurethral microwave thermotherapy?

Temporary nonmetallic stents offer an alternative to an indwelling catheter for the management of voiding problems after heat-based therapies for benign prostatic hyperplasia. Patient comfort is improved, and they are able to void immediately after the procedure. Unlike a catheter, stents function on the principle of active drainage. Thus, a functioning detrusor muscle is imperative for stent success. Single-center clinical trials have reported encouraging results; however, predictable success criteria are yet to be established. Multicenter trial data are awaited.

Endoprostatic stents for management of benign prostatic hyperplasia.

Endoprostatic stents have been developed for relieving bladder outlet obstruction secondary to benign hyperplasia of the prostate. The stents are designed either for permanent or for temporary placement. The short-term temporary stents of various biostable and biodegradable polymers are needed after minimally invasive therapy of prostate with heat. The temporary stents are a management option, whereas the permanent stents are a treatment option. Permanent stents offer immediate relief and their sustained results for 4-7 years make them ideally suited for medically compromised patients.

Uncommon complications of permanent stents.

The UroLume endoprosthesis has been used for recurrent bulbar urethral strictures, benign prostatic hyperplasia, and detrusor-external sphincter dyssynergia. Complications of the UroLume have been described by the North American Multicenter Trial as migration, encrustation, hyperplastic tissue growth, in addition to pain and irritative voiding symptoms. Generally, complications have been minimal, and few of the stents required removal. Patients with bulbar strictures were felt to be at relatively greater risk of hyperplastic tissue reaction if their stricture was secondary to trauma or if they had a prior urethroplasty. On the other hand, patients with benign prostatic hyperplasia were at risk of developing complications if they had median lobe enlargement or a short (<2.5 cm) prostatic urethra. We describe two cases in which off-label compassionate use of UroLumes in the anterior urethra and in an irradiated urethra led to adverse reactions such as stent separation, poor epithelialization, hyperplastic tissue growth, encrustation, or obstruction necessitating removal.

Outcome of vaportrode transurethral vaporization of the prostate using pressure-flow urodynamic criteria.

OBJECTIVES: To use pressure-flow urodynamic parameters to evaluate the outcome of patients with benign prostatic hyperplasia (BPH) who were treated with transurethral vaporization of the prostate (TUVP) using the Vaportrode. METHODS: Forty consecutive patients (mean age 71.7 years) undergoing TUVP for treatment of symptomatic obstructive BPH or urinary retention were evaluated preoperatively and postoperatively with American Urological Association (AUA) Symptom Score, uroflowmetry, and pressure-flow multichannel urodynamic studies. RESULTS: Twenty-nine patients were voiding preoperatively. Eleven patients presented with urinary retention and were analyzed separately. At 3-month mean follow-up, the AUA Symptom Score decreased from 20.7 to 7.2 (n = 26). Peak uroflow rate (Qmax) increased from 8.2 to 15.5 mL/s (n = 27), whereas detrusor pressure at maximal flow (Pdet) decreased from 95.0 to 44.7 cm H2O (n = 24), indicating relief of obstruction. Postvoid residual urine volume decreased from 181.8 to 37.3 mL (n = 27). At 1-year mean follow-up, the AUA Symptom Score was 5.6 (n = 15) and Qmax was 14.3 mL/s (n = 19). The overall complication rate was 17.5% and included meatal stenosis (n = 1), bulbar urethral stricture (n = 1), refractory detrusor hyperreflexia (n = 1), dystrophic bladder neck calcification (n = 1), prostatic synechial formation requiring revision (n = 2), and residual prostatic tissue requiring revision (n = 1). CONCLUSIONS: This study provides objective evidence that TUVP is effective in providing prompt relief of bladder outlet obstruction with durable improvement in symptoms and flow rate with no acute morbidity. Accordingly, TUVP should continue to be considered as a minimally invasive surgical alternative to transurethral resection of the prostate.

Pubovaginal sling using polypropylene mesh and Vesica bone anchors.

OBJECTIVES: To report preliminary results from a modified pubovaginal sling procedure using polypropylene mesh as the sling suspended by nonabsorbable sutures anchored to the pubic tubercle with Vesica bone anchors. METHODS: Thirty-five women with type III stress urinary incontinence (SUI) (with or without associated urethral hypermobility) or type II SUI with additional risk factors such as obesity, chronic obstructive pulmonary disease, or failed prior incontinence-correcting procedures underwent this modified pubovaginal sling procedure. Postoperative voiding status was evaluated during office follow-up visits and telephone surveys. RESULTS: With a mean follow-up of 8.4 months (range 2 to 18), 32 women (91.4%) were dry, 1 improved, and 2 remained incontinent. The pubovaginal sling procedure was the only operation performed in 46% of patients, with a mean operative time of 72 minutes, a mean estimated blood loss of 137 mL, and a mean hospital period of 2.3 days. Patients on whom concomitant gynecologic procedures were performed had a mean duration of surgery of 122 minutes, a mean estimated blood loss of 202 mL, and a mean hospitalization period of 2.9 days. Thirteen women had preoperative urgency that persisted in 31% of patients. De novo urgency developed in 3 patients. Seven women required prolonged suprapubic tube drainage but no patient remained in permanent retention. There has been no infection or erosion. CONCLUSIONS: Our experience with this modified pubovaginal sling procedure using polypropylene mesh and Vesica bone anchors showed excellent results with greater technical ease, minimal morbidity, and decreased hospitalization period when compared to a traditional pubovaginal sling performed in our hands. Additional follow-up will be needed to assess long-term efficacy.

Sphincteric incontinence: the primary cause of post-prostatectomy incontinence in patients with prostate cancer.

Post-prostatectomy incontinence in patients with cancer of the prostate is often the result of sphincteric injury. However, recent studies have emphasized the role of detrusor instability and decreased bladder compliance in the etiology of post-prostatectomy incontinence. To further clarify the primary cause of incontinence, we reviewed the urodynamic studies of 39 patients referred for evaluation of incontinence after prostatectomy (35 radical, 4 TURP and radiation) for prostate cancer. Multichannel videourodynamic studies were performed to characterize bladder function, and sphincteric incontinence was assessed by Valsalva leak point pressure (VLPP). Flexible cystourethroscopy was used to evaluate the vesicourethral anastomosis. A pad scoring system was used to measure symptom severity. Sphincteric damage was found to be the sole cause of urinary incontinence in 23 patients (59%) and a major contributor in 14 others (36%). Twenty-seven patients (69%) had VLPP less than 103 cmH2O (mean = 55) with a urethral urodynamic catheter in place. An additional 10 (26%) had VLPP less than 150 cmH2O (mean = 63) upon removal of the catheter. VLPP is an indication of the severity of sphincteric damage. The importance of removing the urodynamic catheter during measurement of the VLPP is emphasized. Urethral fibrosis was confirmed by cystourethroscopy in 26 (67%) patients. Bladder dysfunction characterized by detrusor instability and/or decreased bladder compliance was seen in 15 patients (39%). In contrast to previous studies, our results indicate that sphincteric damage, and not bladder dysfunction, accounts for the vast majority of post-prostatectomy incontinence in patients with prostate cancer. However, it is essential to identify and treat bladder dysfunction in order to optimize the outcome of treatment for sphincteric incontinence.

Role of permanent stents.

The application of permanent stents in the urinary tract followed their success in the vascular system. Permanent metal stents have been used in the treatment of urethral stenosis, bladder outlet obstruction secondary to benign prostatic hyperplasia (BPH), and detrusor-sphincter dyssynergia. In addition, stents are used in the ureter for ureteroileal strictures and malignant obstruction. Despite the favorable early results, concerns have been raised about their biocompatibility, hyperplastic tissue response, encrustation, and carcinogenicity. This paper reviews the long-term data on permanent stents, primarily the Urolume device, which has been studied extensively in multicenter trials in North America and was recently approved for use in the urethra and for the treatment of bladder outlet obstruction secondary to BPH.

Epithelialization of permanent stents.

The permanent Urolume Wallstent has been used for the relief of bladder outlet obstruction (BOO), detrusor-external sphincter dyssnergia (DESD), and recurrent bulbar urethral strictures. Because of its woven construction, it allows ingrowth of urothelial tissue, resulting in complete epithelialization by 6 to 12 months. Certain risk factors are associated with poor epithelialization that may lead to hyperplastic tissue growth and occlusion of the urethral lumen. We review the literature and discuss the 5-year results of the North American Multicenter Urolume Trial with regard to epithelialization, hyperplastic tissue growth, and treatment of hyperplastic growth.

Evaluation of transurethral vaporization of prostate with pressure-flow analysis and other clinical measures.

Transurethral vaporization of the prostate (TUVP) is a promising new alternative modality for resection of obstructing adenomatous prostatic tissue. We evaluated the efficacy of TUVP for treatment of symptomatic benign hyperplasia (BPH) or urinary retention using pressure-flow analysis and other clinical measures. Twenty-seven men (mean age 72) with symptomatic BPH (N = 21) or urinary retention (N = 6) underwent TUVP using the VaporTrode loop. Patients were evaluated both preoperatively and postoperatively by subjective and objective criteria including AUA symptom score, uroflowmetry, postvoiding residual volume (PVR), and detrusor pressure (Pdet) at maximum flow. Complete follow-up data were available in 19 patients with an average follow-up of 9 weeks (range 4-32). The average symptom score was reduced from 19.9 to 5.58 (p < 0.0001). The average peak uroflow rate (Qmax) improved from 7.0 ml/sec to 18.1 mL/sec (p < 0.001). The average PVR was reduced from 163 mL to 14 mL (p < 0.003), and there was a similar reduction in Pdet at maximum flow from 96 cm H2O to 44 cm H2O (p < 0.001). The overall complication rate was 11%. These included meatal stenosis (N = 1), temporary urinary retention (N = 1), and residual prostate tissue causing obstruction (N = 1). In conclusion, TUVP with the VaporTrode yields a significant improvement in AUA symptom score, peak uroflow rate, PVR, and detrusor pressure at maximum flow, denoting relief of bladder outlet obstruction. This review of our experience with TUVP provides additional evidence for the use of the VaporTrode as a safe and effective alternative surgical modality for the treatment of symptomatic BPH.

Anesthetic considerations in the geriatric patient.

As the population ages the incidence of many urologic diseases increases. The elderly patient often is afflicted with many other concomitant diseases in addition to the general deterioration in their overall health status that occurs as a part of the normal aging process. With new advances in technology, many less invasive techniques have become available to treat many of these conditions, thus making many more elderly patients candidates for surgery. In the geriatric population the anesthetic consideration for surgery is as important as the surgical consideration and good communication between the patient, the family, the urologist and the anesthesiologist can make the entire surgical experience a successful one and achieve the desired outcome.

Contact laser vaporization of the prostate: sidefire technique.

With the development of contact sidefiring fibers, urologists have gained a valuable tool to deliver laser energy more precisely into prostatic tissue. Contact laser prostatectomy can now be viewed as a well-established procedure that offers several distinct advantages over conventional methods such as transurethral resection of the prostate. The results of experimental and clinical studies are presented, supporting the value of this new modality.

Complications of laser prostatectomy.

The appeal of laser therapy is rooted in its absence of complications relative to the gold standard of transurethral electroresection. As in any evaluation of a new medical intervention, efficacy must be weighed against the degree of complications that accompany it. Although there has been a relative paucity of literature specifically addressing the safety of this new modality, several studies are presented testifying to the clinical efficacy and relative absence of complications of laser prostatectomy.

Laparoscopic transperitoneal bladder diverticulectomy: surgical technique.

A large bladder diverticulum causing poor emptying in an 84-year-old man was removed laparoscopically in a 6.5-h operation. The patient was discharged from the hospital on the third postoperative day, having had minimal analgesic requirements. A Council catheter and stylet in the diverticulum greatly facilitated identification of the sac with the laparoscope. Difficulties with intracorporeal knot tying were avoided by using the Lapra-Ty system. Experienced laparoscopic surgeons may find this method of diverticulectomy valuable. With experience, the operating time should be reduced.

Laparoscopic entry and exit.

Minimal access surgery has emerged as an acceptable means of performing therapeutic and diagnostic surgical procedures. Although the gynecologist has utilized the laparoscope for several decades, only recently has laparoscopic surgery gained increased acceptance in the general surgical and urologic community. The number of laparoscopic procedures being performed routinely is now extensive and growing rapidly. It appears that the critical step in performing laparoscopic surgery is the establishment of pneumoperitoneum and the placement of the trocars. This initial part of the procedure when performed properly ensures safe and reliable access allowing the procedure to commence. Difficulties with this part of the procedure may preclude the operative procedure and more importantly may result in potentially severe injuries. Therefore a detailed discussion of the method of performing laparoscopic entry and exit will provide the urologist with the essentials to perform safe and successful laparoscopy.

Failed endopyelotomy: implications for future surgery on the ureteropelvic junction.

During the last 8 years we performed 212 endopyelotomies with an overall success rate of 86%. To determine if the failed endopyelotomies resulted in a more difficult subsequent open corrective procedure, we compared the procedures and outcomes of 15 failed endopyelotomies with 16 control patients undergoing pyeloplasty who had not undergone a previous endopyelotomy. The variables of duration of the surgical procedure, average estimated blood loss, average number of transfusions and average length of hospitalization were analyzed for both groups. No statistically significant differences were detected for any of these variables. We conclude that despite a previously failed endopyelotomy, a subsequent open operation on the ureteropelvic junction, although slightly more difficult, was not associated with an increased morbidity rate nor less successful than de novo pyeloplasty. Therefore, we continue to advocate endopyelotomy as the procedure of choice for obstruction of the ureteropelvic junction.

Results of 212 consecutive endopyelotomies: an 8-year followup.

Between 1983 and 1991 we performed 212 endopyelotomies on 110 cases of primary and 102 of secondary obstruction of the ureteropelvic junction. Of the 189 patients in the series 89% have been followed for a minimum of 6 months postoperatively, 63% for more than 3 years (3 to 8-year followup). Our overall success rate has been 86% with little difference being detected between the success that we have obtained with primary and secondary obstructions (85% versus 86%). Other variables, such as patient age, sex or side of obstruction, have little bearing on the outcome of the procedure. Endopyelotomy is passing the test of time as a safe and reliable means to correct ureteropelvic junction obstruction. Endopyelotomy should be the first choice for the correction of ureteropelvic junction obstruction in most patients.