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The aim of the present study is to analyze the outcomes of urethral bulking in the treatment of non-neurogenic female stress and mixed urinary incontinence and to assess predictors of clinical outcomes. We retrospectively included all consecutive patients affected by stress or mixed urinary incontinence and treated with urethral bulking. Outcomes were evaluated via the PGI-I questionnaire and the 24-h pad test. Between January 2010 and January 2020, we treated 216 patients (Bulkamid n = 206; Macro-plastique n = 10). The median age at surgery was 66 years (IQR 55−73.75). The median follow-up was 12 months (IQR 12−24). In total, 23.8% of patients were subjected to prior incontinence surgery, 63.8% of patients were affected by genuine stress urinary incontinence, 36.2% reported mixed urinary incontinence, whereas detrusor overactivity was confirmed in only 24.9%. The dry rate was 32.9%; nevertheless, 69.9% of patients declared themselves "very improved" or "improved" (PGI-I1-2). Low complications were observed, mostly classified as Clavien I. After univariate and multivariate analyses, the only statistically significant independent predictor of "dry" outcome was the 24 h pad test, p < 0.001. Urethral bulking could be proposed with more expectations of success in patients with mild urinary incontinence. Patients affected by moderate−severe incontinence are less likely to obtain clinical success; therefore, they should be carefully counselled about clinical expectations before the procedure.
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AIMS: To analyze the outcomes of urethral re-bulking in the treatment of female stress urinary incontinence. MATERIALS AND METHODS: We performed a multicenter observational retrospective study, which included all consecutive patients treated with urethral re-bulking for the treatment of persistent stress or mixed urinary incontinence after a previous urethral bulking. Objective outcomes were evaluated with the 24 h pad-test, while PGI-I questionnaires were administered to evaluate subjective outcomes. Clinical outcomes were assessed before re-bulking procedure and at last follow-up. Mann-Whitney's U test was used for subgroup analysis. Shapiro-Wilk's tests were used as normality tests. RESULTS: In total, 62 patients who underwent urethral re-bulking between 2013 and 2020 in a multicenter setting were included. Most patients did not reach complete continence after the first procedure (n = 56) while the remainder reported recurrence of urinary incontinence after initial benefit. Median age at surgery was 66 (IQR: 55-73). Median overall follow-up was 30 months (IQR: 24-41). Median time occurred between the first procedure and reintervention was 12 months (IQR: 7-27). Bulking agents for the re-bulking procedures were bulkamid(n = 56), macroplastique(n = 4), and Prolastic(n = 2). A statistically significant reduction of median 24 h pad test from 100 g(IQR: 40-200) to 35 g(IQR: 0-120) was observed (p = 0.003). Dry rate after rebulking was 36.6%, while 85.4% patients declared themselves 'very much improved' or 'much improved' (PGI-I 1-2). Very few low-grade complications were observed (n = 4). A single case of major complication occurred. CONCLUSIONS: Urethral re-bulking can be an effective technique for the treatment of stress urinary incontinence refractory to a previous urethral bulking and can determine a cumulative benefit after the first procedure.
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Context Stress urinary incontinence (SUI) after radical prostatectomy (RP) continues to be a significant problem with several implications including patient quality of life and other critical postoperative outcomes. Objectives To report the results in terms of efficacy (pad count, 24 hr pad test, QOL questionnaires) and safety (complication rate and type of complications) of all surgical devices approved for the treatment of SUI after RP. Evidence Acquisition A systematic review was conducted in accordance with the PRISMA Statement. A literature search was carried out through the PubMed/Medline, SCOPUS, and Web of Science databases using the keywords "incontinence," "radical prostatectomy," and "'treatment". Inclusion criteria were: number of patients higher than 30, mean follow up longer than 12 months and definition of a successful outcome as the use of 0 to 1 safety pads a day. Evidence Synthesis 113 papers underwent primary review. 51 papers met the inclusion criteria with a total sample size of 4022 patients. Efficacy (0-1 safety pads) was on average 65.7% for AUS, 48.2% for Invance Sling, 48.8% for Advance Sling, 64.2% for ProACT. Twenty four hour pad test and QOL questionnaires were respectively available only in 4 and 18 studies. The overall complication rate was 19.43% for AUS, 7.4% for Invance Sling, 12.3% for Advance Sling, 12.3% for ProACT. Authors' Conclusions Due to the poor overall quality of available studies, it was impossible to identify or refute clinically important differences between the alternative surgical procedures. Although our data seems to suggest that AUS has the highest efficacy in the treatment of SUI following RP it is also associated with the highest complication rate, but this may be due to the longest follow up. Larger rigorous trials are needed in order to support this evidence. Neurourol. Urodynam. 35:875-881, 2016. © 2015 Wiley Periodicals, Inc.
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Complicações Pós-Operatórias/cirurgia , Prostatectomia/efeitos adversos , Incontinência Urinária por Estresse/etiologia , Incontinência Urinária por Estresse/cirurgia , Procedimentos Cirúrgicos Urológicos Masculinos/métodos , Humanos , Masculino , Resultado do Tratamento , Procedimentos Cirúrgicos Urológicos Masculinos/efeitos adversosRESUMO
Men with good functional results following radical retropubic prostatectomy (RRP) and requiring radical cystectomy (RC) for subsequent bladder carcinoma seldom receive orthotopic bladder substitution. Four patients aged 62-72 years (median 67 years), who had undergone RRP for prostate cancer of stage pT2bN0M0 Gleason score 6 (n = 1), pT2cN0M0 Gleason score 5 and 6 (n = 2) and pT3bN0M0 Gleason score 7 (n = 1) 27 to 104 months before, developed urothelial bladder carcinoma treated with RC and ileal orthotopic bladder substitution. After radical prostatectomy three were continent and one had grade I stress incontinence, and three achieved intercourse with intracavernous alprostadil injections. Follow-up after RC ranged between 27 and 42 months (median 29 months). At the 24-month follow-up visit after RC daily urinary continence was total (0 pad) in one patient, two used one pad for mild leakage, and one was incontinent following endoscopic incision of anastomotic stricture. One patient died of progression of bladder carcinoma, while the other three are alive without evidence of disease. The three surviving patients continued to have sexual intercourse with intracavernous alprostadil injections. Men with previous RRP have a reasonable chance of maintaining a satisfactory functional outcome following RC and ileal orthotopic bladder substitution.
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Cistectomia , Segunda Neoplasia Primária/cirurgia , Prostatectomia/métodos , Neoplasias da Próstata/cirurgia , Neoplasias da Bexiga Urinária/cirurgia , Derivação Urinária/métodos , Idoso , Alprostadil/administração & dosagem , Cistectomia/efeitos adversos , Humanos , Tampões Absorventes para a Incontinência Urinária , Injeções , Masculino , Pessoa de Meia-Idade , Gradação de Tumores , Estadiamento de Neoplasias , Segunda Neoplasia Primária/patologia , Ereção Peniana/efeitos dos fármacos , Prostatectomia/efeitos adversos , Neoplasias da Próstata/patologia , Reoperação , Disfunções Sexuais Fisiológicas/tratamento farmacológico , Disfunções Sexuais Fisiológicas/etiologia , Disfunções Sexuais Fisiológicas/fisiopatologia , Fatores de Tempo , Resultado do Tratamento , Neoplasias da Bexiga Urinária/patologia , Derivação Urinária/efeitos adversos , Incontinência Urinária/etiologia , Incontinência Urinária/fisiopatologia , Incontinência Urinária/terapia , Micção , Agentes Urológicos/administração & dosagemRESUMO
OBJECTIVE: To analyze the morphologic changes visible on magnetic resonance imaging (MRI) after sling procedure in continent patients and to compare MRI findings with the incontinent ones, to detect possible factors explaining the different clinical outcomes. METHODS: Twenty-seven male patients who were treated with Advance sling for urinary stress incontinence after prostate surgery were enrolled: 16 had clinical recovery, whereas 11 had persistent incontinence. Patients after sling were defined as continent if used 0-1 dry "security pad" or incontinent >1 pad. Magnetic Resonance examinations were performed with a 3 Tesla system and included 3-dimensional T2-weighted sequence. Three readers performed a qualitative (representation of the bulb and indentation of the sling) and a quantitative analysis (length of the bulb posterior to the sling and distance of the sling from a line bisecting the pubic symphysis). RESULTS: The sling was clearly recognizable in all 16 continent patients but only in 2 of 11 incontinent ones. The length of the bulb posterior to the sling was >10 mm (range, 10-28) in all continent patients and in 2 of the incontinent ones. The sling was coincident with a line drawn through the long axis of the pubic bone in 9 of 16 continent patients. A statistically significant association was found between MRI qualitative findings and continence status (P <.0001). CONCLUSION: On the basis of our MRI results, the position of the sling and, in particular, the length of the urethral bulb posterior to the sling seem to be correlated with continence and must be considered in case of treatment failure.
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Imageamento por Ressonância Magnética , Implantação de Prótese/métodos , Slings Suburetrais , Incontinência Urinária por Estresse/diagnóstico , Incontinência Urinária por Estresse/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Humanos , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Urológicos Masculinos/métodosRESUMO
INTRODUCTION: Orgasm-Associated Incontinence (OAI) or climacturia has been observed in male patients maintaining sexual potency after radical prostatectomy and cystectomy. AIM: We investigated the incidence and video-urodynamic aspects of this event in continent and potent patients after bladder neck-sparing (BNS) radical prostatectomy (RP). MAIN OUTCOME MEASURE: Comparing functional and morphological aspects between climacturic and non-climacturic patients to identify a possible explanation of this unusual kind of leakage that could seriously impact the sexual life after surgery. METHODS: In a pool of 84 men, potent and continent at least 1 year after BNS RP, 24 (28.6%) reported climacturia and 7 agreed to undergo video-urodynamic evaluation (group 1), which was performed also in 5 controls (group 2). Those 12 men were also evaluated with 24-hour pad test, 5-item International Index of Erectile Function and International Prostate Symptom Score questionnaires. RESULTS: Functional urethral length (FUL) was significantly lower in the climacturia group (P=0.02) and time to continence recovery was significantly longer (P=0.05). No other significant differences were found between the two groups. The radiological appearance of the vesicourethral junction at voiding cystourethrography was similar. CONCLUSIONS: To the best of our knowledge, this is the first functional and morphological evaluation of climacturia after RP. In our experience, this event is indirectly associated with a reduced FUL in the sphincter area, although both patients and controls were continent during daily activities. BNS technique seems to reduce time to continence recovery, although climacturic patients need longer time than control patients. Since in our series no rigidity of the vesicourethral anastomosis was radiographically evident, we believe that differences in FUL could explain OAI. Anatomical difference in membranous urethra length could explain the occurrence of this symptom in patients treated with the same surgical technique.
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Orgasmo , Prostatectomia/efeitos adversos , Incontinência Urinária/fisiopatologia , Idoso , Cistectomia/efeitos adversos , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Prostatectomia/métodos , Inquéritos e Questionários , Uretra/cirurgia , Bexiga Urinária/fisiopatologia , Bexiga Urinária/cirurgia , Incontinência Urinária/etiologia , Incontinência Urinária/cirurgia , Urodinâmica , Gravação de VideoteipeRESUMO
OBJECTIVES: To report our experience of transvaginal diverticulectomy with pubovaginal sling placement in a series of 32 women with recurrent urethral pseudodiverticula. METHODS: A total of 32 women underwent surgical repair from January 2000 to June 2007. Of the 32 women, 12 had undergone other concomitant previous urethral surgery, predominantly for stress urinary incontinence. Transvaginal excision of the diverticulum and concomitant pubovaginal sling placement were performed routinely. The women were evaluated postoperatively for symptom relief, anatomic result, and postoperative continence status at 1, 6, and 12 months and annually thereafter. Pelvic magnetic resonance imaging was repeated after 1 year. RESULTS: The mean follow-up was 4.3 years. In all cases, the voiding urethrogram after catheter removal showed a good urethral shape with an absence of urinary leaks. At the postoperative urodynamic investigation, 27 patients had an unobstructed and 5 an equivocal Blaivas-Groutz nomogram. Three patients (20%) reported a persistent degree of stress urinary incontinence, including 2 with grade 1 stress urinary incontinence and 1 with mixed incontinence. Two patients presented with clinically evident diverticulum recurrence, and in 1 patient, an intraurethral diverticulum, was found at the 1-year magnetic resonance imaging examination. CONCLUSIONS: A pubovaginal sling added routinely to all diverticulectomy procedures offers significant support to the urethral repair and/or prevention of urinary incontinence, including in recurrent cases, and does not increase the risk of erosion into the urethra or fistula formation.
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Divertículo/cirurgia , Slings Suburetrais , Doenças Uretrais/cirurgia , Adulto , Divertículo/complicações , Feminino , Humanos , Pessoa de Meia-Idade , Recidiva , Fatores de Tempo , Doenças Uretrais/complicações , Incontinência Urinária por Estresse/complicações , Incontinência Urinária por Estresse/cirurgia , Adulto JovemRESUMO
Hemorrhagic cystitis is a common complication in hematopoietic stem cell transplant recipients. We report here a case of severe BKV-associated hemorrhagic cystitis who did not respond to intravenous cidofovir. Overt hematuria successfully resolved after a few days on hyperbaric oxygen and intravesical instillations of cidofovir, while BK viruria dropped after a few weeks and remained low. We review the literature for therapeutic options in hemorrhagic cystitis and try to explain how hyperbaric oxygen stimulates mucosal repair in the urinary bladder.
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Antivirais/administração & dosagem , Cistite/terapia , Citosina/análogos & derivados , Oxigenoterapia Hiperbárica , Organofosfonatos/administração & dosagem , Administração Intravesical , Adulto , Antineoplásicos/efeitos adversos , Vírus BK , Cidofovir , Cistite/etiologia , Infecções por Citomegalovirus/terapia , Citosina/administração & dosagem , Transplante de Células-Tronco Hematopoéticas , Hematúria/etiologia , Hematúria/terapia , Humanos , Leucemia Mieloide Aguda/terapia , Leucemia Mieloide Aguda/virologia , Masculino , Infecções por Polyomavirus/complicações , Infecções por Polyomavirus/terapia , Infecções por Polyomavirus/urina , Infecções Tumorais por Vírus/complicações , Infecções Tumorais por Vírus/terapia , Infecções Tumorais por Vírus/urinaRESUMO
AIMS: In this prospective controlled randomized trial we assessed the effects of early, intensive, prolonged pelvic floor exercises (PFE) on urinary incontinence following bladder neck (BN) sparing RRP. METHODS: A sample of 152 patients with localized prostate cancer underwent RRP with BN preservation. Out of this group we randomized 107 incontinent patients into 2 groups. We considered incontinent patients with 24 hr Pad test >2 g. The T group received instructions regarding an intensive program of PFE, from 7 days after catheter removal for as long as any degree of incontinence persisted, within a period of 1 year. The control (C) group did not receive instructions. The outcome was assessed using the 24 hr Pad test, a visual analogue scale (VAS) and a single question of QoL. Results at baseline and at 1, 3, 6, and 12 months were available for 54 and 40 patients, respectively. RESULTS: The overall spontaneous continence rate after catheter removal was 23.6%. The proportion of men still incontinent was significantly higher in the C group than treatment (T) group at 1 (97.5% vs. 83.3%; P = 0.04), 3 (77.5% vs. 53.7%; P = 0.03), 6 (60% vs. 33.3%; P = 0.01), and 12 months (52.5% vs. 16.6%; P < 0.01). Similarly, the VAS and the response to the QoL question at 12 months significantly differed between the two groups (P = 0.01 and 0.03, respectively). CONCLUSIONS: Our study suggests that early intensive prolonged PFE can further increase the number of continent patients and this improvement persists in the first 12 months. The second 6 months following surgery are still useful to recovery.