Endoscopic stone management in an ectopic ureter inserting into the prostatic urethra.

We report a case of successful endoscopic stone management in a patient with ectopic ureteric insertion. The patient had a complete duplex collecting system, with the upper moiety ureter inserting ectopically into his prostatic urethra, and an obstructing ureteric stone in the distal portion of the ectopic ureter. This made both characterisation of the patient's anatomy and initial emergency stone management challenging.The case offers several learning points for clinicians who may encounter similar situations. By describing the challenges of managing this patient's presentation, we highlight considerations in imaging interpretation and operative approach that may help the reader manage a similar presentation to their practice. Additionally, we remind the urologist to consider the implications of an ectopic duplex ureter on future procedures, such as transurethral resection of the prostate or radical prostatectomy.

The Importance of Cystoscopy in Diagnosis and Treatment of Urethral Stricture Following Transurethral Prostatectomy.

BACKGROUND: Transurethral prostatectomy is the gold standard surgical treatment of bladder outlet obstruction due to benign enlargement of the prostate, with more than 30,000 procedures performed annually in the United States alone. The success rate of this minimally invasive procedure is high and the results are durable. The development of urethral stricture is a long-term complication of the procedure and is noted in about 2% of patients. The stricture narrows the urethral lumen, leading to re-appearance of obstructive urinary symptoms. Traditionally, the evaluation of the stricture was performed by retrograde urethrography. Advancements in the fields of flexible endoscopy allowed rapid inspection of the urethra and immediate dilatation of the stricture in selected cases. OBJECTIVES: To compare the efficacy of urethrography versus cystoscopy in the evaluation of urethral strictures following transurethral prostatectomy. METHODS: A retrospective review was conducted of a series of 32 consecutive patients treated due to post-transurethral resection of prostate (TURP) urethral stricture. RESULTS: Twenty patients underwent both tests. In 16 there was concordance between the two tests. Four patients had no pathological findings in urethrography but had strictures in cystoscopy. All strictures were short (up to 10 mm) and were easily treated during cystoscopy, with no complaints or re-surgery needed in 24 months follow-up. CONCLUSIONS: Cystoscopy was superior to urethrography in the evaluation of post-TURP strictures. Strictures where often short and treated during the same procedure. We recommend that cystoscopy be the procedure of choice in evaluating obstructive urinary symptoms after TURP, and retrograde urethrography be preserved for selected cases.

Buccal epithelium Expanded and Encapsulated in Scaffold-Hybrid Approach to Urethral Stricture (BEES-HAUS) procedure: A novel cell therapy-based pilot study.

OBJECTIVES: To describe the feasibility of a novel cell-based endoscopic technique using buccal epithelium, expanded and encapsulated in a thermoreversible gelation polymer scaffold for the treatment of urethral stricture. METHODS: Six male patients with bulbar urethral stricture ranging from 2.0 to 3.5 cm in length were included in this pilot study. Autologous buccal epithelial cells from a small buccal mucosal biopsy were isolated, cultured and encapsulated in thermoreversible gelation polymer scaffold, and were implanted at the stricture site after a wide endoscopic urethrotomy. RESULTS: All the patients voided well, with a mean peak flow rate of 24 mL/s. Urethroscopy carried out at 6 months showed healthy mucosa at the urethrotomy site. However, two of the six patients had recurrence at 18 and 24 months, respectively. CONCLUSIONS: This endoscopic-based Buccal epithelium Expanded and Encapsulated in Scaffold-Hybrid Approach to Urethral Stricture (BEES-HAUS) technique is a promising alternative for the open substitution buccal graft urethroplasty. It is possible to achieve the benefits of open substitution buccal urethroplasty with this endoscopic technique.

Prevalence analysis of urinary incontinence after radical prostatectomy and influential preoperative factors in a single institution.

AIMS: To assess prevalence of urinary incontinence (UI) after radical prostatectomy (RP) and to analyze which preoperative characteristics of the patients have influence on UI. METHODS: Between 2002 and 2012, 746 consecutive patients underwent RP for clinically localized prostate cancer. We defined UI according to International Continence Society (ICS) definition: "the complaint of any involuntary leakage of urine" after 12 months of recovery, international consultation on incontinence questionnaire (ICIQ-SF) and pads/day was collected too. Clinical features and magnetic resonance imaging measurements were assessed. A multivariable logistic regression model predicting incontinence were built-in after adjust by cofounding factors and bootstrapping. RESULTS: About 172 (23%) of the patients were classified as incontinent according to the ICS definition. The mean value of the ICIQ-SF was 10.87 (±4). 17.8% of patients use at least one pad/day, 11.9% use more than one pad/day. The preoperative factors independently influential in UI are: age [OR: 1.055; CI 95% (1.006-1.107), p = .028], urethral wall thickness [OR: 5.03; CI 95% (1.11-22.8), p = .036], history of transurethral resection of the prostate [OR: 6.13; CI 95% (1.86-20.18), p = .003] and membranous urethral length [OR: 0.173; CI 95% (0.046-0.64), p = .009]. The predictive accuracy of the model is 78.7% and the area under the curve (AUC) value 71.7%. CONCLUSIONS: Urinary incontinence after radical prostatectomy has different prevalence depending on the definition. Age, prior transurethral resection of the prostate (TURP), membranous urethral length (MUL) and urethral wall thickness (UWT) were risk factors.

A novel urethral sparing technique for high-dose-rate prostate brachytherapy after transurethral resection of the prostate.

PURPOSE: The purpose of this study was to assess retrospectively the variability of the urethral dose optimized using a Foley catheter versus urethral contrast injected using a new modified triple-lumen catheter, in CT-based high-dose-rate (HDR) prostate brachytherapy of posttransurethral resection of prostate (TURP) patients. METHODS AND MATERIALS: At our institution, there were six post-TURP patients with prostate carcinoma between July 2014 and April 2016 who underwent transperineal interstitial HDR brachytherapy (16 needles). A custom modified triple-lumen catheter was placed to inject contrast into the TURP defect. Three-dimensional optimal plans using inverse planning simulated annealing algorithm was generated according to radiation therapy oncology group dose requirements. Alternative plans were retroactively generated for comparison using standard technique based on a Foley catheter as a urethral constraint volume for each patient with the same weighting factors. We compared the dosimetry parameters in each planning using Wilcoxon's ranked sum nonparametric test. RESULTS: The median followup of all patients was 17.5 months. No significant genitourinary or gastrointestinal toxicity was noted using this technique. In the dosimetric analysis, the prostate V100 values and TURP urethral V100 were significantly different between plans with and without the contrast (V100 [mean]: 92.4 [%] vs. 94.4 [%], p = 0.046; TURP UV100 [mean]: 1.4 cc vs. 2.2 cc, p = 0.028). There were no statistical differences in the mean values of planning target volume V150%, V200%, and D90, and each bladder V75 and rectum V75. CONCLUSIONS: Post-TURP HDR brachytherapy with urethral contrast showed significantly more volume effect of the TURP defect than that with a Foley catheter alone. Better visualization of the TURP defect should lead to more accurate urethral sparing administration of HDR brachytherapy which is necessary to prevent urethral complication.

The clinical value of sonourethrography after bipolar transurethral plasmakinetic prostatectomy.

The aim of this study was to assess the value of transrectal sonourethrography in the diagnosis of dysuria after bipolar transurethral plasmakinetic prostatectomy (TUPKP). Seventy-seven male patients with dysuria after TUPKP underwent transrectal sonourethrography. The clinical data were then compared with the surgical outcomes. The following pathologies were diagnosed: Bladder neck atresia (17/77), bladder orifice strictures (15/77), membranous urethral strictures (21/77), pars cavernosa urethral stricture (12/77), residual prostate gland (5/77), external urethral orifice stricture (2/77), calculi in the prostatic urethra (2/77), flap in the internal urethral orifice (2/77), and postoperative dysfunction of the bladder detrusor muscle (1/77). Transrectal sonourethrography is a reliable diagnostic method for numerous pathologies that occur in patients with dysuria after TUPKP and is a clinically useful tool.

Investigation of optimal cues to instruction for pelvic floor muscle contraction: a pilot study using 2D ultrasound imaging in pre-menopausal, nulliparous, continent women.

AIMS: Optimal urethrovesical positioning (UVP) may be important for continence. Pelvic floor muscle contraction (PFMC) influences UVP. PFMC instruction cues vary and often encourage anterior PFM recruitment that may result in sub-maximal posterior facilitation. STUDY HYPOTHESIS: posterior or combined cues are more influential in optimizing UVP during PFMC following a brief practice period than anterior cue. METHODS: Seventeen pre-menopausal, nulliparous, continent women were taught selective PFMC using different cues: anterior; posterior; anterior and posterior combined. Perineal ultrasound images of three PFMC for each cue were captured in supine and standing twice, 5 min apart. For reliability two raters measured data using angle of urethral inclination (AUI). Data analysis was undertaken using a customized General Linear Model ANOVA testing for interactions between all variables; subject, cue, posture, and test. Post hoc Bonferroni correction was used with a significance level of 0.05. RESULTS: The ANOVA showed significant differences between variables (P = 0.000). Post hoc analysis indicated significant differences between posterior and anterior cues 4.240° (P = 0.003); combined and anterior 3.756° (P = 0.009) but not between posterior and combined cues -0.484° (P = 1.00). Mean difference in AUI between supine and standing was 9.496° (P = 0.000); however, the interaction of cues and postures was not significant. CONCLUSIONS: AUI was significantly more acute/optimal when PFMC instruction included a posterior cue. This may be due to optimal recruitment of puborectalis and other posterior regional muscles which may be sub-maximally recruited with anterior cue. Investigation of the potential impact of these findings and possible usefulness of standardized instructions in PFM training is required.

Highlights in the minimally invasive treatment of SUI in women.

OBJECTIVE: Treatment of stress urinary incontinence consists of a wide range of options, from conservative therapies like lifestyle changes, medication, pelvic floor muscles exercises, electro-stimulation, to minimally invasive procedures--injection of collagen, suburethral slings TVT/TOT and last but not least, invasive surgical treatment reserved for recurrent and complex cases. Among the latest minimally invasive procedures reported in literature, the injection of intra-and perisphincterian of autologous stem cell (mioblasts and/or mature fibroblasts grown and multiplied in the laboratory from biopsy samples taken from the pectoralis muscles). MATERIAL AND METHOD: On October 18, 2010, in 'Fundeni' Clinical Institute of Uronephrology and Renal Transplantation was performed the first stem cell implantation procedure in the urethral sphincter, in Romania. RESULTS: Assessment at 6 weeks, the quality of life questionnaires, micturition diary and clinical examination revealed a stunning decrease of urine loss from 6 pads/day at one per day, which significantly improved the patient's quality of life. CONCLUSIONS: Stem-cell-mioblasts therapy may represent in the future an every-day intervention in the urologist's armamentarium. The effectiveness of this treatment can change the course of therapy and last but not least, the accessibility to urological evaluation of patients with stress urinary incontinence. Clinical and urodynamic evaluations will continue and will be future scientific topics.

[Combined treatment of complicated chlamydial infection in males with ozone therapy].

Urogenital chlamydial monoinfection was diagnosed in 127 males using enzyme immunoassay, polymerase chain reaction, transrectal ultrasound examination of the prostatic gland. Of them, 72 patients had chronic urethroprostatitis. Microhemodynamics of these patients was studied with laser doppler flowmetry of the prostate and urethra. The patients received etiotropic therapy with fromilide, regional transurethral and transrectal ozone therapy. The symptoms relieved in 4-6 weeks. Repeated enzyme immunoassay and polymerase chain reaction stated elimination of the infective agent. Improvement of hemodynamics and urethral, prostatic microcirculation was stated after administration of regional ozone therapy.

The influence of geometrical changes on the dose distribution after I-125 seed implantation of the prostate.

PURPOSE: After prostate implantation, dose calculation is usually based on a single imaging session, assuming no geometrical changes occur during the months of dose accumulation. In this study, the effect of changes in anatomy and implant geometry on the dose distribution was investigated. MATERIALS AND METHODS: One day, 1 month and 312 months after seed implantation, a combined TRUS-CT scan was made of 13 patients. Based on these scans changes in dose rate distribution were determined in prostate, urethra and bladder and a 'geometry corrected' dose distribution was estimated. RESULTS: When based on the day-1 scan, parameters representing high dose volumes in prostate and urethra were largely underestimated: V150 of the prostate 18+/-10% and V120 of the urethra 47+/-32%. The dose to a 2cm(3) hotspot in the bladder wall (D2cc), however, was overestimated by 31+/-35%. Parameters based on scans 1 month post-implant or later were all within +/-5% of geometry corrected values. CONCLUSION: Values meant to indicate the adequacy of dose coverage of the prostate, V100 and D90, were not influenced by geometrical changes and were independent of the post-implant scan date. Other parameters representing high dose volumes changed strongly within the first month after implantation.

Does water delivery affect pelvic floor? Ultrasound evaluation of perineal function.

OBJECTIVE: The aim of the study is to analyse urethral mobility and excursion of the pubo-rectal angle, using perineal ultrasound, after normal vaginal delivery and water delivery. MATERIALS AND METHODS: A total of 52 primiparous women were enrolled: 25 who had delivery in water (W Group), 27 who had delivery without using water (NW Group). Every woman underwent perineal ultrasound assessment at 6 months after having given birth. The following parameters were assessed: urethral mobility during Valsalva's manoeuvre, movement of the puborectal sling angle during contraction of the levator ani muscle. RESULTS: Data obtained show that the urethral mobility during Valsalva's manoeuvre is higher in the W Group (34.9 degrees) in comparison to the NW Group (29.5 degrees), without statistically significant differences. The excursion of the pubo-rectal sling angle resulted lower in the W Group (8.7 degrees) than in the NW Group (11.0 degrees), without statistically significant differences. CONCLUSION: The present study found no statistically differences in pelvic floor, using perineal ultrasound, between water and "non-water" delivery.

Interstitial temperature mapping during Prolieve transurethral microwave treatment: imaging reveals thermotherapy temperatures resulting in tissue necrosis and patent prostatic urethra.

OBJECTIVES: Temperature mapping of the prostate during transurethral microwave thermotherapy and imaging of the resultant zones of tissue necrosis have been previously performed using several commercial systems. This study was performed using the Prolieve Thermodilatation System, which simultaneously compresses the prostate with a 46F balloon circulating heated fluid and delivering microwave energy into the prostate. METHODS: Interstitial temperature mapping during Prolieve treatment was performed on 10 patients with benign prostatic hyperplasia using 24 temperature sensors arrayed throughout the prostate. Voiding cystourethrograms were performed on 3 additional patients treated without temperature mapping to document the patency of the prostatic urethra 1 hour after treatment. Gadolinium-enhanced magnetic resonance imaging studies were performed on all patients 1 week after treatment to determine the extent and pattern of tissue necrosis resulting from transurethral microwave thermotherapy. RESULTS: Interstitial temperature mapping found that the heating pattern generated by the Prolieve system created average peak temperatures of 51.8 degrees C an average of 7 mm away from the prostatic urethra. These temperatures were greater near the bladder neck and mid-gland than toward the prostatic apex. Subtherapeutic temperatures were seen adjacent to the urethra, consistent with the viable tissue seen on gadolinium-enhanced magnetic resonance imaging sequences. Magnetic resonance imaging also revealed necrotic zones that were consistent with sustained temperatures greater than 45 degrees C. Voiding cystourethrograms showed widely patent prostatic urethras 1 hour after treatment. CONCLUSIONS: Transurethral microwave thermotherapy with the Prolieve Thermodilatation System produced sustained therapeutic temperatures that resulted in tissue necrosis while maintaining viable tissue surrounding a temporarily dilated prostatic urethra.

Curvilinear transurethral ultrasound applicator for selective prostate thermal therapy.

Thermal therapy offers a minimally invasive option for treating benign prostatic hyperplasia (BPH) and localized prostate cancer. In this study we investigated a transurethral ultrasound applicator design utilizing curvilinear, or slightly focused, transducers to heat prostatic tissue rapidly and controllably. The applicator was constructed with two independently powered transducer segments operating at 6.5 MHz and measuring 3.5 mm x 10 mm with a 15 mm radius of curvature across the short axis. The curvilinear applicator was characterized by acoustic efficiency measurements, acoustic beam plots, biothermal simulations of human prostate, ex vivo heating trials in bovine liver, and in vivo heating trials in canine prostate (n=3). Each transducer segment was found to emit a narrow acoustic beam (max width <3 mm), which extended the length of the transducer, with deeper penetration than previously developed planar or sectored tubular transurethral ultrasound applicators. Acoustic and biothermal simulations of human prostate demonstrated three treatment schemes for the curvilinear applicator: single shot (10 W, 60 s) schemes to generate narrow ablation zones (13 x 4 mm, 52 degrees C at the lesion boundary), incremental rotation (10 W, 10 degrees/45 s) to generate larger sector-shaped ablation zones (16 mm x 180 degrees sector), and rotation with variable sonication times (10 W, 10 degrees/15-90 s) to conform the ablation zone to a predefined boundary (9-17 mm x 180 degrees sector, 13 min total treatment time). During in vivo canine prostate experiments, guided by MR temperature imaging, single shot sonications (6 W/transducer, 2-3 min) with the curvilinear applicator ablated 20 degree sections of tissue to the prostate boundary (9-15 mm). Multiple adjacent sonications ("sweeping") ablated large sections of the prostate (180 degrees) by using the MR temperature imaging to adjust the power (4-6.4 W/transducer) and sonication time (30-180 s) at each 10 degrees rotation such that the periphery of the prostate reached 52 degrees C before the next rotation. The conclusion of this study was that the curvilinear applicator produces a narrow and penetrating ultrasound beam that, when combined with image guidance, can provide a precise technique for ablating target regions with a contoured outer boundary, such as the prostate capsule, by rotating in small steps while dynamically adjusting the net applied electrical power and sonication time at each position.

Hypnosis reduces distress and duration of an invasive medical procedure for children.

OBJECTIVE: Voiding cystourethrography (VCUG) is a commonly performed radiologic procedure in children that can be both painful and frightening. Given the distress that some children experience during the VCUG and the need for children to be alert and cooperative during the procedure, finding a psychological intervention that helps children to manage anxiety, distress, and pain is clearly desirable. This study was designed to examine whether relaxation and analgesia facilitated with hypnosis could reduce distress and procedure time for children who undergo this procedure. METHODS: Forty-four children who were scheduled for an upcoming VCUG were randomized to receive hypnosis (n = 21) or routine care (n = 23) while undergoing the procedure. The sample consisted of 29 (66%) girls and 15 (34%) boys with a mean age of 7.6 years (SD: 2.5; range: 4-15 years). Ethnic/racial backgrounds were 72.7% white, 18.2% Asian, 4.5% Latino, 2.3% black, and 2.3% Filipino. The mean number of previous VCUGs was 2.95 (SD: 2.51; mode: 2; range: 1-15). Potential participants were identified through computerized hospital records of upcoming VCUGs. Parents were contacted by telephone and invited to participate if their child was eligible. To be eligible for the study, the child must have undergone at least 1 previous VCUG, been at least 4 years of age at that time, and experienced distress during that procedure, and both the child and the participating parent had to be English speaking. Each eligible child and parent met with the research assistant (RA) before the day of the scheduled procedure for an initial assessment. Children were queried regarding the degree of crying, fear, and pain that they had experienced during their most recent VCUG. Parents completed a series of parallel questions. Immediately after this assessment, those who were randomized to the hypnosis condition were given a 1-hour training session in self-hypnotic visual imagery by a trained therapist. Parents and children were instructed to practice using the imaginative self-hypnosis procedure several times a day in preparation for the upcoming procedure. The therapist was also present during the procedure to conduct similar exercises with the child. The majority (83%) of those who were randomized to the routine care control group chose to participate in a hospital-provided recreation therapy program (offered as part of routine care). The program includes demonstration of the procedure with dolls, relaxation and breath work training, and assistance during the procedure. On the day of the VCUG, the RA met the family at the clinic before the procedure, and both the child and the parent rated the child's present level of fearfulness. During the procedure, the RA recorded observational ratings of the child's emotional tone and behavior and timed the overall procedure and its phases. Immediately after the VCUG, the child was asked how much crying, fear, and pain he or she had experienced during the procedure; the parent rated the child's experience on the same dimensions and also how traumatic the procedure had been (both generally and compared with their previous one), and the medical staff rated the degree of procedural difficulty. Outcomes included child reports of distress during the procedure, parent reports of how traumatic the present VCUG was compared with the previous one, observer ratings of distress during the procedure, medical staff reports of the difficulty of the procedure overall, and total procedural time. RESULTS: Results indicate significant benefits for the hypnosis group compared with the routine care group in the following 4 areas: (1) parents of children in the hypnosis group compared with those in the routine care group reported that the procedure was significantly less traumatic for their children compared with their previous VCUG procedure; (2) observational ratings of typical distress levels during the procedure were significantly lower for children in the hypnosis condition compared with those in the routine care condition; (3) medical staff reported a significant difference between groups in the overall difficulty of conducting the procedure, with less difficulty reported for the hypnosis group; and (4) total procedural time was significantly shorter-by almost 14 minutes-for the hypnosis group compared with the routine care group. Moderate to large effect sizes were obtained on each of these 4 outcomes. CONCLUSIONS: Hypnotic relaxation may provide a systematic method for improving the overall medical care of children with urinary tract abnormalities and may be beneficial for children who undergo other invasive medical procedures. Because the VCUG is an essential part of the evaluation of urinary tract infections and vesicoureteral reflux in children, lower distress during the procedure may improve patient and family compliance with initial as well as follow-up evaluations. These findings augment the accumulating literature demonstrating the benefits of using hypnosis to reduce distress in the pediatric setting. The present findings are noteworthy in that this study was a controlled, randomized trial conducted in a naturalistic medical setting. In this context, we achieved a convergence of subjective and objective outcomes with moderate to large effect sizes, including those that may have an impact on patient care and procedure cost, that were consistently supportive of the beneficial effects of hypnosis-a noninvasive intervention with minimal risk. The findings, therefore, have immediate implications for pediatric care. Limitations of this study include the lack of participant and staff blindness to the child's condition assignment, which could have introduced bias into reports. However, the objective procedural time differences between groups were consistent with the other, more subjective outcome findings. The sample was also small and primarily white in ethnic/racial makeup, which may have restricted our ability to detect some differences and may limit the generalizability of findings to more representative samples. In addition, the sample comprised children who had already undergone at least 1 VCUG during which they had had difficulty. Consequently, additional research is needed to determine whether hypnosis would be helpful to those who are undergoing their first VCUG. Additional limitations, clinical observations, and directions for future research are also discussed.

Comparison of dose length, area, and volume histograms as quantifiers of urethral dose in prostate brachytherapy.

PURPOSE: To determine the magnitude of the differences between urethral dose-volume, dose-area, and dose-length histograms (DVH, DAH, and DLH, respectively, or DgH generically). METHODS AND MATERIALS: Six consecutive iodine-125 ((125)I) patients and 6 consecutive palladium-103 ((103)Pd) patients implanted via a modified uniform planning approach were evaluated with day 0 computed tomography (CT)-based dosimetry. The urethra was identified by the presence of a urinary catheter and was hand drawn on the CT images with a mean radius of 3.3 +/- 0.7 mm. A 0.1-mm calculation matrix was employed for the urethral volume and surface analysis, and urethral dose points were placed at the centroid of the urethra on each 5-mm CT slice. RESULTS: Although individual patient DLHs were step-like, due to the sparseness of the data points, the composite urethral DLH, DAH, and DVHs were qualitatively similar. The DAH curve delivered more radiation than the other two curves at all doses greater than 90% of the prescribed minimum peripheral dose (mPD) to the prostate. In addition, the DVH curve was consistently higher than the DLH curve at most points throughout that range. Differences between the DgH curves were analyzed by integrating the difference curves between 0 and 200% of the mPD. The area-length, area-volume, and volume-length difference curves integrated in the ratio of 3:2:1. The differences were most pronounced near the inflection point of the DgH curves with mean A(125), V(125), and L(125) values of 36.6%, 31.4%, and 23.0%, respectively, of the urethra. Quantifiers of urethral hot spots such as D(10), defined as the minimal dose delivered to the hottest 10% of the urethra, followed the same ranking: area analysis indicated the highest dose and length analysis, the lowest dose. D(10) was 148% and 136% of mPD for area and length evaluations, respectively. Comparing the two isotopes in terms of the amount of urethra receiving a given dose, (103)Pd implants were significantly cooler than (125)I implants over most of the range of clinical interest, from 100% to 150% of mPD. CONCLUSION: Dose gradients in prostate implants result in the observed ordering of DAH, DVH, and DLH from higher to lower doses. The three histogram approaches remain in close agreement up to 100% of the mPD but diverge at higher doses. Although urethral point doses are the most easily determined, they underestimate the amount of urethra at risk at higher doses compared to dose area analysis. Because dosimetric parameters detailing high-dose regions such as D(10) show only slight differences between calculation methods, they are recommended over the corresponding geometric entities G(150) or G(175). The differences between the D(gg) entities are sufficiently small that they are unlikely to be of clinical significance or to confound analyses attempting to correlate urinary morbidity with urethral dosimetry.

Holmium laser resection v transurethral resection of the prostate: results of a randomized trial with 2 years of follow-up.

BACKGROUND AND PURPOSE: The holmium laser (2140 nm) can be used to ablate, resect, and enucleate the enlarged prostate. The 2-year results of a randomized trial comparing holmium laser resection of the prostate (HoLRP) and transurethral resection (TURP) are presented. PATIENTS AND METHODS: The 120 patients were randomized to either TURP (N = 59) or HoLRP (N = 61). The patients were reviewed at 1, 3, 6, 12, 18, and 24 months postoperatively. Eighty six (72%) of the patients were available for review at the 2-year mark. RESULTS: At 2 years, there was no significant difference between the two groups in AUA Symptom Score, peak flow rate (Qmax) value, or quality of life score. Adverse events, including reoperations, incontinence, and loss of erectile potency, were also similar. CONCLUSIONS: The HoLRP and TURP procedures result in similar clinical outcomes at 2 years.

Dose reduction in gastrointestinal and genitourinary fluoroscopy: use of grid-controlled pulsed fluoroscopy.

OBJECTIVE: We evaluated the diagnostic accuracy of a grid-controlled fluoroscopy unit compared with a conventional continuous fluoroscopy unit for a variety of abdominal and pelvic fluoroscopic examinations. SUBJECTS AND METHODS: Seventy patients (29 men and 41 women; age range, 24-78 years) were enrolled in one of seven abdominal and pelvic fluoroscopic examinations, including upper gastrointestinal series (n = 20), barium enema (n = 10), voiding cystourethrogram (n = 10), percutaneous abdominal catheter tube injection (n = 10), hysterosalpingogram (n = 10), and percutaneous needle insertion and catheter placement (nephrostomy, percutaneous biliary drainage) (n = 10). Each patient underwent at least 10 sec of continuous fluoroscopy that was randomly and blindly compared with 10-sec periods of pulsed fluoroscopy at 15, 7.5, and 3.75 frames per second. A radiologist outside the examination room, unaware of the frame rate per second, evaluated the procedure in real time on a television monitor. The radiologist assessed image quality and diagnostic acceptability using a scoring system. Statistical analysis was performed using the paired Student's t test. RESULTS: For all procedures at all frame rates, we found no statistically significant superiority of one frame rate over another. For most procedures, the slower frame rates were considered equivalent to continuous fluoroscopy when the images were assessed for image quality and diagnostic confidence. CONCLUSION: Our findings suggest that most abdominal and pelvic fluoroscopic procedures can be performed at substantially lower frame rates than those used for continuous fluoroscopy; adopting this procedure may lead to substantial dose savings for the patient and the fluoroscopy operator.

Preliminary results of muscle cuff cervicoplasty in the ewe for the treatment of urinary incontinence.

OBJECTIVE: Muscle cuff cervicoplasty consists of dissecting a strip of the superior slip of the levator ani muscle, by sectioning it flush with the symphysis pubis, and applying it like a cuff around the urethra below the bladder neck. METHODS: We conducted a preliminary study in 12 ewes, including preoperative urodynamic assessment, intravenous urography with retrograde cystography on day 15, and another urodynamic assessment 1 and 3 months after the operation. Two animals died, but the other 10 animals were able to be evaluated. An increase in the urethral functional length with an infracervical plateau was revealed on all postoperative urethral profiles. Only transrectal electrostimulation, performed on the last 5 ewes, demonstrated an elevation of the closure pressure by 5-10 cm H2O. At sacrifice of the animals at 4 months, in situ stimulation of the muscle strip induced muscle contraction in 7 of 10 cases. Histological examination demonstrated persistence of muscle fibers in the cuff, despite the presence of marked fibrosis. RESULTS: The preliminary results are encouraging: urinary continence was improved with a minimal risk of retention, and cervicoplasty appears to retain its contractile activity, suggesting the possibility of a long-term sphincteric and proprioceptive action. CONCLUSION: This technique could be proposed in women suffering from urinary stress incontinence with sphincter hypoactivity.