Long-term results of suprapubic bladder neck closure for treatment of the devastated outlet.

OBJECTIVES: To assess the long-term success of suprapubic bladder neck closure in patients with irreparably damaged bladder outlets. METHODS: A cohort of 35 patients with intractable urinary incontinence secondary to severe posterior urethral/bladder neck damage underwent suprapubic bladder neck closure. Patients were assessed with regard to the success of procedure, as well as early and late complications. RESULTS: With a mean follow-up of 79 months (range 12 to 164), suprapubic bladder neck closure was successful in 29 (83%) of 35 patients. One revision of the bladder neck improved the success rate to 94% (33 of 35). Early and late complications, excluding bladder neck fistula, were reported in 3 (9%) and 5 (14%) of 35 patients, respectively. CONCLUSIONS: High success and acceptable complication rates can be achieved with suprapubic bladder neck closure for the treatment of severe urinary incontinence secondary to a devastated bladder outlet.

Gastric patch pyeloplasty: development of an animal model to produce upper tract urinary acidification for treating struvite urinary calculi.

PURPOSE: Struvite calculi form in an alkaline environment created by urease producing uropathogens. We developed a viable upper tract urinary acidification model by performing gastric patch pyeloplasty in the rabbit. This model produces urinary acidification sufficient for the treatment and prevention of struvite renal calculi. We evaluated the physiological, metabolic and surgical outcomes. MATERIALS AND METHODS: gastric segment was harvested based on branches of the left gastro-epiploic artery. The flap was folded along the transverse axis and the adjacent edges were closed. The mouth of this reconfigured pouch provided optimal dimensions for anastomosis with the diminutive renal pelvis. Half of the rabbits were treated with internal stenting and H-2 blockade. Urinary pH was assessed by weekly cage collection and direct collection from the cannulated ureters. Urine culture was done, and serum gastrin and electrolytes were assessed at regular intervals. The rabbits were sacrificed at 3 to 26 weeks. Histological examination was routinely performed. RESULTS: A total of 15 rabbits were available for complete assessment. Sustained urinary acidification was produced in 7 animals (47%) with a mean pH decrease of 2.27. In another 2 rabbits (13%) the urine was initially acidic but subsequently became alkaline due to ureteral obstruction. Electrolytes and gastrin were unchanged in these rabbits and urine culture was positive in 2. Histological testing revealed nonspecific inflammatory changes of the renal pelvis. Anastomotic complications were the most common surgical complication and the most common cause of failed acidification. The cohort treated without stents and H-2 blockade was at significantly greater risk for anastomotic leakage. CONCLUSIONS: Gastric patch pyeloplasty may significantly increase urinary acidity in the rabbit model without altering the serum electrolyte balance or gastrin level. The procedure utilizes common techniques of reconstructive urology and may be possible with laparoscopy. Further study is required to assess the in vivo effect of this procedure for treating and preventing upper tract struvite calculi.

The impact of contemporary bladder management techniques on struvite calculi associated with spinal cord injury.

OBJECTIVE: To evaluate the incidence, risk factors and complications of upper tract struvite calculi, often associated with spinal cord injury (SCI), as such patients have a high incidence of urinary infection complicating their neurogenic voiding dysfunction, by reviewing a large population of patients with SCI in whom modern techniques of bladder management were used. PATIENTS AND METHODS: Between 1982 and 1996, 1669 patients with SCI were admitted to our institution; 1359 of these patients sustained their injuries during the study period. During this time, their bladder management was based on urodynamic and imaging criteria, using techniques such as early intermittent catheterization, sphincterotomy and bladder augmentation where possible to create a catheter-free, low-pressure reservoir. All instances of upper tract struvite calculi in this population were documented. Risk factors for stone development, presentation and complications, management and recurrence rates were assessed. RESULTS: Over the 15 years, 58 patients (3.5% of the SCI population) were treated for a total of 144 episodes of struvite calculi. The incidence of stones in those injured since 1982 was 1. 5%; 67% of these patients had complete spinal cord lesions, 54% had lesions of the cervical cord and 53% developed their first stone >10 years after injury. Only 22% presented within 2 years of injury. The group of patients developing stones had a significantly higher incidence of indwelling catheters (49%), bladder stones (52%) and vesico-ureteric reflux (28%) than those who were stone-free. The development of recurrent urinary tract infections was the most common mode of presentation. The stone-free rate after treatment was 87%. Normal renal function was preserved in 72% of patients. CONCLUSIONS: In a large population of patients with SCI managed using contemporary bladder techniques the incidence of upper tract calculi was 3.5%; 30% of these stones were complete or partial staghorns. Those patients with complete cord lesions, permanent indwelling catheters and vesico-ureteric reflux were at the highest risk. Stone clearance was 87% and recurrent stones occurred in 69% of patients. Struvite renal calculi continue to be a significant problem in the spinal cord injury population.

Percutaneous management of caliceal diverticular calculi: technique and outcome.

OBJECTIVE: Symptomatic renal calculi found within caliceal diverticula are difficult to treat. We present a single-surgeon cohort of 21 consecutive patients undergoing percutaneous treatment of stones within caliceal diverticula over a 12-year period. PATIENTS AND METHODS: Each patient was managed by a one-stage percutaneous nephrolithotomy (PCNL). The majority of diverticula were situated at the upper pole. Access was gained via a direct target puncture, a Y puncture from a parallel calix, or through the diverticular stalk in the neighboring calix. The approach was commonly supracostal. A single-stage dilator was used to establish the track. Stones were removed intact or fragmented with ultrasonic lithotripsy, and the diverticular necks were treated with endoscopic division or dilation and splinted with a 22F nephrostomy tube for several days. RESULTS: Total stone clearance was obtained by PCNL alone in 95% of cases. The only case with incomplete clearance was cleared successfully with shockwave lithotripsy (SWL). Twenty patients were assessed with an intravenous urogram at 3 months and then annual plain films and clinical assessment. Further imaging was performed in selected cases. The diverticula were obliterated or had improved drainage in 85% of assessable cases. Three patients developed recurrent stones and were treated with SWL, laparoscopic diverticulectomy, on partial nephrectomy. One further patient required partial nephrectomy for poor drainage and ongoing pain. Of the 21 patients, 17 have remained stone, symptom, and infection free with clinical and radiologic follow-up ranging from 6 months to 12 years. CONCLUSIONS: This series demonstrates that percutaneous surgery can clear calculi from caliceal diverticula and, in most cases, correct or remove the underlying anatomic abnormality.

Management of invasive penile cancer by synchronous penile lengthening and radical tumour excision to avoid perineal urethrostomy.

BACKGROUND: Adequate excision of invasive penile carcinoma often results in a penile stump of inadequate length to control the urinary stream. A simple technique to lengthen the stump and avoid urethrostomy is described here. METHODS: Additional corporal length is gained by dividing the dorsal suspensory ligaments through a transverse lower abdominal skin incision. Skin length is gained by vertical closure of this incision. RESULTS: This technique has been successful in two cases where the stump length after partial penectomy was borderline. Each patient has a functional stump with satisfactory cosmesis. CONCLUSIONS: In selected cases this technique may avert the need for perineal urethrostomy after adequate excision of a penile cancer.

Prospective assessment of incontinence after radical retropubic prostatectomy: objective and subjective analysis.

OBJECTIVES: To assess prospectively-using pad test and questionnaire-the rate and degree of incontinence after radical retropubic prostatectomy, to analyze factors that may predispose individuals to postoperative incontinence, and to assess the impact of incontinence on patient lifestyle. METHODS: Fifty-one consecutive patients were assessed at 3-month intervals for 1 year after radical retropubic prostatectomy. Patients were objectively assessed using a 1-hour pad test and subjectively assessed by questionnaire. Incontinence was graded objectively according to the change in weight of the pad at 1 hour and subjectively by the number of pads used per day. Lifestyle modifications were assessed by questionnaire at 12 months. A number of variable factors were studied to assess risk factors for postoperative incontinence. RESULTS: Continence continued to improve up to 12 months. At 12 months, pad testing revealed 84% of patients were dry, 6% were mildly incontinent. 6% were moderately incontinent, and 4% were severely incontinent. Questionnaire assessment revealed 80% wore no pad, 14% had mild incontinence, 4% had moderate incontinence, and 2% had severe incontinence. Pad testing was not as sensitive as the questionnaire for the detection of minimal incontinence but was more reliable for moderate and severe levels. Patients made lifestyle changes proportional to the level of incontinence. No predisposing factor was identified for the development of incontinence after radical retropubic prostatectomy. CONCLUSIONS: Significant incontinence after radical prostatectomy occurs in as many as 10% of patients. Pad testing provides an inexpensive and simple form of objective assessment in patients with bothersome incontinence and allows documentation of improvement over time.

Congenital bulbar urethral strictures occurring in three brothers.

Three brothers with identical congenital bulbar urethral strictures are presented. These rare lesions are distinct from posterior urethral valves although the exact embryological origin is uncertain. The current literature is also reviewed.