Multicenter randomized clinical trial comparing surgery and collagen injections for treatment of female stress urinary incontinence.

OBJECTIVES: To compare, in a multicenter, randomized clinical trial, collagen injections versus surgery with regard to efficacy, quality of life, satisfaction, and complications. METHODS: Of 133 women with stress urinary incontinence, 66 were randomized to collagen injection and 67 to surgery (6 needle bladder neck suspensions, 19 Burch, and 29 slings). After randomization, 15 women refused their allocated treatment. "Intent-to-treat" and "per protocol" analyses were applied. Women assigned to collagen injection could receive up to three injections before it was considered a failure. A "top-up" injection was allowed within 3 months after cure. Success as the primary outcome at 12 months was defined as a dry 24-hour pad test (2.5 g or less of urine) after having received only the allocated intervention. RESULTS: The per protocol analysis showed that the success rate 12 months after collagen injections (53.1%) was much lower than that after surgery (72.2%). The difference was 19.1% (95% confidence interval -36.2% to -2%). The general and disease-specific quality-of-life scores measured by the Rand Medical Outcomes Study 36-item Health Survey and Incontinence Impact Questionnaire were similar in the two groups (P = 0.306). Women treated by surgery were, on average, more satisfied (79.6%) than those treated by collagen injection (67.2%), but the difference was not significant (P = 0.228). Finally, complications were less frequent and severe with collagen injection: 36 events in 23 subjects for collagen injection versus 84 events in 34 subjects for surgery (P = 0.03). CONCLUSIONS: One year after intervention, the success rate of collagen injection as a treatment for stress urinary incontinence was about 19% lower than that after surgery. This has to be tempered by the similar changes in quality of life and satisfaction in both groups and that the number and severity of complications were much greater after surgery than after collagen injection. The results of this study indicate that collagen injections might be a worthwhile alternative to surgery for the treatment of stress urinary incontinence.

Evaluation of Spigelian hernia by CT.

Spigelian hernias are uncommon abdominal wall hernias with subtle clinical findings. The CT studies of three cases are reported. All our patients presented with abdominal mass and vague symptoms. The CT evaluation allowed preoperative diagnosis.

Ultrasonographically indeterminate renal parapelvic masses.

Ultrasonography is excellent in the evaluation of renal masses. Simple cysts can be distinguished from more complex or solid renal masses. Rarely, sonographic examination cannot be used to categorize renal masses, particularly those that are small and in a parapelvic location. We report six patients having sonographically indeterminate parapelvic masses. Subsequent computed tomographic examination demonstrated each of these masses to be a parapelvic cyst. Failure to make an ultrasonographic diagnosis was thought to be due to their parapelvic location. Complex interactions between cyst and normal renal sinus structures caused alteration and distortion of the anatomy of both, making exact diagnosis difficult. Computed tomography can be used to define the anatomy precisely and provide the correct diagnosis.

Radiographic demonstration of a toxic agent.

The abdominal radiographs obtained on a young man attempting suicide by stabbing revealed an unusual opacity in the true pelvis, confirmed as being due to unsuspected carbon tetrachloride ingestion. This is the first known radiologic demonstration of oral ingestion of a rapidly acting toxic substance.

Prophylactic antihistamines in the management of radiographic contrast reactions.

Two hundred and twenty consecutive patients, referred for intravenous pyelography, were assessed for adverse reactions. The effect of prophylactic antihistamines was evaluated. Patients were divided randomly into control, saline or chlorpheniramine treated groups. Changes in serum total haemolytic complement (CH50) and immune complexes (IC) at times 0, 1, 5, 10 and 20 min after injection of radiocontrast material were assayed. Forty-two of the 220 patients suffered reactions, classified clinically into allergic and non-allergic types. There was no difference in the incidence of allergic reactions between control and saline groups. However, significantly less (P less than 0.05) allergic reactions were noted in the antihistamine pre-treatment group. Depressed CH50 occurred in forty-three, of eighty-eight patients tested and persisted for at least 20 min in twenty-two. There was no correlation between CH50 depressions and clinical symptoms. The IC remained unchanged throughout. In conclusion, prophylactic antihistamines may diminish the incidence of allergic reactions. Complement activation occurs in a large number of patients, unrelated to symptomatology, and does not appear to be the only factor responsible for adverse reactions.

Radionuclide detection of iatrogenic arteriovenous fistulas of the genitourinary system.

Radionuclide angiography is a valuable screening test for arteriovenous (AV) fistulas. Seven iatrogenic AV communications of the genitourinary system were initially diagnosed by radionuclide imaging, and untreated patients are being followed up by yearly nuclear examinations. Contrast arteriography is reserved for patients requiring interventional therapy and for symptomatic patients with a negative radionuclide study.

The signs of a passed ureteral stone.

Ten patients with typical renal colic fortuitously passed a urinary calculus, which was retrieved during or shortly after excretory urography. Characteristic alterations in the urogram included: (a) no delay in passage of contrast medium down the entire length of the ureter, (b) decreased radiodensity of contrast on the affected as compared to that of the normal side, (c) dilatation of the ureter on the affected side and (d) a hazy appearance of the ureter with poor definition of its borders. Post-obstructive diuresis explains these changes. This constellation of findings, with accompanying absence of an opaque calculus on the plain film, correctly diagnoses a recently passed stone. The sign complex indicates that obstruction has been relieved, even when the calculus remains in situ.