Comparison of transurethral versus periurethral collagen injection in women with intrinsic sphincter deficiency.

Two different injection techniques for collagen injection have been described for the treatment of intrinsic sphincter deficiency (ISD) in women: periurethral and transurethral. The purpose of this review was-to compare these two different techniques to determine whether or not one method clearly is superior. Forty-five women, ages 43 to 88 years (mean 67 years), with ISD underwent collagen injection therapy using either the periurethral or transurethral route. A retrospective analysis was performed comparing initial and final incontinence grades, change in daily pad use, initial Valsalva leak point pressure (VLPP), total amount of collagen used, number of treatment sessions performed, anesthesia required, and complications related to injections. Twenty-four patients underwent transurethral injection, and 21 underwent periurethral injection. There was no significant difference in preoperative incontinence grade, initial VLPP, or age between the two groups. At a mean follow-up of 6.3 months, 11 (46%) of the transurethral group were cured, 12 (50%) improved, and 1 (4%) unchanged. The periurethral group with a mean follow-up of 8.8 months experienced a 33% cure rate and 67% improvement rate (p > .05). The average amount of collagen injected was 4.7 cc (1.5-12.5) transurethrally and 10.1 cc (5-20) periurethrally (p < .001). The number of treatment sessions was identical (1.3) regardless of the method used. Complications were minimal [minor bleeding (2), urinary tract infection (1) in periurethral vs. minor bleeding (2), urinary tract infection (1) in the transurethral group, and not significant between the two groups]. Overall, success was equivalent using either method. The amount of collagen injected was significantly more when utilizing the periurethral method. The transurethral method appears to offer similar results as the more commonly described periurethral technique. The transurethral method is an acceptable technique for collagen injection therapy in women.

Contemporary diagnosis and treatment of fibroepithelial ureteral polyp.

Fibroepithelial polyps of the ureter are rare, benign tumors often not easily distinguished from malignant transitional-cell carcinomas by radiologic means. Historically, many patients have undergone unnecessary nephroureterectomy for these lesions. With recent advancement in endourologic instrumentation, a biopsy-proven diagnosis of suspect upper-tract lesions can be made prior to definitive therapy. We describe a typical case of fibroepithelial ureteral polyp wherein the diagnosis and surgical treatment was accomplished entirely by endoscopic means.

The effect of a standardized patient instructor experience on students' anxiety and confidence levels performing the male genitorectal examination.

BACKGROUND: Standardized patient instruction (SPI) is recommended as a nonthreatening method for teaching the male genitorectal examination. The article's purpose is to describe the method's effectiveness in reducing anxiety and increasing confidence among men and women students from diverse cultures. DESCRIPTION: We implemented an SPI program in 1993 to teach the examination to 2nd-year students. Students performed their examinations in mixed gender groups of three; a man student was responsible for disrobing the SPI and performing the first exam. During the 45-min session, each of the three students performed the examination in turn, and each received immediate feedback on their technique and interpersonal approach to the patient. EVALUATION: All students (n = 190) evaluated their SPI encounter immediately after the session had ended. CONCLUSIONS: Men and women students from all ethnic groups reported decreased anxiety and increased confidence levels after the SPI session. These findings indicate that a carefully orchestrated SPI session is effective in reducing students' anxiety about crossing personal space boundaries, overcoming a variety of proscriptions on gender-appropriate interactions, and increasing their confidence to perform this sensitive examination.

Recalcitrant gross hematuria secondary to left renal vein hypertension.

Left renal vein hypertension is a most uncommon and rarely a well-documented cause of gross hematuria. We report a case of lateralizing, gross hematuria resulting from left renal vein hypertension in an individual with a history of a prior Whipple procedure. The diagnosis was suspected at the time of renal angiography and proven by renal venography. Complete rapid resolution of the hematuria and hypertension was achieved following placement of a left renal vein stent.

Are T1c tumors different from incidental tumors found at autopsy? The risk and reality of overdetection.

The wisdom governing contemporary prostate cancer screening or early detection programs continues to be scrutinized. Although the mild increase in death rate speaks for itself, the enormously disparate and accelerating incidence rates have attained widespread attention. The abrupt recent downstage migration suggests that T1c lesions may be the arguable culprit. For more than 50 years, we have known that incidental prostate cancers found at autopsy are very common. Given these odds, it is not surprising that these cancers will be found antemortem. Mathematical models correctly predict the discovery of small-volume cancers with multiple biopsies. Although there are some anticipated differences between T1c and incidental tumors found at autopsy, the overlap is predictably large, suggesting that a conservative answer to the question posed in the title is: Maybe yes, but often not much.

Stress leak point pressure: a simple and reproducible method utilizing a fiberoptic microtransducer.

OBJECTIVES: This work demonstrates a simple technique utilizing a fiberoptic microtransducer that provides statistically reproducible stress leak point pressure (SLPP) results without the use of fluorourodynamics. METHODS: Nineteen stress incontinent patients with varied clinical histories underwent two SLPP measurements on 2 separate days, totaling four data points. A 14 F catheter sheath was inserted to empty the bladder. Through this sheath, a 5 F fiberoptic microtransducer was inserted into the bladder and zeroed. Then, 250 cc of indigo-carmine solution was instilled, during which a filling cystometrogram was performed. The sheath was removed, leaving only the 5 F transducer in the bladder. A 2 by 2 inch gauze was placed at the meatus. As each participant performed a slow Valsalva maneuver, an event marker was used to note the pressure at which indigo solution was first seen to stain the gauze. RESULTS: SLPPs ranged from 15 to 140 cm water (H2O). A two-tailed paired t test demonstrated no statistical difference (P < 0.6) between the two SLPPs performed on day 1, with a mean difference of 1.05 +/- 2.61 (95% confidence interval [CI]). Comparison of the two SLPPs performed on day 2 also revealed no statistical difference (P < 0.8), with a mean difference of -0.17 +/- 5.65 (95% CI). Lastly, comparison of the mean SLPPs from day 1 with the mean SLPPs from day 2 revealed no statistically significant difference (P < 0.8), with the mean difference of -0.59 +/- 1.62 (95% CI). CONCLUSIONS: This study demonstrates a simple technique that produces reproducible SLPP measurements in a wide variety of clinical settings and avoids ionizing radiation.

Compliance and complications of clean intermittent catheterization in the spinal cord injured patient.

The optimal management of the neuropathic bladder secondary to spinal cord injury remains unsettled. Some have advocated the use of chronic indwelling catheters in tetraplegic patients supposedly due to comparable complication rates with non-indwelling catheter management. We assessed the urological complication and compliance rates in a group of spinal cord injured patients followed over a mean of 5.9 years. Complication rates from clean intermittent catheterization were comparable if not better than the rates previously reported for clean intermittent catheterization and significantly better than chronically catheterized patients. The compliance rate in our series was 71% as determined by the number of patients remaining on clean intermittent catheterization at their last urological follow-up. We conclude that the use of clean intermittent catheterization can provide optimal management of the lower urinary tract in spinal cord injured patients.

Perineal xanthogranulomatous pseudotumor due to intermittent catheterization: a liposarcoma mimic. Case report.

A large perineal fatty tissue mass shown to be an encapsulated xanthogranulomatous reaction was found in a spinal cord injured man whose neuropathic bladder was for a long time being managed by clean intermittent catheterization, but who had chronic urinary tract infection. He was also known to be a chronic alcoholic. We would say that an alcohol numbed sensorium and multiple catheterizations led to recurrent small urethral perforations which in the setting of chronic bacteriuria promoted the unusual inflammatory mass. Appreciating the increasing use of clean intermittent catheterization for the spinal cord injured, we suspect that similar cases of 'xanthogranulomatous pseudotumors' will be found, and therefore we describe this most unusual clinical presentation.

The effect of terazosin on bladder function in the spinal cord injured patient.

We prospectively studied the effect of terazosin on bladder compliance in 12 spinal cord injured patients. All study patients had demonstrated previously poor compliance despite clean intermittent catheterization and maximum anticholinergic therapy. Patients were started on 5 mg. terazosin nightly for 4 weeks. They were evaluated with a history, physical examination, symptom score, and synchronous cystoscopy and cystometry before, during and after terazosin therapy. Detrusor compliance improved in all patients during the treatment phase. The change in bladder pressure and the safe bladder volume were statistically and clinically significant. Patients also reported fewer episodes of incontinence and dysreflexia. The improvement in compliance and continence suggests that in the spinal cord injured patient terazosin may have an effect on alpha receptors in the detrusor muscle or central effects and that improved compliance is not due to decreased outlet resistance.

Determination of indwelling ureteral stent patency: comparison of standard contrast and nuclear cystography, and lasix renography.

OBJECTIVE: Because of the difficulty in determining patency of Double-J ureteral catheters, a study was devised at Madigan Army Medical Center to determine the best method to demonstrate stented ureteral patency. METHODS: Forty-two patients requiring Double-J ureteral stenting for various clinical reasons were the study group. Outpatients underwent contrast retrograde cystography, nuclear cystography, and diuretic renography every four to six weeks during the stent duration or just prior to stent removal if the stents were indwelling for less than four weeks. In addition, four weeks after stent removal diuretic renography alone was done to evaluate for possible delayed obstructive effect of the ureteral stenting. RESULTS: A total of 53 stents and 42 patients were evaluated. Seventy-seven sets of studies were obtained. In only four instances did all three imaging methods agree on the obstruction. In the remaining 73 sets of data, at least one imaging technique indicated stented ureteral patency. The contrast retrograde cystogram was positive for reflux 52 times (71%). Nuclear cystography showed patency 54 times (74%) and an unobstructed diuretic renogram was obtained 59 times (81%). In addition, five of the six diuretic renograms accomplished with patients in the supine position only and which showed obstruction were repeated with patients in the upright position, and they showed unobstructed function. The overall sensitivity for diuretic renography was 89 percent when the diuretic renogram was done with patients in the supine and upright positions. CONCLUSIONS: Diuretic renography is the most sensitive test for detecting stented ureteral patency. This test needs to be performed with patients in both the supine and upright positions.

Specificity of the American Urological Association voiding symptom index: comparison of unselected and selected samples of both sexes.

The American Urological Association voiding symptom index questionnaire for benign prostatic hypertrophy was administered to an elderly unselected sample and a selected urology clinic sample of both sexes to investigate the ability of this instrument to identify prostatic pathological conditions. The female subjects in these cohorts provided a control. In the large unselected sample the male subjects scored statistically higher in only 2 categories, weak stream (487 subjects) and strain (507) (p < 0.05 for both categories). The clinical significance of these scores is questionable, however, since they were low (less than 2 of 5). In the selected group (145 subjects) the female subjects showed a higher total mean score due to the contribution of statistically higher irritative scores (p < 0.05). We conclude that the American Urological Association voiding symptom index does not specifically identify prostatic pathological conditions, and that elderly men and women have similar voiding symptom scores. Therefore, treatment that results in improvement in symptom scores may not specifically affect the prostate. Other factors, such as an aging detrusor, changes in physiological production of urine or other unknown factors, may contribute to the symptoms.

Synchronous cystoscopy and cystometry in the management of neurogenic bladder dysfunction.

The physical difficulties associated with cystoscopy and cystometry in the spinal cord injury patient led to a clinical trial of synchronous cystoscopy and cystometry in these individuals. Following a disappointing experience with external transducer methodology, a recently available fiberoptic microtransducer system was used and an effective system was developed. A total of 20 individuals with spinal cord injury underwent a standard water cystometrogram on an examination table followed by synchronous flexible cystoscopy and cystometry using a 5F fiberoptic microtransducer while seated in a chair. The results showed both pressure tracings to be clinically identical. Uninhibited contraction spikes, compliance curves and leak point pressures were essentially the same by both methods and artifact was not a problem. Given the speed, ease and reproducibility of this method, the difficulties with patient transfer for these studies have been virtually eliminated. Two urethral instrumentations have been replaced by 1. Examination room time was decreased from 60 to approximately 10 to 15 minutes with half of the required personnel. Perhaps more importantly, these occasionally problematic individuals clearly prefer this streamlined approach and patient compliance with followup has improved.

Fiberoptic microtransducer pressure technology: urodynamic implications.

The FST 200 is a novel commercially available pressure measurement system that combines microtechnology and fiberoptics and is particularly well suited for invasive urodynamic studies. Pressure recording with this system is highly accurate and reproducible. The pressure curves obtained parallel those from standard water cystometry. Being small and portable, the system lends itself to invasive transurethral monitoring in the privacy of an examination room. Additionally, the 5F catheter size allows the performance of leak point pressures and pressure/flow voiding studies with minimal urethral stenting artifact often seen with larger catheters. The technical aspects of this system are presented.

Detection of non-palpable prostate cancer. A mathematical and laboratory model.

Prostate cancer is currently the most commonly diagnosed cancer among males in the United States. As technology improves and the search for this enigmatic condition intensifies, we are detecting greater numbers of non-palpable tumours. These tumours are generally treated aggressively, given the uncertainty of their behaviour, but this approach may be over-zealous for small volume disease. The likelihood of detecting any cancer volume can be derived from Bayes' theorem of conditional probability. A laboratory model using coloured clay was created to contrast tumour volumes of 2.5, 5 and 20% (n = 75). Six random systematic biopsies were taken from each model in a blind fashion; 36% of the 2.5%, 44% of the 5% and all of the 20% models had at least 1 positive biopsy. Twenty-two of the 25 models representing 20% tumour had 3 or more biopsy cores positive. These data suggest that low volume disease with low biological potential will be found by random biopsy as the mathematical probability predicts. The high incidence of occult prostate cancer in the older population makes this a worrying observation. Also, and perhaps more important, there is a direct correlation between the volume of disease and the number of positive biopsies. This correlation is easily seen in both models and may allow for an estimation of tumour volume. This ability to estimate tumour volume may be a useful clinical tool that helps to guide therapy and assess prognosis.

Secondary penile malignancies: the spectrum of presentation.

Secondary penile carcinoma is a rare disease with signs and symptoms covering a wide spectrum, from simple erythema to priapism. We report two cases of penile metastatic involvement that are illustrative of this spectrum.

Renal leiomyosarcoma: plea for aggressive therapy.

We report a case of renal leiomyosarcoma arising from the renal pelvis with immunohistochemical confirmation of the diagnosis. Treatment was extirpative surgery for both primary and metastatic lung lesions as well as adjunctive radiation and chemotherapy. This patient remains disease-free twelve months following treatment.

Prostate-specific antigen and digital rectal examination in long-term follow-up of stage A1 prostatic carcinoma.

Twenty-six individuals with Stage A1 carcinoma of the prostate (less than or equal to 5%, Gleason score less than or equal to 4) diagnosed from 1969 to 1980 were evaluated with digital rectal examination (DRE) and prostate-specific antigen (PSA). This unique cohort, sixty-one to eight-two years of age (median 72 years), had a mean interval from diagnosis of thirteen years (median 12.5 years). Abnormal findings on DRE were found in 6 individuals, whereas only one elevated PSA was detected. Ninety-six percent of the PSA levels were less than 3.0 ng/mL and nearly 60 percent of the group had 1.0 ng/mL or less. These levels compare favorably with healthy control subjects under forty years of age and with the limited data available for PSA in healthy men over seventy years of age (87% and 26%, respectively). While biopsy showed persistent or recurrent carcinoma in 2 of 5 individuals, further evaluation disclosed only localized disease. Though the PSA provided little additional information to DRE in the individual patient, it appears from an overview of this group that a low level of PSA in Stage A1 prostatic carcinoma may be associated with long-term survival.

Digitally-directed transrectal biopsy using Biopty gun versus transrectal needle aspiration: comparison of diagnostic yield and comfort.

A technique for digitally-directed core biopsy using the Biopty device and prospective comparison of accuracy and comfort, using this technique simultaneously with transrectal needle aspiration, are presented. To better estimate the true prevalence of carcinoma in the study population, a repeat combined procedure was performed on all subjects who did not have carcinoma confirmed on the initial core biopsies. All procedures were done by one investigator and all pathology reviewed by one senior pathologist. A total of 180 combined procedures were performed on 100 consecutive patients with palpably abnormal prostates; 30 carcinomas were detected. Digitally-directed Biopty biopsy yielded a sensitivity rate of 87 percent compared with 57 percent for needle aspiration (p less than 0.05). Using a numerical comfort scale, the Biopty device was also rated less painful than needle aspiration (p = 0.0001). The morbidity of the combined procedure was minimal, with a minor complication rate of 2.2 percent. No infections occurred.

Use of resectoscope for colon cancer.

Urologic endoscopic resectoscopes greatly simplify electrofulguration and resection of rectal tumors. The most important advantage is the enhanced visibility that allows determination of the depth of resection and good hemostasis. The indications for this procedure are otherwise-poor surgical candidates, palliation, excision of locally aggressive tumors such as villous adenomas, and bowel diversion prior to definitive therapy. Bleeding, peritoneal perforation requiring colostomy, and postoperative infection have all been reported, but the complication rate appears to be acceptable. Further clinical studies are necessary to determine if, indeed, this can be considered a curative procedure. Finally, because the practicing urologist is intimately aware of the technical aspects of the urologic resectoscope, he will probably be called on to perform, and should be aware of, this procedure.

Elective cholecystectomy during major urological surgery.

A total of 6 patients underwent a major urological operation with simultaneous elective cholecystectomy for cholelithiasis. All patients did well with no morbidity or increased hospital stay attributable to the biliary operation. Numerous articles in the vascular, general and gynecological surgery literature advocate concomitant cholecystectomy when gallstones are present. The complications of nonoperated biliary calculous disease, including postoperative cholecystitis, are well known. A concomitant operation could reduce over-all risks and costs to the patient and health care system.