Surgical management of non-obstructive urinary retention.

Non-obstructive urinary retention is a complex disorder that can pose diagnostic and therapeutic problems to the treating urologist. A through history and physical examination coupled with well performed and interpreted urodynamic testing can offer insight into the etiology and prognosis of the disease. Myriad pharmacologic and conservative therapies exist to treat non-obstructive retention but success is limited. The majority of patients with non-obstructive retention are consigned to long-term bladder decompression with the preponderance of evidence-based studies supporting clean intermittent catheterization. Surgical treatment is essentially limited to sacral nerve stimulation. Published data cites success rates with sacral nerve stimulation approaching 80% with a catheterization-free rate of close to 50%. And while future study is needed to refine and identify which patients will benefit the most, the profound improvement afforded by sacral nerve stimulation makes it the treatment of choice for patients with otherwise refractory non-obstructive retention.

Clinical experience with the Storz Modulith SL 20 lithotriptor.

BACKGROUND: A Food and Drug Administration pre-market approval study evaluated the safety and effectiveness of the Storz Modulith SL 20 lithotriptor. METHODS: Protocol was a maximum of 2,000 shock waves per treatment and no more than three treatments per patient. Safety and effectiveness parameters were defined and followed. RESULTS: The overall success rate was 74.6% with a stone-free rate of 63.6%. No clinically or statistically significant adverse trends were noted acutely or in follow-up. CONCLUSIONS: The Storz Modulith SL 20 lithotriptor is a safe and effective device to treat renal and ureteral calculi in an outpatient setting using intravenous sedation/analgesia.

Suction-assisted lipectomy for the correction of stomal dysfunction.

Poorly fitting appliances for urinary or fecal stream stomas can lead to frequent leaking and subsequent social embarrassment, stomal stenosis, hyperkeratosis, skin breakdown, and increased cost secondary to frequent changing. Obese patients with abnormal skin folds frequently are more prone to these problems. Herein is described the use of suction-assisted lipectomy for abdominal wall contouring in an effort to improve and simplify appliance application as well as lengthen appliance life. Between 1989 and 1996, five patients (three females, two males) ages 13 to 47 years, were treated with abdominal wall suction-assisted lipectomy in an attempt to improve stomal function. Preoperatively, an average of 1.25 appliance changes a day were required for leaking. Three patients had one procedure removing 400 to 600 cc of fat. Two patients had staged suction, removing a total of 900 to 1600 cc of fat. At 6-month follow-up, the average appliance life was 4 days, and the incidence of skin problems and leaking was markedly reduced. The technique of suction-assisted lipectomy is a simple outpatient procedure with low morbidity that can successfully be used to improve stomal function in obese patients with poorly fitting appliances secondary to skin folds, poor body habitus, or abdominal scarring.

Anesthetic management of patients receiving calculus therapy with a third-generation extracorporeal lithotripsy machine.

We reviewed the anesthetic requirements for satisfactory use of a third-generation electromagnetic-source design for extracorporeal shockwave lithotripsy (SWL). Medical records were reviewed for a period of 9 months on all patients receiving anesthesia care for SWL with and without other urologic procedures. The Modulith SL20 was used on 56 ASA Class I-III patients having 87 SWL treatments. Demographic and anesthetic variables were recorded. Complications documented included dysrhythmias, nausea necessitating treatment, and conversion from sedation to regional or general anesthesia. The majority of procedures (83%) were performed on an outpatient basis. Patients were classified as ASA physical status I (27%), II (63%), or III (10%). Monitored anesthesia care with intravenous sedation was utilized in 93% of cases. Of these cases, 78 involved a combination of intravenous propofol, fentanyl, and midazolam; the remaining 3 involved propofol, alfentanil, and/or midazolam. The mean treatment duration was 36 minutes. Patients were discharged within 1 hour after procedure completion in 77 cases (89%). Nausea necessitating treatment was rare (3%). The mean dose of propofol administered with SWL as the only procedure was 272 +/- 112 mg. When SWL was combined with other urologic procedures, the mean dose of propofol was 334 +/- 121 mg. Continuous intravenous propofol infusion provides excellent procedural conditions for SWL on the Modulith SL120, a third-generation lithotripter.

Blind-ending ureteral duplication: cause of asymptomatic abdominal mass.

Blind-ending ureteral duplication is a rare anomaly. The authors report on a 5-year-old girl who presented with an asymptomatic abdominal mass in which computerized axial tomography was used to make the diagnosis. The embryology of this anomaly is reviewed.

Vesical calculus: an unusual complication of renal transplantation.

Vesical calculus formation in renal transplant patients is rare. We describe seven patients who developed calcium oxylate or combination calcium oxylate-magnesium ammonium phosphate stones on a polypropylene suture nidus at the site of a ureteroneocystostomy. The use of a nonabsorbable suture in the urinary tract should be avoided.

Primary female urethral carcinoma. A retrospective comparison of different treatment techniques.

Between July 1951 and January 1984, 14 female patients (11 black and three white; average age, 58 years) were treated for primary urethral carcinoma. Five patients had radical surgery, six received preoperative radiotherapy (2000 cGy in five fractions) followed by anterior exenteration, and three had definitive radiotherapy (external beam 4000 to 5000 cGy plus 2800 to 3000 cGy interstitial implant). The mean follow-up times were 5.6, 3.9, and 2 years, respectively. In the first two groups, two of 11 patients (18%) are alive and well with no evidence of disease. The rest died of local as well as distant disease. In the third group, two of three patients (67%) are alive and well with no evidence of disease. The third patient died of papillary adenocarcinoma of the uterus 30 months later with no evidence of the primary tumor.

Pelvic lipomatosis: 35-year experience.

From 1950 through 1985, 18 patients 26 to 65 years old (mean age 44.5 years) presented with pelvic lipomatosis. Followup ranged from 6 months to 17 years, with a mean of 7.5 years. Of these 18 patients 16 (89 per cent) are alive, 1 (6 per cent) died of uremia and 1 (6 per cent) was lost to followup after 6 months. During this period 7 patients (39 per cent) required operative procedures for urinary obstruction. Although pelvic lipomatosis is a benign proliferation of fat in the true pelvis that is known to lead to urinary tract, fecal and even vena caval obstruction, it also may remain dormant and cause no significant symptoms for many years.

DNA distribution patterns of prostatic tissue obtained at time of transurethral resection.

One hundred fifty-seven patients with vesical outlet obstruction underwent transurethral prostatic resection with prostatic chips sent for routine histology and for flow cytometry (FCM) using a modification of the Vindelov technique. One hundred nine patients had benign prostatic hypertrophy (BPH) and 48 had adenocarcinoma. Using the criteria of 90 per cent G0-G1 cells and/or less than 10 per cent S + G2 + M cells as normal or benign, the false positive rate was 1 per cent (1/109), and the false negative rate was 12.5 per cent (6/48). The range of cells in G0-G1, for the BPH group was 89-98 per cent, mean 95 per cent, and for the carcinoma group 22-94 per cent, mean 74 per cent. The range of cells in the S + G2 + M compartment for the BPH group was 2-11 per cent, mean 7 per cent, and for the carcinoma group 6-78 per cent, mean 26 per cent. Only 4 cases had aneuploid stem cell lines. FCM measurements of single cell prostatic tissue suspensions are an accurate, objective means of quantifying nuclear DNA content and rate of cell proliferation. How useful this technique is or will be in predicting prognosis and determining therapy in a given individual remains to be determined.

Flow cytometry deoxyribonucleic acid determinations and cytology of bladder washings: practical experience.

Flow cytometry deoxyribonucleic acid measurements of bladder washings, routine bladder irrigation cytology and cystoscopic results were compared in a prospective fashion during 33 months of clinical urology practice. Of the 204 patients (286 specimens) studied 74 had bladder tumors or a history of bladder tumors and 130 had other genitourinary pathological conditions, including hematuria, cystitis, benign prostatic hypertrophy or prostatic carcinoma. Flow cytometry and cytology agreed with the cystoscopic findings in 93 per cent of the cases, whereas flow cytometry agreed with cytology in 84.6 per cent. When combined, flow cytometry and cytology were negative in only 1 case when several papillomas or grade I papillary carcinomas were present on cystoscopy, yielding a diagnostic accuracy of 99 per cent. The false negative rates for flow cytometry and cytology were 4.3 and 5.2 per cent, respectively, with false positive rates of 4.2 and 3.1 per cent, respectively. As expected the specimens that were missed by cytology were low grade tumors and those missed by flow cytometry were usually ulcerated invasive tumors. We believe that flow cytometry is a valuable adjunct to cytology and cystoscopy in the diagnosis, management and followup of patients with known or suspected bladder cancer. In addition, criteria for the diagnosis of cancer are changed such that specimens with a deoxyribonucleic acid tail and a large amount of hyperdiploid cells without a distinct stem line are considered suspicious and indicative of bladder pathology but they are not synonymous with the presence of carcinoma.

Bilateral pelvic lymphadenectomy, iridium 192 template, and external beam therapy for localized prostatic carcinoma: complications and results.

Thirty-five patients with prostatic adenocarcinoma were treated by bilateral pelvic lymphadenectomy and temporary implantation of iridium 192 strands with adjuvant external beam radiotherapy. With the implant the prostate received between 3,200 and 3,500 gray (Gy) followed in two weeks by small-field external beam irradiation for an additional dose of approximately 3,400 Gy. Morbidity included an ileofemoral thrombosis in one patient, and transient radiation proctitis in four patients; one patient required transurethral prostatic resection for obstruction at one year. Local response of the primary tumor was dramatic in every case at three-month follow-up. In 11 of 15 patients (73%), biopsy at one year showed no evidence of disease.

Extrarenal adult Wilms' tumor.

Extrarenal Wilms' tumor is a very rare disease, occurring mostly in children. Sixteen cases have been reported in the world medical literature. A case of retroperitoneal extrarenal Wilms' tumor is reported in a 36-year old white male and the literature reviewed. Pathologic examination revealed both undifferentiated renal blastoma plus differentiated areas containing immature tubules and glomeruli. No evidence of extrarenal teratomatous tissue was seen. Theories for the histogenesis of this rare tumor are discussed.

Carcinoma of the female urethra: combined iridium Ir 192 interstitial and external beam radiotherapy.

Three female patients (mean age 55) with carcinoma of the urethra were treated with combined external beam irradiation (4,000 to 5,000 rads) and interstitial irradiation with iridium Ir 192 (2,700 to 3,000 rads) applied with a modified Syed-Neblett template. Two patients are alive with no evidence of disease at 27 and 37 months. One patient died of a second primary tumor at 30 months, without histologic evidence of the original urethral neoplasm. No patient had significant complications of therapy. This treatment regimen is effective for selected women with urethral carcinoma.