Von Recklinghausen neurofibromatosis with urinary bladder involvement.

von Recklinghausen neurofibromatosis is an autosomal dominant transmitted disease with 100% penetrance but variable phenotypic expression. The incidence of this systemic disease is 1 in 3000 live births; however, genitourinary manifestations are rare. We report on our management of 1 case during the past 16 years.

Nipple complication caused by a mesenteric GORE-TEX sling reinforcement in a Kock ileal reservoir: report of a case.

INTRODUCTION: The surgical trend after proctocolectomy at present is to perform a pelvic pouch reservoir with an ileoanal anastomosis. Before that a continent ileal Kock pouch was the procedure of choice, which enabled the patient to collect the intestinal discharge for several hours and avoid involuntary escape of reservoir contents, thus making the wearing of plastic bags unnecessary. Although in the majority of patients an increased life quality can be observed, different complications with a Kock pouch may occur. METHODS: We present a case of a young female with signs of outlet obstruction several years after a Kock reservoir was performed because of complicated ulcerative colitis. The obstruction was caused by a fecal-coated GORE-TEX sling that had penetrated through the nipple-valve base into the pouch. The mesenteric sling was introduced as a modification of the original Kock procedure to reinforce the efferent ileal segment, thus preventing nipple prolapse. The perforation site was closed with interrupted sutures and an ileostomy was performed. RESULTS: Three months thereafter, the ileostomy was closed and at a follow-up visit one year later the patient had no complaints and a well-functioning reservoir. CONCLUSION: If continence is desired after definitive ileostomy or if failure of the ileoanal reservoir occurs, a Kock pouch procedure still has a place in the surgical armamentarium of colorectal surgery. Many experts today do not use sling reinforcement maneuvers, and most of these procedures seem to work well without it.

The International Prostate Symptom score in both sexes: a urodynamics-based comparison.

The aim of our study was to determine the urodynamic basis for the observation that aging women report comparable benign prostatic hyperplasia (BPH) symptom scores as age-matched men. Sixty-seven women (mean age, 60.4 +/- 1.5 years; mean +/- standard error of the mean) and 70 age-matched men (mean age, 63.7 +/- 0.9 years; P > 0.05) entered this prospective study. Men were referred for the diagnostic workup of lower urinary tract symptoms (LUTS) due to BPH and women predominantly for urinary incontinence. All patients completed the International Prostate Symptom score (IPSS) with quality-of-life assessment and underwent a detailed clinical and urodynamic evaluation including a multichannel pressure-flow study. Results of the IPSS, quality-of-life assessment, and irritative and obstructive component of the IPSS were correlated with urodynamic findings and the respective data were compared in both sexes. The mean IPSS was 15.7 for men and 13.0 for women (P = 0.02), quality-of-life score was higher in women (4.2 vs. 3.4; P = 0.0008). The irritative score was significantly higher in women (8.7 vs. 6.8; P = 0.003). Incidence of detrusor instability (DI), however, was higher in men (women, 38.1%; men, 48.6%; P = 0.015) and bladder capacity was higher in women (425 vs. 333 ml; P = 0.0001). There was no correlation between incidence and degree of DI with the irritative score in both sexes. The obstructive score was significantly higher in men (8.8 vs. 4.4; P = 0.0001). Ninety-one percent (64/70) of men had urodynamically documented bladder outlet obstruction (BOO), whereas this was the case in only 9% (6/67) of women. In parallel to the irritative score, we could not identify a correlation between the degree of urodynamically proven BOO and the obstructive score in both sexes. This urodynamics-based comparison fails to give an explanation for the observation that aging women report similar BPH scores as men. These data suggest that other mechanisms, such as changes in diurnal urine production, structural alterations of the aging detrusor, endocrine disturbances affecting lower urinary tract function, and subtle urodynamic changes are responsible.

Interrelationships of bladder compliance with age, detrusor instability, and obstruction in elderly men with lower urinary tract symptoms.

Data on the interrelationships of bladder compliance (BC), detrusor instability (DI), and bladder outflow obstruction (BOO) in elderly men with lower urinary tract symptoms (LUTS) are scarce and were therefore assessed in this study. Principle inclusion criteria for this study were men aged > or = 50 years suffering from LUTS as defined by an International Prostate Symptoms Score (IPSS) of > or = 7 and a peak flow rate (Qmax) of < or = 15 ml/sec. Patients with previous surgery of the bladder, prostate, or urethra as well as a pathological neurourological status were excluded from this study. The following parameters were studied in all patients: IPSS, prostate volume calculated by transrectal ultrasonography, free uroflow study, post-void residual volume determined by transurethral catheterization, and a multichannel pressure flow study (pQS). A group of 170 men were included in the analysis. The mean BC in the overall group was 32 +/- 2 ml/cm H2O (mean +/- standard error of the mean [SEM]; range, 4-100 ml/cm H2O). In 36.5% of patients, BC was significantly reduced (< or = 20 ml/cm H2O), and in a further 37.1%, it ranged from 20 to 40 ml/cm H2O. BC decreased statistically significantly (p < 0.05) in patients with advanced age, lower Qmax, higher voiding pressures, and larger prostates. In men with DI (n = 61), mean BC was significantly lower (22 +/- 3 ml/cm H2O) compared to those without (37 +/- 3 ml/cm H2O; p = 0.001; n = 109). Patients with severe BOO as defined by a linear passive urethral resistance relationship of > or = 3 (n = 109), had a significantly lower BC (23 +/- 2 ml/cm H2O) compared to those without or minimal obstruction only (39 +/- 3 ml/cm H2O; p = 0.0002; n = 61). Stepwise logistic regression analysis revealed that DI, a low bladder capacity, and a high maximum detrusor pressure were independent predictors of markedly reduced BC (< 20 ml/cm H2O). BC is decreased in elderly men with high voiding pressures, BOO, and DI. The mechanism leading to the reduction of BC under these circumstances is largely unknown and could result from cytostructural alterations of the detrusor and changes in detrusor innervation.

Implantable microballoons: an attractive alternative in the management of intrinsic sphincter deficiency.

PURPOSE: All current bulking agents employed for treating stress urinary incontinence (SUI) have significant limitations due to various side effects, technical difficulties and inadequate long-term results. Implantable microballoons were therefore tested as a new therapeutic modality for female urinary incontinence. MATERIAL AND METHODS: The microballoons are implanted with a new system which consists of the self-detachable cross-linked silicone balloon, biocompatible filler material and a delivery system. Nineteen female patients (mean age 63.3 years) with SUI grade 1 or 2 were studied prospectively. Using the Blaivas-Olsson classification, 6 patients had stress incontinence type I, 4 had type II and 9 had type III. Three to seven balloons (mean 4.2) were implanted per patient. Patients were followed up with pad tests (g) and determination of leak point pressure (LPP; cm H2O) and maximal urethral closing pressure (Pura max; cm H2O) at 1, 3, 6, 12 and 18 months. RESULTS: The biocompatibility of the microballoons was excellent. No significant adverse events were associated with the procedure. With a mean follow-up of 14.4 months (range 10-18) 42.1% (8/19) of the women are dry. In the latter the pad test improved from a preoperative mean of 22.6 g (2-75) to 0 and the LPP increased from a preoperative mean of 38.5 cm H2O (25-60) to 80.5 cm H2O (68-106). 36.8% (7/19) of the patients showed significant improvement of their incontinence. In this group the pad test improved from a preoperative mean of 39.1 g (8-112) to 9.7 g (2-29) and LPP from a mean of 37.1 cm H2O (25-50) to 42.0 cm H2O (30-58). In 4 patients (21.05%) the technique failed. Seven of the 8 cured patients had type III incontinence; the eighth patient had type I incontinence. It failed in all patients with type II incontinence. CONCLUSION: The implantation of microballoons is a safe, well-tolerated and clinically effective modality for the treatment of type III SUI, i.e. intrinsic sphincter deficiency.

The aging lower urinary tract: a comparative urodynamic study of men and women.

OBJECTIVES: The fact that aging women report similar voiding symptoms as age-matched men prompted us to compare age-related changes of urodynamic parameters in both sexes. METHODS: Four hundred thirty-six patients (253 men and 183 women) 40 years of age or older underwent the following investigations: free uroflowmetry, measurement of postvoid residual volume, and full urodynamic testing, including a pressure-flow study (pQs). Additional investigations were a urethral pressure profile in women and quantification of prostate volume by transrectal ultrasonography in men. All men were referred for lower urinary tract symptoms suspicious of bladder outflow obstruction and women predominantly for urinary incontinence. Patients with previous surgery of the lower urinary tract (prostate, bladder, urethra) and those taking medication with a major effect on voiding function (alpha-receptor blockers, 5 alpha-reductase inhibitors, anticholinergic agents) were excluded. RESULTS: The mean +/- standard deviation (SD) age in the female (f) population (n = 183) was 59 +/- 16 years (range 40 to 93), in the male population (m) (n = 253) 67 +/- 9 years (range 40 to 90). In both sexes, we observed a statistically significant increase of postvoid residual volume (f: P = 0.0001; m: P = 0.02) and a decrease of peak flow rate (f: P = 0.019; m: P = 0.014), average flow rate (f: P = 0.007; m: P = 0.04), voided volume (f: P = 0.007; m: P = 0.002), and bladder capacity determined by urodynamics (f: P = 0.003; m: P = 0.0004) with progressing age. In both sexes, there were no age-related changes (P >0.05), demonstrable for maximum detrusor pressure and detrusor pressure at peak flow rate. In women, there was a significant decrease of functional urethral length (P = 0.012) and maximum urethral closing pressure (P = 0.0001) with higher age; in men, the prostate volume increased significantly with age (P = 0.0001). With respect to detrusor instability, we observed an increase in men from 23.4% (40 to 60 years) to 46.7% (more than 80 years) (P = 0.004), whereas in women no significant age-related changes were present (P >0.05). CONCLUSIONS: These data show that age-associated urodynamic changes in both sexes are comparable for a number of parameters. They provide an explanation for the fact that aging women report comparable voiding symptoms as men and suggest a primary, non-sex-specific aging process of the urinary bladder.

A 3,500-gram leiomyoma of the bladder: case report on a 3-year follow-up after surgical enucleation.

We report on a unique-sized large leiomyoma of the bladder wall in a male patient. After open surgical intervention all symptoms resolved spontaneously and no relapse occurred within a 3-year follow-up period. In conclusion, for symptomatic leiomyoma of the bladder surgical intervention should be considered as an early treatment option since it is associated with low morbidity, a high cure rate for this type of tumor and an immediate relief of urological symptoms.

The urodynamic impact of transrectal high-intensity focused ultrasound on bladder outflow obstruction.

OBJECTIVES: The aim of this study was to determine the urodynamic impact of transrectal high-intensity focused ultrasound (HIFU), which is presently evaluated as a minimally invasive treatment option for benign prostatic hyperplasia (BPH), on bladder outflow obstruction by means of pressure flow analyses. METHODS: A total number of 30 patients suffering from symptomatic BPH underwent pressure flow studies before and after transrectal HIFU (mean time interval: 4.5 months; range: 3-6 months). In parallel, the international prostate symptom score (IPSS), free flow and postvoid residual volume were determined at regular time intervals postoperatively. RESULTS: The IPSS decreased from preoperatively 15.8 +/- 5.9 (n = 30; mean +/- SD) to 6.9 +/- 4.4 at 3 months (n = 30) and 7.2 +/- 5 at 6 months (n = 30). Within the same time period the maximum uroflow (Qmax; ml/s) increased from 8.8 +/- 2.2 to 11.3 +/- 3.4 (3 months) and 12.1 +/- 3.6 (6 months) and the postvoid residual volume (ml) declined from 100 +/- 47 to 44 +/- 33 and 55 +/- 50, respectively. Pressure flow studies revealed a reduction of the minimal voiding pressure (cm H2O) from preoperatively 70 +/- 23 (mean +/- SD) to 51 +/- 22 (p < 0.005) postoperatively and a decline of the detrusor pressure at maximum flow (cm H2O) from 74.2 +/- 24 to 57 +/- 15 (p < 0.005). The linear passive urethral resistance relations (linear PURR) dropped from 3.7 +/- 1.1 to 2.2 +/- 1.2 (p < 0.005). According to the Abrams-Griffiths nomogram, 24 (80%) patients were classified preoperatively as obstructed, the remaining 20% as being in equivocal zone. Postoperatively, 13% were obstructed, 50% in the equivocal zone and 37% of patients were rated as obstructed. CONCLUSION: Transrectal HIFU is capable of improving objective and subjective BPH parameters as well as of decreasing the degree of bladder outflow obstruction.