Relationship of symptoms of prostatism to commonly used physiological and anatomical measures of the severity of benign prostatic hyperplasia.

In previous studies the severity of symptoms of prostatism in men with benign prostatic hyperplasia have not correlated well with prostate size, degree of bladder trabeculation, uroflowmetry or post-void residual volume. As part of a prospective cohort study of benign prostatic hyperplasia treatment effectiveness in 4 university-based urology practices, we correlated symptom severity and these commonly used measures of disease severity. Symptom severity was quantified using the American Urological Association symptom index. Analyses were based on 198 outpatients completing a standardized evaluation (84 of these men have completed 6 months of followup after treatment with prostatectomy, balloon dilation, terazosin or watchful waiting). At baseline, symptom severity was not correlated with uroflowmetry, post-void residual, prostate size and degree of bladder trabeculation. However, symptom severity was much more strongly related to overall health status than the other measures. Reduction in symptoms with treatment did correlate with improvements in uroflowmetry. This poor baseline correlation with symptoms may reflect unreliability in measurement of the physiological/anatomical variables. Alternatively, these parameters may be measuring different pathophysiological phenomena.

Use of glycosylated hemoglobin to identify diabetics at high risk for penile periprosthetic infections.

We report an 18-month prospective study of 90 patients undergoing penile prosthesis implantation to evaluate a possible cause-and-effect relationship between degree of diabetic control and the risk of infection complicating the operation. Long-term diabetic control was objectively evaluated by measurement of the glycosylated hemoglobin of the patient, which is known to provide an objective value for degree of control for the preceding 60 to 90 days. Of 90 patients 5 (5.5%) had a periprosthetic infection requiring explantation and all infections occurred in the 32 diabetics (36%) in the population (p less than 0.009). Of the 32 diabetics 13 (41.1%) were poorly controlled with time as demonstrated by a glycosylated hemoglobin level of greater than 11.5% and 4 of the infections occurred in this group. Of the 19 remaining controlled diabetics (glycosylated hemoglobin level less than 11.5%) only 1 infection occurred. Therefore, infection occurred in 31% of the poorly controlled versus 5% of the adequately controlled patients (p less than 0.0003). Measurement of glycosylated hemoglobin values appears to be a useful tool to evaluate diabetic patients before implantation of a penile prosthesis. Patients with a glycosylated hemoglobin level of 11.5% or greater should be more optimally controlled before undergoing implantation in an effort to avoid infectious complications.

Acute urinary retention associated with prostatic carcinoma.

We describe the prospective evaluation of 90 patients seen at 2 medical centers who presented with acute urinary retention. All patients had a pre-retention history obtained, as well as careful prostate examination, perineal prostate biopsy and followup treatment or monitoring. Prostate cancer was found in 12 of the 90 patients (13.3 per cent), while 1 had metastatic leukemia to the prostate. Of the 90 patients 69 (76.7 per cent) had a palpably benign prostate and 2 malignancies (2.9 per cent) were diagnosed, while 11 malignancies occurred in 21 patients (52.4 per cent) with a suspicious examination. A total of 46 patients (51.1 per cent) underwent further prostate resection and no malignancy was found in any of these specimens: 43 underwent transurethral resection (24.9 gm. average), while 3 underwent open prostatectomy (97 gm. average). Other etiologies of acute retention included benign hyperplasia, other underlying illness, medical procedures, medications, prostatitis and prostatic infarction. Among the 44 patients who did not undergo prostatectomy 13 had treatment of the diagnosed cancer, 9 had resolution of retention and symptoms without intervention, 9 remained catheterized due to severe medical problems, 8 were treated for prostatitis, 2 had discontinuation of sympathomimetic drugs and 1 each underwent urethrotomy, bladder neck incision and resolution of prostatic infarction. In contrast to the older literature in which approximately 25 per cent of the patients presenting with acute urinary retention had prostate cancer, our data suggest a lower incidence. Prostatic biopsy for patients who present with acute urinary retention and a benign examination does not appear to be justified.

Urethroplasty management in 100 cases of urethral stricture: a rationale for procedure selection.

We performed 100 urethroplasties for urethral strictures that fulfilled our criteria for surgical intervention. Strictures were located in the pendulous urethra in 14 cases, bulbar urethra in 33 and membranous urethra in 32, while the entire urethra or multiple adjacent areas were strictured in 21. The etiology of the strictures was traumatic in 47 patients and inflammatory in 22, and no cause was identified in 31. One-stage repairs were performed in 76 cases. Anastomotic repairs were optimal for short traumatic strictures, with 1 failure among 29 cases. Full thickness skin graft repairs were performed for more lengthy inflammatory strictures in 34 cases, with 5 failures. Mitigating against success in these patients were extrapenile skin donor sites, tubed grafts and poor graft beds. Vascularized island flap repairs were performed in 13 patients with 1 failure but there was an associated problem of redundant repairs. Two-stage repairs were reserved primarily for long or multiple strictures, with 2 failures in 24 cases. We conclude that procedure selection should be determined by stricture characteristics, including location, etiology, length and the presence of local adverse factors. An over-all rate free of stricture of 91 per cent was achieved.

Urethrovaginal fistula: a review of the surgical management.

Urethrovaginal fistulas may occur after external or surgical trauma and result commonly in urinary incontinence. Various repair procedures have been suggested. However, it appears that the Martius operation with labial fat pad interposition between the repaired urethra and vagina is as satisfactory as any.

Troubleshooting the malfunctioning Scott artificial urinary sphincter.

A rational approach to problems with the Scott artificial urinary sphincter is presented, which includes preoperative radiographic, endoscopic and urodynamic studies, and intraoperative electrical testing of device integrity and pressure/volume characteristics of the system.