Tension-free vaginal tape and percutaneous vaginal tape sling procedures.

PURPOSE: Midurethral synthetic sling procedures for treatment of stress urinary incontinence (SUI) are gaining increased attention from surgeons specializing in female pelvic reconstructive techniques seeking successful patient outcomes through reproducible simplicity. This report describes the procedural steps and methods used to maximize the potential for successful outcomes using techniques of midurethral synthetic sling placement. Reported complications and surgical outcomes are reviewed with respect to patient selection and minimizing the potential for morbidity and mortality as long-term clinical experience is accumulated. MATERIALS AND METHODS: Tension-free vaginal or transvaginal tape (TVT) and the recently introduced percutaneous vaginal tape (PVT) are two new procedural choices for placement of synthetic sling material at the midurethra. Both procedures use sling material composed of polypropylene mesh, a nonabsorbable synthetic material, placed at the level of the midurethra via an antegrade (PVT, using a percutaneous ligature carrier) suprapubic approach or retrograde (TVT, using vaginal trocars) vaginal approach. Patient selection, procedural techniques, and methods described are based on observations obtained or reported from clinical experience. Outcomes and complications for TVT are derived from a literature review of all published articles in Index Medicus from 1996 to 2000. RESULTS: The experience with TVT for the last 5 years is encouraging. At 3-year follow-up for TVT, reported cure rates for SUI range from 80% to 95%. A multitude of worldwide reports on PVT with shorter follow-up support the findings of the TVT experience. Reproducible findings with midurethral synthetic slings are the short operative times recorded for the sling procedure, ease of technical performance, minimal patient discomfort, and a high rate of early return of normal voiding function. The rate of complications such as obstructive voiding or de novo instability (0-15%) and urinary retention necessitating a secondary procedure (2-4%) appear to be equal to the rates of contemporary competing technologies and procedures for treatment of SUI. CONCLUSIONS: Preliminary reports and the experience at our institution suggest that the techniques of midurethral synthetic sling placement of TVT and PVT are reproducible, easy to master, and minimally invasive with respect to tissue handling. Although complications with all anti-incontinence procedures exist, understanding the anatomical considerations and methodology of these unique procedures should minimize patient morbidity, avoid patient mortality, and produce a high rate of durable success.

Bone anchor infections in female pelvic reconstructive procedures: a literature review of series and case reports.

PURPOSE: We determined the reported prevalence of infectious osseous complications due to the use of bone anchors for suture fixation in female pelvic reconstructive procedures. In addition, the type and method of bone anchors as well as the reported pathogens associated with osseous infections were reviewed. MATERIALS AND METHODS: Primary reported series of female pelvic reconstructive procedures involving bone anchor suture fixation referenced in Index Medicus from January 1990 to July 2000 were extracted using the MEDLINE bibliographic database on English language articles involving humans. All case reports of infectious osseous complications due to bone anchor use in female reconstructive procedures were also reviewed during this period. RESULTS: Since the inception of bone anchor suture fixation for female pelvic reconstructive procedures 10 years ago, the overall prevalence of related infectious complications has been 6 cases in 1,018 procedures (0.6%). This type of adverse event developed between followup weeks 1 and 24. The prevalence of suprapubic bone anchors has been 6 cases in 698 procedures (0.86%). For transvaginal bone anchor procedures no infectious cases have been reported in the combined series of 314 procedures and the same is true for 1 reported case of sacral bone anchor placement in 6 procedures. No statistical difference was noted in regard to the prevalence of infection in procedures involving suprapubic bone anchors and transvaginal bone anchor combined with sacral bone anchor placement (Fisher's exact test p = 0.19). The organisms reported in case reports suggest a coliform, skin or hematogenous source for contamination of the bone anchor site. CONCLUSIONS: An infectious bone anchor complication in female pelvic reconstructive procedures is an uncommon event with a reported prevalence of 0.6%. Currently there is no evidence of differences in the prevalence of osseous complications after transvaginal versus suprapubic bone anchor fixation. Preoperative broad-spectrum antibiotics are recommended to decrease the potential of infectious bone anchor complications.

Use of collagen for the treatment of stress urinary incontinence: an update.

This article provides a comprehensive and updated overview of the current role of collagen injections in the management of genuine stress incontinence. The clinical indications for collagen injection are described, and relevant technical advances are discussed. Finally, we review the latest outcome data on the use of collagen injection, as well as the factors that affect outcome.

Collagen injection for the treatment of incontinence after cystectomy and orthotopic neobladder reconstruction in women.

PURPOSE: We determine the clinical efficacy of endoscopically injected collagen for the treatment of new onset urinary incontinence in women following cystectomy and orthotopic neobladder. MATERIALS AND METHODS: Three women 58 to 74 years old underwent transurethral collagen injection for stress urinary incontinence following cystectomy and orthotopic neobladder. Before cystectomy 2 women denied having any stress urinary incontinence while 1 complained of mild incontinence. Onset of incontinence following cystectomy and neobladder formation ranged from 8 months to 3 years, and average pad use ranged from 3 to 5 per 24-hour period. All patients underwent video urodynamic evaluation before collagen injection. Neobladder capacity was 180 to 400 cc and Valsalva leak point pressures ranged from 30 to 60 cm. water. RESULTS: A total of 6 injections were given, including 3 injections in 1 patient, 2 in 1 and 1 in 1. All 3 women had significant improvement or became dry with initial injection but required repeat injections to maintain improved continence status. At 7 to 8 months after the last injection 1 woman was dry, 1 used 1 or no pad daily and 1 reported no durable change in stress urinary incontinence. CONCLUSIONS: Collagen injection appears to be a successful, minimally invasive treatment for new onset stress urinary incontinence following cystectomy and orthotopic neobladder in women.

Hand-assisted laparoscopic live donor nephrectomy.

Minimally invasive live donor nephrectomy has been described using both standard laparoscopic dissection and "gasless" endoscopically assisted techniques. We report another method, hand-assisted laparoscopic live donor nephrectomy, which uses an occlusive sleeve to maintain pneumoperitoneum. The procedure is performed under excellent laparoscopic visualization in a generous operative field, and is facilitated substantially by manual assistance, which takes advantage throughout the procedure of the incision that is necessary for intact organ removal. The results of our first procedure are encouraging.

Postsurgical changes in the testis: a diagnostic dilemma.

Postsurgical changes in the testicle following epididymal surgery may mimic neoplastic transformation on ultrasound evaluation. We report a case in which postoperative ultrasound findings following epididymectomy, which in retrospect were consistent with tubular ectasia of the rete testis, resulted in unnecessary testicular biopsy and orchiectomy.

The effect of prostatitis, urinary retention, ejaculation, and ambulation on the serum prostate-specific antigen concentration.

PSA remains an immensely valuable tool in the diagnosis of prostate adenocarcinoma. Factors such as prostatitis, urinary retention, ejaculation, and inpatient versus outpatient measurement, however, may have a profound effect on the serum PSA concentration. Furthermore, prostate biopsy and TURP result in an increase in the serum PSA value that resolves in 4 to 6 weeks. It is imperative that these factors be taken into account to interpret serum PSA values, to optimize the diagnostic utility of the PSA test.

Ejaculation increases the serum prostate-specific antigen concentration.

OBJECTIVES: To determine the effect of ejaculation on the serum prostate-specific antigen (PSA) concentration in men at risk for developing prostate cancer. METHODS: A prospective, community-based study was conducted in which 64 men, aged 49 to 79 years, underwent a serum PSA determination immediately before ejaculation (baseline) and at 1 hour, 6 hours, and 24 hours following ejaculation. The serum PSA also was measured 48 hours and 1 week after ejaculation if the concentration had not returned to the baseline value by the previous time interval. All subjects abstained from ejaculation for a minimum of 7 days prior to the study and until the PSA concentration returned to the baseline level. Absolute and relative change in serum PSA concentration, as well as the time to return to baseline PSA concentration following ejaculation, were assessed. RESULTS: The serum PSA concentration increased following ejaculation in 87% of the subjects. The mean baseline PSA was 1.8 ng/mL (median, 0.7 ng/mL). The mean absolute PSA change +/- standard deviation 1 hour, 6 hours, 24 hours, and 48 hours after ejaculation was 0.8 +/- 1.32 ng/mL, 0.3 +/- 0.66 ng/mL, 0.2 +/- 0.33 ng/mL, and 0.4 +/- 0.40 ng/mL, respectively. The mean relative PSA change +/- standard error 1 hour, 6 hours, 24 hours, and 48 hours after ejaculation was 41 +/- 4%, 9 +/- 1.5%, 8 +/- 1.3%, and 10 +/- 2.3%, respectively. The absolute and relative changes in PSA concentration noted 1 hour, 6 hours, and 24 hours after ejaculation were statistically significant (P = 0.0001). A strong correlation was observed between absolute change in PSA and baseline serum PSA, at each time interval (1 hour: r = 0.68, 6 hours: r = 0.77, 24 hours: r = 0.70; P < 0.0001) after ejaculation. Similarly, a significant correlation was noted between absolute change in PSA and patient age at each time interval (1 hour: r = 0.37, 6 hours: r = 0.38; P = 0.002, 24 hours: r = 0.55; P < 0.0001). Ninety-two percent of subjects returned to baseline by 24 hours (95% confidence interval (Cl) = 83% to 97%), whereas 97% of subjects returned to baseline by 48 hours (95% Cl = 89% to 99%). CONCLUSIONS: Ejaculation causes a significant increase in the serum PSA concentration in men between 49 and 79 years of age that may persist for up to 48 hours. This change appears to correlate with age and baseline PSA. It is recommended that men abstain from ejaculation for 48 hours prior to having a serum PSA determination.

The role of prostate-specific antigen in the evaluation of benign prostatic hyperplasia.

This article reviews the role of prostate-specific antigen (PSA) in the evaluation of BPH. Efficacy of the PSA test in differentiating patients with BPH from patients with early, potentially curable prostate cancer is discussed. In addition, this complete overview provides a critical analysis of various concepts (PSA density, PSA velocity, age-specific reference ranges, and free versus complexed serum PSA), that are devised to optimize the diagnostic value of the serum PSA concentration in a population in which prostate cancer and BPH are almost equally prevalent. A clinical algorithm, useful to the practicing clinician for the early detection of prostate cancer in the BPH patient, is also proposed.

Homologs of genes and anonymous loci on human chromosome 13 map to mouse chromosomes 8 and 14.

To enhance the comparative map for human Chromosome (Chr) 13, we identified clones for human genes and anonymous loci that cross-hybridized with their mouse homologs and then used linkage crosses for mapping. Of the clones for four genes and twelve anonymous loci tested, cross-hybridization was found for six, COL4A1, COL4A2, D13S26, D13S35, F10, and PCCA. Strong evidence for homology was found for COL4A1, COL4A2, D13S26, D13S35, and F10, but only circumstantial homology evidence was obtained for PCCA. To genetically map these mouse homologs (Cf10, Col4a1, Col4a2, D14H13S26, D8H13S35, and Pcca-rs), we used interspecific and intersubspecific mapping panels. D14H13S26 and Pcca-rs were located on the distal portion of mouse Chr 14 extending by approximately 30 cM the conserved linkage between human Chr 13 and mouse Chr 14, assuming that Pcca-rs is the mouse homolog of PCCA. By contrast, Cf10, Col4a1, Col4a2, and D8H13S35 mapped near the centromere of mouse Chr 8, defining a new conserved linkage. Finally, we identified either a closely linked sequence related to Col4a2, or a recombination hot-spot between Col4a1 and Col4a2 that has been conserved in humans and mice.