The value of cystoscopy in major vaginal surgery.

This article reviews the case histories of 236 patients who had cystoscopy as part of their major vaginal operations. Seven had cystoscopically detected potential lower urinary tract injuries. Five of these injuries were ureteral obstructions, one occurring after anterior repair, three associated with a McCall culdoplasty, and one associated with a modified Pereyra bladder neck suspension. Two injuries were subtle cystotomies. These compromises of the lower urinary tract were detected during the main operative procedure and immediately rectified. We propose that routine intraoperative cystoscopy associated with intravenous administration of indigo carmine is an excellent method for detecting actual and potential lower urinary tract surgical injury. Cystoscopy cannot distinguish which surgical distortion or injury will spontaneously resolve. The identification of non-blood-tinged urine from both ureteral orifices and the absence of bladder trauma should eliminate the possibility of lower urinary tract surgical injury, except for ischemic necrosis. Cystoscopy, like laparoscopy, is a procedure that should benefit our patients and should not isolate a specialty.

Use of a surgical sponge facilitates rib resection in flank incisions.

Dissection of the rib in a flank incision is often tedious and difficult. Entry into the pleural space and subcostal nerve injury are two frequent complications. In an effort to reduce the frequency of these complications and to facilitate the ease of rib dissection and resection, we describe a technique that uses a moistened surgical sponge to dissect free the posterior surface of the rib.

Osteomyelitis secondary to an osteoenteric fistula.

Osteomyelitis involving the symphysis pubis is a rare complication of pelvic surgery, and differentiation with osteitis pubis may be difficult. Herein we present a case of a patient in whom a disabling public pain developed 4 months after a radical cystectomy for bladder cancer. His pain was unresponsive to medical and antibiotic therapy and subsequently proved to be caused by public osteomyelitis secondary to a small-bowel fistula precipitated by cancer recurrence.

Renal vein thrombosis presenting as renal mass.

The excretory urogram of patients with acute renal vein thrombosis typically demonstrates symmetric enlargement of the involved kidney. We report a case of renal vein thrombosis that presented as a discrete renal mass on excretory urography and abdominal computerized tomography. The entity of renal vein thrombosis is briefly reviewed along with the computerized tomography findings seen in this setting.

Use of the Cobb-Ragde needle in pubovaginal sling surgery.

The use of the suburethral sling in the treatment of intrinsic sphincter deficiency has grown in popularity and acceptance. The technique of pubovaginal sling surgery with the use of the Cobb-Ragde needle is described. This method combines the familiar use of the urethropexy suspension needle with the simplicity of the transvaginal approach.

Valsalva leak-point pressure changes after successful and failed suburethral sling.

The aim of the study was to investigate whether changes in Valsalva leak-point pressure (VLPP) relate to the success of suburethral sling operations. We retrospectively reviewed the medical records of 31 suburethral sling operations in 30 women with stress urinary incontinence in whom VLPP was quantified before and after the operation. Operative success was determined by documented physical examination and telephone interview. The patients' mean age was 70.7 years (range 51-81). The operation was successful in 24 cases and unsuccessful in 7. VLPP increased significantly after successful operations (mean change 61.1 cmH(2)O; P<0.001) but not after failure (9.7 cmH(2)O); P = 0.226), with a significantly greater change for successful operations ( P = 0.0011). All patients with postoperative VLPP >126 cmH(2)O had successful operations. We concluded that there are significant increases in VLPP after successful suburethral sling operations, but not after unsuccessful operations.

Complications and initial continence rates after a repeat pubovaginal sling procedure for recurrent stress urinary incontinence.

PURPOSE: We evaluated the safety and efficacy of repeat pubovaginal sling procedures for recurrent stress urinary incontinence. MATERIALS AND METHODS: We retrospectively reviewed the records of 14 patients in whom an initial suburethral sling procedure failed, who then underwent a repeat pubovaginal sling procedure for recurrent stress urinary incontinence at our institution and who were available for followup evaluation. Mean followup after re-operation was 17 months (range 5 to 41). The response to surgery was assessed using the Blaivas-Groutz anti-incontinence surgery response score. RESULTS: There were no intraoperative complications. Mean blood loss was 155 cc (range 50 to 750) and average operative time was 101 minutes (range 80 to 145). Long-term urinary retention developed in 1 of the 14 patients (7%). There were no deaths. Two patients (14%) had postoperative complications, including a pelvic abscess and osteomyelitis pubis in 1 each. Based on the Blaivas-Groutz anti-incontinence scale 7 of the 14 patients (50%) were cured, 1 (7%) had a good response, 4 (29%) had a fair response, 2 (14%) had a poor response and none had treatment failure. Subjectively 12 of the 14 women (86%) considered themselves cured or improved and 2 (14%) considered the operation to have failed. CONCLUSIONS: Our data imply that a repeat pubovaginal sling procedure after an initial failed operation is associated with low complication and acceptable continence rates. It should be considered a reasonable treatment option in select women with recurrent stress urinary incontinence.

Valsalva leak point pressure and bladder volume.

Twenty-nine females with stress urinary incontinence (SUI) were evaluated with fluorourodynamics, including Valsalva leak point pressure (VLLP) determinations. VLPP was determined at bladder volumes of 150 ml, 300 ml, and total bladder capacity. The VLPP determinations were analyzed using the signed rank and sign tests. Fluoroscopy was used to analyze change in type of SUI based on bladder volume. No significant difference in VLPP determinations was noted at various bladder volumes. No change in type of SUI was noted at various bladder volumes. We believe the volume in the bladder does not alter the category of SUI or statistically change the VLPP determination.

VLPP in the evaluation of the female with stress urinary incontinence.

The Valsalva leak-point pressure has become an important urodynamic test in the evaluation of incontinent women. A review of the history of the test, its methodology, and variables that can influence its performance is presented. Correlation with clinical findings, reproducibility and comparison with other urodynamic tests are discussed. Although the test is still evolving and several major variables have been recognized as affecting its results, it remains sound and reliable. It has excellent correlation with the clinical severity of incontinence and a high degree of inter- and intraexaminer reproducibility.

Urological assistance during therapeutic pubectomy.

PURPOSE: A technique is described to optimize exposure during female pubectomy to minimize injury to associated urological structures. MATERIALS AND METHODS: Three females with diagnosed osteomyelitis pubis underwent pubectomy. Before resection of the bone, the patients underwent a formal combined transvaginal and retropubic dissection. This dissection allowed complete freeing of the urethra and bladder from areas of orthopedic resection and optimized surgical exposure. RESULTS: All operations were completed successfully with no incidence of intraoperative urological structure injury and no postoperative pelvic instability. None of the patients required intraoperative or postoperative blood transfusions. Pelvic pain resolved in all 3 patients. CONCLUSIONS: Using a combined transvaginal and retropubic technique, the urologist may assist the orthopedic surgeon at the time of pubectomy. This technique potentially minimizes the incidence of vesical and urethral injury.

Transitional cell carcinoma of the kidney with vena caval involvement: report of 3 cases and a review of the literature.

Vena caval tumor thrombus in association with transitional cell carcinoma of the kidney is uncommon, with only 9 cases having been reported to our knowledge. We report 3 additional cases and review this subject with particular attention to symptoms, radiographic evaluation and the importance of early diagnosis.

Suprameatal transvaginal urethrolysis.

PURPOSE: We describe and assess a method of urethrolysis using a transvaginal suprameatal approach without lateral perforation of the urethropelvic ligament. MATERIALS AND METHODS: Between March 1993 and December 1997, 32 consecutive women 32 to 79 years old underwent suprameatal transvaginal urethrolysis at 2 institutions. In all cases anti-incontinence surgery was done previously, including a pubovaginal sling procedure in 12, Marshall-Marchetti-Krantz procedure in 8, Burch colposuspension in 6, modified Pereyra transvaginal urethropexy in 4, and Gittes suspension and anterior repair in 1 each. Of the 32 patients 20 were in urinary retention and 12 had primarily urge and/or irritative voiding symptoms, or urge incontinence. In the patients in urinary retention average maximal detrusor pressure was 41.4 cm. water. In all cases physical examination, cystourethroscopy and video urodynamics were done before suprameatal transvaginal urethrolysis. Obstruction was defined as detrusor pressure greater than 20 cm. water at maximum urinary flow of less than 12 ml. per second. Urethral obstruction was presumed when examination revealed urethral angulation, tethering, narrowing or scarification. Impaired detrusor contractility was diagnosed when detrusor pressure at maximum urinary flow was less than 20 cm. water at maximum urinary flow of less than 12 ml. per second. RESULTS: After suprameatal transvaginal urethrolysis 13 of the 20 women (65%) in urinary retention voided well and in 8 of the 12 (67%) with urgency symptoms resolved. Postoperative stress urinary incontinence developed in only 1 case. CONCLUSIONS: The success rate of suprameatal transvaginal urethrolysis to treat urinary obstruction associated with anti-incontinence procedures compares favorably to that of other described alternative approaches. The success rate in patients with definite urodynamic criteria for obstruction was not significantly better than in those who underwent suprameatal transvaginal urethrolysis based on physical examination and clinical judgment. Preoperative maximal urinary flow rate was associated with operative success (p = 0.018), while preoperative post-void residual urine and maximum detrusor pressure failed to reveal a difference between operative success and failure.

Radiographic imaging of the artificial urinary sphincter pressure regulating balloon.

PURPOSE: Radiography of the artificial urinary sphincter is done for the postoperative evaluation of recurrent incontinence. We investigated the ability of urologists and radiologists to detect changes in the radiographic appearance of the pressure regulating balloon at various volumes of contrast solution. MATERIALS AND METHODS: We obtained 20 sequential radiographs of a pressure regulating balloon lying atop the pelvic region of a body phantom. The volume of contrast solution within the balloon was decreased by 1 cc in each radiograph from 20 to 1 cc. Urologists and radiologists examined the radiographs for changes in balloon size, density and circularity. Radiographs were reviewed in side-by-side comparison with a baseline radiograph and also independently without reference to baseline study. RESULTS: On side-by-side comparison changes in balloon size, density and circularity were first seen at 17, 13 and 8 cc of contrast solution, respectively. On independent review changes in size, density and circularity were first seen at 10, 8 and 6 cc, respectively. CONCLUSIONS: If there are no contraindications, contrast solution should be used to fill the balloon component of the artificial urinary sphincter system. Immediately after implantation a baseline radiograph should be obtained. Without a baseline film for comparison radiographic imaging of the balloon does not detect changes until at least 50% of its volume has been lost. Because comparison imaging is invaluable for detecting volume loss, a radiograph should be obtained immediately after initial placement of the artificial urinary sphincter.

Systematic transperineal ultrasound guided template biopsy of the prostate in patients at high risk.

PURPOSE: A negative biopsy result does not necessarily equate with cancer in specific high risk groups. We describe an alternative systematic biopsy technique for evaluating this subgroup of patients. MATERIALS AND METHODS: From March 1997 to May 1999 a total of 88 men underwent systematic ultrasound guided biopsy using the transperineal template technique. All patients had undergone at least 1 and 75 (85%) had undergone 2 or more previous sets of biopsies. In addition, study inclusion required high risk parameters, including prostate specific antigen (PSA) velocity greater than 0.75 ng./ml., PSA greater than 10 ng./ml. or previous prostatic intraepithelial neoplasia on biopsy, and/or atypical small cell acinar proliferation. RESULTS: Cancer was identified in 38 of the 88 men (43%) in this high risk subgroup undergoing repeat biopsy. A mean of 15.1 previous biopsy cores had been obtained. The most common biopsy grade was 6 (range 4 to 9). Adenocarcinoma was identified in the transition zone area in 29 of 38 cases (76%), including 15 (39%) in which disease was detected in the transition zone only. Persistent PSA acceleration greater than 0.75 ng./ml. was the major indicator for transperineal template biopsy in 83 of the 88 patients (94%). The only significant independent variable predictive of positive biopsy was prostate volume. Mean prostate volume in the positive and negative biopsy groups was 48 and 73 gm., respectively (p <0.001). Complications were rare and self-limiting, consisting primarily of hematuria and urinary retention requiring overnight catheterization in 2 patients. CONCLUSIONS: Systematic transperineal template biopsy of the prostate is a safe and precise repeat biopsy technique in patients who remain at high risk for adenocarcinoma.