[Preoperative cystometric analysis of benign prostatic hyperplasia--special reference to the natural history and postoperative outcomes].

Four hundred and thirty-seven patients with benign prostatic hyperplasia selected for elective prostatectomy underwent preoperative cystometry. Of these patients 263 (60.2%) had bladder instability, who tended to be more irritative and more obstructive in their preoperative objective assessment than the others. Forty-seven patients (12.5%) revealed vesical denervation supersensitivity, of these patients all but one had bladder instability. Significant correlation was found between occurrence of the bladder dysfunction and the severity of obstruction. The occurrence of both bladder dysfunction developed with age. Four hundred and fourteen patients (94.7%) had successful outcome in voiding postoperatively, but elderly patients with low bladder compliance and severe emptying failure tended to need several months in their recovery. Postoperative incontinence was found in 100 patients (22.9%) with high incidence of preoperative bladder instability in the early phase, but was reduced in most cases 6 months later. Eighteen prolonged incontinent cases showed high incidence of low bladder capacity and low compliance with instability at preoperative cystometry. In these cases, the incidence of elderly patients was higher than that of dry cases. It is concluded that most of these bladder dysfunction is secondary to the infravesical obstruction which depends upon severity and duration of the disease, but aging also appears to play a role in its appearance. We assume that detrusor instability represents a kind of compensation for infravesical obstruction, and that the development of denervation supersensitivity indicates that the bladder damage is severely progressing.

[Urethral opening pressure: its clinical significance in prostatic obstruction].

BACKGROUND: In the evaluation of prostatic obstruction by using the pressure-flow study (PFS), we defined intravesical pressure at initiation of voiding as urethral opening pressure. This simple parameter could reflect the degree of compressive prostatic obstruction to some extent. The aim of this study is to analyze if a correlation exsists between clinical signs and urethral opening pressure, and if they bear any prognostic value in postoperative outcome of the patients. METHODS: We analyzed 46 patients with clinical benign prostatic hypertrophy who underwent urodynamic evaluations including PFS. They were divided into 2 groups according to their urethral opening pressure. The high opening pressure was defined as greater than 70 cm water, which was noted in 24 patients (group A). Twenty-two patients had lower opening pressure (group B). Comparison of the clinical findings in these patients were reviewed. Medium-filling cystometry and PFS were performed transurethrally, by using a microtip transducer and rectal balloon. Cystoscopy was performed when possible, wherein we could examined the presence or absence of detrusor trabeculation. Transurethral prostatectomy was indicated in a total of 26 patients (16 in group A and 10 in group B), in whom postoperative clinical findings were analyzed with regard to the difference in preoperative urethral opening pressure. The patients who void with straining or who void following uninhibited detrusor contraction were excluded from this study. RESULTS: International Prostatic Symptoms Score (I-PSS) revealed no significant difference in both groups, however, patients in group A were often suffering from urge incontinence preoperatively. Significant correlation was found among the incidence of detrusor instability, detrusor trabeculation and increased opening pressure. In PFS the patients with high opening pressure tended to have higher detrusor pressure at maximum flow and greater contractile power of the detrusor in voiding. There were no difference in Qmax and residual volume both groups. Postoperatively, symptomatic improvement was significant in both groups. There was no statistical difference in postoperative I-PSS between group A and B. Although 6 patients in group A demonstrated poor urinary control at 1 month, only two patients remained incontinent at 6 months postoperatively. As to urodynamic findings, the difference in PFS were markedly reduced between both groups. No difference was noted in postoperative Qmax as well. CONCLUSION: Significant difference was found in preoperative objective findings except the flow rate between the patients with and without high urethral opening pressure, while no symptomatic difference was noted except urege incontinence in both groups. No prognostic value was demonstrated in urethral opening pressure, however, poor postoperative urinary control was often associated with initial high opening pressure in the short term. It was suggested that 1) compensatory detrusor hyperactivity improved voiding efficacy in the patients with prostatic obstruction, which was gradually normalized after the relief of obstruction, 2) symptomatic improvement was highly related to the relative improvement of the obstructive findings on PFS.

[One-stage-bilateral adrenalectomy by thoracoabdominal approach for bilateral large pheochromocytomas in men type IIa. A case report].

We experienced a case of MEN type 2a with bilateral and large pheochromocytomas. A 39-year-old man was admitted to the previous hospital with complaints of paroxysmal headache. hypertension and diabetes mellitus. Radiographic imagings showed thyroid tumors in both lobes and bilateral adrenal tumors. Thyroid tumors were histologically proved to be medullary thyroid carcinoma by needle biopsy and systemic investigations revealed an excessive secretion of plasma and urinary cathecholamines which suggested the presence of pheochromocytoma. The patient was diagnosed as MEN type 2a. He was admitted to our hospital for the treatment of bilateral adrenal tumors for which we performed one-stage bilateral adrenalectomy by thoracoabdmonal approach. Both adrenal tumors were histologically confirmed as pheochromocytoma. The patient's postoperative course was uneventful. He underwent uneventful total thyroidectomy approximately 2 months after bilateral adrenalectomy. Even in bilateral and large pheochromocytomas, one-stage bilateral adrenarectomyenables safe postoperative managements. We concluded that the thoracoabdominal approach is feasible in the patients with huge and cranially spreading adrenal tumor, which gives us a wide operative field for easy vascular control.

[Endourology update].

In urology, endoscopic surgery and laparoscopic surgery are generally named as endourology. Transurethral endoscopic surgery was originated in mid 19th century, and established by 1950s. At present, transurethral resection of the prostate, transurethral resection of the bladder tumor, transurethral incision of the urethral stricture, transurethral vesicolithotripsy, and transurethral ureterolithotripsy, were commonly performed in many urological clinics. Percutaneous nephrolithotripsy and extracorporeal shock wave lithotripsy were introduced in 1980s, and now, open operation for urolithiasis are rarely performed. In 1990s, as a new endourologic procedure, laparoscopic operations are being increasingly applied to the treatment of urological diseases; for example, laparoscopic pelvic lymphadenectomy, laparoscopic varicocelectomy, laparoscopic exploration of non-palpable testis, laparoscopic nephrectomy, and laparoscopic adrenalectomy etc. Of the variety of treatment modalities available, the most effective and least invasive method should be selected appropriately. So, we anticipate the further advancement in minimally invasive therapy, interdependently with our sufficient experience and skills.

Feasibility of urodynamic study (combined cystometry and electromyography of the external urethral sphincter) under general anesthesia in children.

BACKGROUND: To assess the feasibility of urodynamic study under general anesthesia (GA) we performed electromyography of the external urethral sphincter (EUS-EMG) on 73 children and cystometry (CM) alone on 10 children. METHODS: Subjects were divided into 3 groups. Those in groups I and II were suspected of having voiding dysfunction with (group I) or without (group II) overt neurospinal defects, while those in group III were thought to be functionally normal. EUS-EMG was performed under light anesthesia following cystourethroscopy to examine structural abnormalities. Atropine sulfate premedication was not used for the anesthetic procedure; muscle relaxants were used only for tracheal intubation. RESULTS: Voiding was observed in 83% of the patients. Among patients who voided, detrusor-external sphincter dyssynergia (DSD) was noted in 7 (38%) group I patients and 6 (19%) group II patients; in group III, voiding was synergic in all patients. In 10 cases, CM alone was carried out both under anesthesia and in the waking state; anesthesia suppressed detrusor hyperreflexia (DH) in all 9 patients but produced no change in bladder compliance. CONCLUSIONS: In children with urinary disorders, urodynamic study under GA following cystourethroscopy is a feasible method for assessing EUS function and documenting DSD; DH is not evaluable, however. Stratifying urinary management on the basis of these examinations resulted in satisfactory clinical outcomes.

Detrusor contraction duration as a urodynamic parameter of bladder outlet obstruction for evaluating men with lower urinary tract symptoms.

PURPOSE: Recent studies suggest that detrusor contraction duration increases with bladder outlet obstruction and correlates with the American Urological Association (AUA) symptom index. Since the detrusor contraction duration may also depend on detrusor contractility and bladder volume, its use alone in characterizing bladder outlet obstruction is debatable. Therefore, we studied the relationship between detrusor contraction duration and bladder outlet obstruction, bladder capacity, detrusor contractility and symptoms to determine whether detrusor contraction duration is a useful parameter for characterizing bladder outlet obstruction in men with lower urinary tract symptoms. MATERIALS AND METHODS: Pressure-flow studies were performed in men with lower urinary tract symptoms. Bladder outlet obstruction was defined as passive urethral resistance relation greater than grade II and contractility was determined from Schäfer's nomogram. Detrusor contraction duration was defined as the contraction time elapsed between the first rise in detrusor pressure from baseline to the time at which detrusor pressure returned to baseline at the end of voiding. AUA symptom index was attained from each patient and categorized as mild (0 to 7), moderate (8 to 19) and severe (20 to 35). RESULTS: Detrusor contraction duration was determined from 58 consecutive pressure-flow studies. This parameter was not significantly different among 23 patients with mild (116.7+/-34.0 seconds), 15 with moderate (102.7+/-61.9 seconds) and 9 with severe (89.2+/-44.4 seconds) AUA symptom index scores. AUA symptom index, as well as irritative and obstructive scores did not significantly correlate with detrusor contraction duration. Detrusor pressure at maximal flow was weakly correlated with detrusor contraction duration (r=0.322, p=0.014). However, detrusor contraction duration in 27 obstructed patients (111.6+/-53.7 seconds) was not significantly different from that of 31 nonobstructed patients (91.5+/-41.5 seconds) and it did not increase with the severity of bladder outlet obstruction. Detrusor contraction duration in 40 patients with good contractility (94.3+/-49.2 seconds) was significantly lower than in 18 patients with poor contractility (115.5+/-43.3 seconds). Detrusor contraction duration was significantly lower in nonobstructed patients with good contractility (72.0+/-21.7 seconds) compared with either nonobstructed patients with poor contractility (118.4+/-47.7 seconds) or obstructed patients with good contractility (112.5+/-58.0 seconds). There was no difference in detrusor contraction duration between nonobstructed patients with poor contractility and obstructed patients with good contractility. Multiple regression analysis showed that detrusor contraction duration can be best predicted by a combination of detrusor pressure at maximal flow, bladder capacity and contractility (r=0.576). CONCLUSIONS: Our study showed that detrusor contraction duration cannot distinguish patients with from those without bladder outlet obstruction, and it does not correlate with the severity of symptoms. Since our results also showed that detrusor contraction duration depends on several factors related to detrusor and outlet function, it cannot be used as a reliable parameter to diagnose bladder outlet obstruction.

Persistent vesicourethral dysfunction following radical surgery for rectal carcinoma: urodynamic features and potential abatement with modified sphincterotomy (radical transurethral resection of the prostate).

BACKGROUND: Vesicourethral function returns after radical rectal surgery during the first year but rarely progresses after 1 year. We examined the urodynamics of patients whose voiding dysfunction remained after 1 year, and treated several with a modified sphincterotomy procedure similar to radical transurethral resection of the prostate. METHODS: We analyzed the urodynamic features of vesicourethral dysfunction in 16 male patients with persistent voiding dysfunction for more than 1 year following radical surgery for rectal carcinoma. Seven patients elected to undergo radical transurethral resection of prostate (radical TUR-P) for the relief of their persistent voiding dysfunction. RESULTS: The mean bladder volume at the first desire to void was 210 mL, the mean maximal bladder capacity was 343 mL, and the mean vesical compliance (Cves) was 27.1 mL/cm H2O. All patients demonstrated either vesical denervation supersensitivity (Vds) or uninhibited contraction. The mean maximal urethral closure pressure was 43.9 cm H2O, and urethral denervation supersensitivity was found in 77.8% (7/9), and sphincter dyssynergia in 66.7% (6/9) of patients. After radical TUR-P, 5 patients became free from the use of self-catheterization, 1 patient had a reduced residual urine rate, and 1 patient was unchanged, but no patient noted a change in urinary control. CONCLUSION: Urethral dysfunction after radical rectal surgery was caused by failure of the bladder to empty along with an underactive detrusor. Radical TUR-P was effective in restoring voiding function in a selected group of these patients.

Preexisting neurogenic voiding dysfunction in children with imperforate anus: problems in management.

We evaluated 22 boys and 2 girls 1 month to 8 years old with imperforate anus to determine the relationship between neurogenic voiding dysfunction and bony sacral or spinal cord anomalies. Lower urinary tract function before anorectoplasty was normal in 12 children (group 1), abnormal (detrusor-sphincter dyssynergia) in 9 (group 2) and not evaluated in 3 (group 3). High lesions of imperforate anus were present in 22% of the patients in group 1 and in 100% of those in group 2. Plain radiography revealed partial sacral agenesis in 1 child in group 1 and 4 in group 2. Magnetic resonance imaging detected occult spinal dysraphism in 1 patient in group 1 and 2 in group 2. (Occult spinal dysraphism included sacral lipoma, tethered cord, syringomyelia and thick filum terminale.) Seven children in group 2 had vesicoureteral reflux before anorectoplasty. All children in group 2 were placed on clean intermittent catheterization for the management of neurogenic voiding dysfunction. Normal upper urinary tract function was maintained in all patients in group 1 and 6 in group 2. The remaining 3 children in group 2 had high grade reflux at presentation associated with severe renal damage or noncompliance with clean intermittent catheterization. These findings indicate that in children with imperforate anus lower urinary tract function should be evaluated before anorectoplasty because of the high incidence of associated congenital neurogenic voiding dysfunction and the potential risk for renal deterioration. When possible, neurogenic voiding dysfunction should be managed with clean intermittent catheterization to prevent renal damage.

Clinical and endocrinological features of adrenocorticotropic hormone- independent bilateral macronodular adrenocortical hyperplasia.

PURPOSE: We report clinical findings in 5 patients with adrenocorticotropic hormone independent bilateral macronodular adrenocortical hyperplasia. MATERIALS AND METHODS: In 4 males and 1 female 32 to 61 years old (median age 50) we evaluated clinical symptoms, endocrinological and radiological characteristics, treatment modality and postoperative clinical course. RESULTS: All cases presented with some features of Cushing's syndrome. Endocrinological examination revealed autonomous adrenal cortisol production with suppressed adrenocorticotropic hormone and a loss in the diurnal circadian rhythm of plasma cortisol. Abdominal computerized tomography showed bilateral enlargement of the adrenal glands with multiple nodules. 131Iodine labeled adosterol scintigraphy demonstrated remarkable bilateral uptake by the adrenal glands. The pituitary gland appeared normal on magnetic resonance imaging. Open unilateral complete adrenalectomy and contralateral partial adrenalectomy were performed in patient 1, open bilateral complete adrenalectomy was done in patients 2 and 3, and 2 and 1-stage laparoscopic bilateral complete adrenalectomy was performed in patients 4 and 5. Single removed adrenal glands weighed 32 to 108 gm. (median 60). The histological diagnosis was macronodular adrenocortical hyperplasia in all cases. Postoperative followup was 3 to 90 months. Clinical symptoms of Cushing's syndrome disappeared or improved after surgery in all cases. CONCLUSIONS: Although adrenocorticotropic hormone independent bilateral macronodular adrenocortical hyperplasia is a rare form of Cushing's syndrome, physicians are advised to consider it when diagnosing and treating cases of Cushing's syndrome with enlarged bilateral adrenal glands. Bilateral complete adrenalectomy is currently recommended as the treatment of choice.

Afferent fibers of the hypogastric nerves are involved in the facilitating effects of chemical bladder irritation in rats.

To evaluate the role of bladder afferent fibers in the hypogastric nerves (HGN) in modulation of the micturition reflex induced by chemical bladder irritation, voiding behavior, continuous cystometry, and spinal c-fos expression following intravesical acetic acid instillation were investigated in rats with or without HGN transection. Voiding behavior and continuous cystometry were examined in unanesthetized conscious rats. Following chemical bladder irritation, a significant increase in urinary frequency associated with a marked decrease in the voided volume per micturition, was noted in control rats with the intact HGN, but not in HGN-transected rats. Continuous infusion of acetic acid in control rats elicited irritative bladder responses characterized by a marked decrease in the intercontraction interval and a marked increase in maximal vesical pressure, both of which were absent in capsaicin-desensitized rats. HGN transection prevented the decrease in the intercontraction interval but not an increase in maximal vesical pressure following chemical bladder irritation. Compared with saline infusion, acetic acid infusion caused a significant increase in c-fos expression at L(1) and L(6) of the spinal cord, and HGN transection significantly reduced c-fos expression in the dorsal horn of the spinal cord at L(1) but not at L(6). These results suggest that capsaicin-sensitive bladder afferent fibers in the HGN, which travel through the rostral lumbar spinal cord, have a role in urinary frequency caused by chemical bladder irritation.

Urodynamic characterization of nonobstructive voiding dysfunction in symptomatic elderly men.

PURPOSE: The pathogenesis of lower urinary tract symptoms in men without bladder outlet obstruction has not been well characterized. Therefore, we defined the urodynamic abnormalities associated with symptomatic nonobstructive voiding dysfunction, and determined the relationship between age and type of dysfunction. MATERIALS AND METHODS: Video urodynamic studies of symptomatic men without outlet obstruction were examined. The criterion for a normal bladder outlet was a pressure gradient across the prostatic urethra of 5 cm. water or less in the absence of distal stricture. A maximum isometric contraction pressure less than 60 cm. water was regarded as impaired detrusor contractility. Detrusor instability was defined as involuntary detrusor contractions during filling or the inability to suppress a detrusor contraction after initiation of flow. Patients were categorized into 4 groups based on the urodynamic findings. RESULTS: Of 193 men (mean age 69.6+/-10.5 years) 40.9% had detrusor instability (group 1), 31.1% had impaired contractility (group 2), 10.8% had detrusor instability and impaired contractility (group 3), and 17.1% were urodynamically normal (group 4). Average patient age was significantly lower in group 4 than all other groups. Bladder capacity was lowest in group 1, and group 3 had the lowest voiding efficiency. Maximum flow rate, bladder compliance and symptom scores were not different among the 4 groups. The prevalence of detrusor instability with and without impaired contractility increased, while the proportion of patients without urodynamic abnormalities decreased with age. Bladder contractility did not correlate with age. CONCLUSIONS: The nonobstructed patient population comprises several groups that are functionally distinct while symptomatically similar. Thus, treatment of nonobstructed cases based on symptoms may lead to inappropriate pharmacological therapy and unsuccessful clinical outcomes.

Preoperative cystometrography in patients with clinical benign prostatic hypertrophy.

Preoperative water cystometrograms obtained from 437 patients with benign prostatic hyperplasia (BPH) were examined in a retrospective study. The cystometrographic results were analyzed regarding the preoperative clinical features: the patients' age, presence or absence of urinary incontinence, history of urinary retention, and rate of residual urine. Their prognostic value in terms of improvement in voiding difficulty and postoperative urinary incontinence was also analyzed at 1 and 6 months after elective transurethral resection of the prostate (TURP). Of these patients, 263 (60.2%) had detrusor instability (group I), whereas 174 did not (group II). Vesical denervation supersensitivity (Vds) to bethanecol chloride was noted in 47 (12.5%) of 375 patients. The observed difference in clinical features was significant between the two groups, with group I being older (P < 0.01) and showing a greater incidence of urinary incontinence (P < 0.001) and retention (P < 0.001). The difference seen between groups I and II in terms of mean bladder capacity (P < 0.01), compliance (P < 0.01), and a greater positive rate of Vds (P < 0.001) was also significant. The clinical and cystometrographic parameters studied worsened with advancing age of the patients. Although the majority of the patients (94.7%) were relieved of obstructive symptoms after TURP (6 months later), 113 (25.9%) showed no relief at 1 month.(ABSTRACT TRUNCATED AT 250 WORDS)

Laparsocopic ureteroureterostomy for retrocaval ureter.

Two cases of retrocaval ureter are reported that were successfully treated by a laparoscopic approach. Case 1 was a 20-year-old woman who presented with symptoms of a right ureter stone. Case 2 was a 23-year-old woman who had suffered from recurrent right flank pain with gross hematuria. A transperitoneal approach was used for case 1, and a retroperitoneal approach was used in case 2. Both were successfully treated with laparoscopic ureteroureterostomy using an intracorporeal suture technique. Laparoscopic surgery should be the first choice for retrocaval ureter not only because of the minimal invasiveness but also because of the cosmetic advantage compared to conventional open surgery. Further technical and instrumental advances are essential for intracorporeal suturing.

Urinary control after radical transurethral resection of the prostate in male paraplegics: urodynamic evaluation of its effectiveness in relieving incontinence.

We report our investigation of urinary incontinence in 51 male paraplegics with radical transurethral resection of the prostate. Pre-operatively, 28 cases (55.9%) had moderate or severe incontinence, which persisted post-operatively only in 21 cases (41.2%) and was less severe. Post-operatively, bladder compliance was improved from 22.1 +/- 22.6 ml/cmH2O to 36.4 +/- 38.5 ml/cmH2O, and the maximum pressure of uninhibited detrusor contraction was reduced from 40.2 +/- 21.5 cmH2O to 18.3 +/- 19.0 cmH2O. These significant improvements are thought to contribute to the relief of urinary incontinence, regardless of the reduction in maximum urethral closure pressure.

Continence mechanism of the orthotopic neobladder: urodynamic analysis of ileocolic neobladder and external urethral sphincter functions.

BACKGROUND: The main objectives of bladder substitution are the preservation of the upper urinary tract and maintenance of urinary continence. Orthotopic bladder substitution makes it possible to achieve urinary continence as well as normal passage of urine through the urethra. Creation of a low pressure reservoir and careful preservation of the distal sphincter mechanism are considered to be of utmost importance for the maintenance of urinary continence after orthotopic bladder substitution. However, sphincter behavior after orthotopic bladder substitution has not been fully elucidated. The purpose of this study was to evaluate the vesicourethral continence mechanism after orthotopic bladder substitution in male patients. METHODS: Urodynamic evaluation was performed in 14 male patients after cystoprostatectomy for bladder cancer and an ileocolic neobladder using a cecourethral anastomosis. RESULTS: Good continence was achieved in 86% (12/14) of the patients during the day and in 79% (11/14) at night. On cystometry, maximum capacity of the neobladders was 434 +/- 21 ml (mean +/- SEM), and basal pressure at maximum capacity was 15.6 +/- 0.9 cm water. Phasic neobladder contraction with amplitudes ranging from 14 to 40 (26.6 +/- 2.7) cm water were noted in 11 of 14 patients. Sphincter electromyography demonstrated an increase in the frequency of action potentials of the external urethral sphincter during neobladder filling from empty to 80% of capacity (from 8.9 +/- 1.6 to 14.6 +/- 2.1 spikes per second; mean percentage increase, 64%, in patients with daytime continence). Maximum urethral closure pressure on urethral pressure profile was 49.9 +/- 3.5 (range, 30 to 64) cm water in patients with daytime continence, while in two patients who were incontinent during the day and at night maximum urethral closure pressure was lower (16 and 24 cm water) and the recruitment of action potentials of the external urethral sphincter during neobladder filling was impaired (percentage increase, 15% and 20%). CONCLUSIONS: An ileocolic neobladder has characteristics of a low pressure reservoir with a satisfactory continence rate. The vesicourethral continence reflex is well preserved in patients with continence after orthotopic bladder substitution.

The relevance of preoperative cystometrography in patients with benign prostatic hyperplasia: correlating the findings with clinical features and outcome after prostatectomy.

Preoperative water cystometrograms in 437 patients with benign prostatic hyperplasia (BPH) were examined in a retrospective study. The cystometrographic results were analyzed regarding the preoperative clinical features: patient age, presence or absence of urinary incontinence, history of urinary retention and rate of residual urine. The prognostic value in improvement in voiding difficulty and postoperative urinary incontinence was also analyzed at 1 and 6 months after elective prostatectomy. Subjective symptoms of the patients were the primary reasons for prostatectomy, the majority of which were performed by a single competent resectionist (K. T.) who evaluated the outcome but was blinded to the cystometric findings. Of these patients 263 (60.2%) had detrusor instability (group 1), while 174 did not (group 2). Vesical denervation supersensitivity to bethanechol chloride was noted in 47 of 375 patients (12.5%). The difference in clinical features was significant between the 2 groups, with group 1 showing older patient age (p < 0.01), and a greater incidence of urinary incontinence (p < 0.001) and retention (p < 0.001). The difference between groups 1 and 2 in mean bladder capacity (p < 0.01), compliance (p < 0.01) and a greater positive rate of vesical denervation supersensitivity (p < 0.001) was also significant. The clinical and cystometrographic parameters studied worsened with advancing patient age. Although the majority of the patients (94.7%) were relieved of obstructive symptoms after transurethral prostatectomy (6 months later), 113 (25.9%) were not at 1 month. Compared to 324 patients with early improvement (74.1%), those without improvement at 1 month were characterized by older age (p < 0.01), greater prevalence of preoperative incontinence (p < 0.05), retention (p < 0.01), greater residual rate (p < 0.05), a less compliant bladder (p < 0.01) and a higher positive rate of vesical denervation supersensitivity (p < 0.05). Cystometrographic findings, however, had no relevance to late (6 months) outcome of voiding difficulty. On the other hand, postoperative incontinence was noted in 100 patients (22.9%) at 1 month after transurethral prostatectomy, with the majority having episodes similar to those experienced preoperatively (70.0%) as well as detrusor instability (87.0%). They also were older (p < 0.01), and had a less compliant bladder (p < 0.01) and a higher positive rate of vesical denervation supersensitivity (p < 0.01) than did continent patients. Only 18 elderly patients (4.1%) remained incontinent 6 months later, all with a less compliant (p < 0.01) and more unstable (p < 0.01) bladder initially. The genesis of this detrusor dysfunction was believed to be aging in male patients, in whom BPH evolves and progresses. In conclusion, preoperative cystometrography in patients with BPH is valuable in that it correlated well with the clinical features and it can predict to some extent the outcome of obstructive symptoms and urinary incontinence after transurethral prostatectomy.

The relevance of urethral resistance in children with myelodysplasia: its impact on upper urinary tract deterioration and the outcome of conservative management.

PURPOSE: Upper urinary tract deterioration, such as vesicoureteral reflux and hydronephrosis, affects the long-term prognosis in children with myelodysplasia. We retrospectively analyzed the relevance of urethral resistance to upper tract deterioration in untreated children with myelodysplasia as well as the outcome of conservative treatment based on urethral resistance. MATERIALS AND METHODS: Included in our study were 32 boys and 29 girls with a mean age at presentation of 3.6 years and a mean followup of 9.2 years. The children were divided into group 1-31 with high and group 2-30 with low urethral resistance, as determined by leak point pressure or maximum urethral closing pressure. Clean intermittent catheterization with or without anticholinergics was instituted in all children in group 1 and those in group 2 with documented upper tract deterioration and/or problematic urinary incontinence after school age. We compared the incidence of upper tract deterioration at the initial evaluation and during followup as well as the final status of the upper tract in the 2 groups. RESULTS: At the initial evaluation 17 of 31 group 1 (55%) and 4 of 30 group 2 (13%) patients had upper tract deterioration (p <0.01). Deterioration was refractory to conservative management in 5 group 1 children who required bladder augmentation. The incidence of de novo upper tract deterioration during followup was not statistically different in the 2 groups (10 and 7% in groups 1 and 2, respectively). At the final evaluation the upper tract was normal in 26 (84%), improved in 3 and stable in 2 group 1 patients, while it was normal in 26 (87%) in group 2. CONCLUSIONS: Urethral resistance is relevant to upper tract deterioration in untreated children with myelodysplasia. Although bladder augmentation was necessary in some children with high urethral resistance, the outcome of conservative treatment was generally satisfactory with the preservation or normalization of the upper tract in more than 80% regardless of urethral resistance.

Experience of Laparoscopic Exploration and Gonadectomy in lntersex Children.

The use of laparoscopic technique to diagnose and treat intersex children is gradually introduced in clinical urology. From 1985 to 1996, abdominal exploration and gonadectomy were performed in 11 intersex children together with urogenital endoscopy and genitoplastic surgery in our institutes. Their median age was 6.0 (range 0-15) years old and initial gender sex was female in 8 and male in 3. The initial 4 cases (group 1) underwent open abdominal exploration together with gonadectomy, while the latter 7 cases (group 2) underwent laparoscopic exploration simultaneously with 3 laparoscopic gonadectomy and 1 open one via a inguinal incision. Their final diagnoses were male pseudohermaphroditism in 4 cases, mixed gonadal dysgenesis in 3, true hermaphroditism in 2, XX gonadal dysgenesis in 1, and XY gonadal dysgenesis in 1. Consequently, 2 of initial male were reared as a female. Operation time, use of analgesics, postoperative hospital stay and postoperative complications were not significantly different between the two groups, however, postoperative abdominal wound appearance was more acceptable in group 2. The most significant advantage of laparoscopic surgery in intersex children is cosmetic appearance especially when social gender is determined as female irrespective types of intersexuality.

Laparoscopic evaluation and the management of the nonpalpable testis.

From June 1992 to December 1996, we performed laparoscopic evaluation for 28 nonpalpable testes in 22 patients (1-21, median 3 years old).The location of 28 testes were divided into 4 categories according to the classification by Malone et al.: canalicular in 17 testes, just canalicular in 2, abdominal in 7, and absent in 2. Two-stage Fowler-Stephens orchiopexy was performed in 3 abdominal testes and planned two-stage orchiopexy was performed in one abdominal testis, while one-stage standard orchiopexy was performed in 10 testes (canalicular 5, just canalicular 2, and abdominal 3). In 10 of 17 canalicular testes no testicular element was found on histological examination of the excised remnant tissue. In two completely absent testicular structures, as verified by vanishing spermatic vessels, no further exploration was done after laparoscopy. There was one complication in this series: jejunal injury which needed oversewing, otherwise there was no postoperative sequela in all cases.Laparoscopic evaluation in patients with nonpalpable testes gives us precise information as to the existence and location of the testicle which is helpful in determining subsequent appropriate procedure and avoiding unnecessary abdominal exploration.