Retrograde pyelography via ureteral stents.

Retrograde pyelography to establish ureteral patency prior to removal of ureteral stent can be done via the stent. A simple technique is described.

Lower urinary tract dysfunction after radical hysterectomy for carcinoma of cervix.

The charts of 22 consecutive patients who had undergone radical hysterectomy for carcinoma of the cervix were reviewed retrospectively. Uroflowmetry, gas cystometry, and postvoid residual measurements were performed pre- and postoperatively, and a questionnaire to evaluate urinary problems experienced postoperatively was mailed to all patients. Twenty responses were received and followed up by a telephone interview with the urologist. The number and kind of problems suggest that the cause of urinary dysfunction commonly reported after radical hysterectomy is disruption of nerve supplies to both bladder and urethra. Data on retention suggest that the characteristics of this dysfunction change with time but generally are stabilized by the end of the first postoperative year. It is noted that recurrent urinary tract infection may occur asymptomatically because of loss of bladder sensation. Because of the diversity of presentation, urodynamics played an important role in individualization of treatment and monitoring of progress.

Experience with inflatable penile prosthesis.

Prosthesis surgery for management of erectile impotence has become an increasingly important aspect of urology. The inflatable penile prosthesis (IPP) provides the impotent patient with a controllable, natural-appearing and physiologically functional penis. Major modifications in the prosthesis and in the surgical implantation technique have been made since its initial introduction. In this article we present a histologic review of the IPP and our ten-year experience with it.

Preoperative irradiation and cystectomy in 135 cases of bladder cancer.

The updated experience of the McGill Teaching Hospitals in treating cancer of the bladder with short course, high-dose radiation and immediate cystectomy is presented. Five-year life table survival for the 135 patients so managed was 43.9 per cent. Survivorship at five years was 34.5 per cent in high-stage disease and 64.1 per cent in low-stage disease. It was concluded that preoperative radiation and surgery as outlined in selected cases remains an effective method of management.

Cigarette smoking and other vascular risk factors in vasculogenic impotence.

A total of 132 consecutive patients with erectile impotence underwent extensive evaluation, including vascular evaluation with intracavernous injection of papaverine and penile duplex ultrasonography, to determine the etiology of impotence. Three vascular risk factors, smoking, diabetes mellitus and hypertension, were investigated for their impact on vasculogenic impotence. The patients were divided into four groups: one with no risk factors, one with one vascular risk factor, one with two vascular risk factors, and one with all three risk factors. The results of penile vascular evaluation in these patient groups were compared. The incidence of penile vascular impairment was found to be higher in patients with one vascular risk factor than in those with none. The proportion of abnormal penile vascular findings significantly increased as the number of risk factors increased. These data confirm the important role of vascular risk factors, smoking, diabetes mellitus, and hypertension, in the pathogenesis of organic impotence.

Corporeal reconstruction procedures for complicated penile implants.

Implantation of a penile prosthesis is now a very much accepted mode of management of organic erectile impotence. In most situations, this operation will involve little or no corporeal reconstruction. However, in the presence of more severe pathologic processes that may lead to corporeal damage, such as infective corporitis secondary to an earlier penile prosthesis or postpriapism fibrosis, and with the increasing public awareness of the availability of therapeutic modalities for impotence, the urologist must be well versed in the diagnostic and surgical techniques of corporeal reconstruction.

Complicated implantations of inflatable penile prostheses.

In conclusion, implantation of an inflatable penile prosthesis into a normal penis is usually a relatively uncomplicated procedure, but the urologist should be aware of the possibility of complications described in this article. He must be familiar with the advantages and disadvantages of the various prostheses and the surgical techniques required to deal with the problems encountered in complicated as well as in routine prosthetic penile implants.

Evaluation of erectile dysfunction and sleep-related erections.

Significant advances in this past decade have improved our understanding of erectile physiology. A variety of tests are available for diagnosing impotence. SRE testing provides objective physiological information that is useful for indexing erectile capability and formulating a rational treatment plan. As such, SRE testing is a powerful noninvasive tool for assessing dysfunction. Nonetheless, in making a final diagnosis, the skillful clinician relies on more than one assessment parameter and on clinical acumen.

Use of human amnion for microvascular interpositional grafts.

A major problem associated with vascular grafting employing an artificial graft is the inflammatory response provoked by the graft and subsequent complications of classical acute rejection phenomena when the graft is implanted subcutaneously into human volunteers. The favorable results obtained by a preliminary study of subcutaneous implantation of amnion in our laboratory have led us to a prospective study to determine its value as a vascular graft. Tubed conduits of glutaraldehyde-treated amnion were hand constructed of varying diameters and lengths. They were employed as segmental interpositional grafts in experimentally created femoral and aortic arterial defects in Sprague-Dawley rats. Patency rates varied from 60 to 90 percent, with all grafts showing remarkable reendothelialization within 3 to 4 weeks postoperatively. Morphology, antigenic reaction, blood flow, and patency of the different experimental amnion grafts were evaluated and compared to appropriate controls.

Experience with the Hydroflex penile prosthesis.

Based on the author's experience, the Hydroflex penile prosthesis is an excellent addition to the urologist's armamentarium in the management of erectile impotence, where so indicated. As with all prostheses, it does have certain advantages and some limitations when compared with other types of penile prostheses. Simplicity of implantation and rigidity of the phallus is equivalent to that of a rigid type of device. Penile flaccidity and concealment is almost equivalent to that achievable with the IPP in the majority of patients. The quality of erection, ie, the length and girth of the penis, is somewhat less than that achieved with the IPP, but certainly better than with the rigid type of prosthesis. To date, the mechanical reliability of the Hydroflex has been excellent. When presenting the surgical prosthetic options to a patient, it is essential for the urologist to describe the advantages and disadvantages of each one of the various prostheses so that a rational decision can be made. However, it is also important to request the patient's permission for the surgeon to make the final decision at time of surgery, so that the optimal results can be attained.

Pregnancy in patients with the artificial urinary sphincter.

Since 1974, 71 female patients between 3 and 25 years old have undergone implantation of the artificial urinary sphincter for treatment of urinary incontinence. Of these women 9 have become pregnant and delivered 11 normal children. In 2 women the artificial urinary sphincter was removed because of erosion before conceiving, while the remaining 7 had a functional artificial urinary sphincter in place at conception, and subsequent pregnancy and delivery. All 11 women had normal pregnancies and, aside from the normally increased frequency of urination and a slight increase in urinary leakage due to elevated pressure on the bladder from the adjacent uterus, the urinary continence was unchanged. Of the women 4 underwent cesarean section at the advice of their obstetricians and the remainder had uneventful vaginal deliveries. During the course of the pregnancies the patients or their obstetricians consulted 1 of us for advice regarding management of the delivery because of the presence of the artificial urinary sphincter. The normalcy of the pregnancies and deliveries led us to conclude that the presence of a functioning artificial urinary sphincter did not increase the risk of complications during pregnancy and childbearing.

Experience with the artificial urinary sphincter model AS800 in 148 patients.

The latest version of the artificial urinary sphincter, AS800, was used in 148 patients with urinary incontinence of different etiologies. Followup ranged from 3 to 37 months, with an average of 20.8 months. There were 112 (76 per cent) male and 36 (24 per cent) female patients. The cuff was implanted around the bladder neck in 78 patients (53 per cent) and around the bulbar urethra in 70 (47 per cent). Socially acceptable urinary control was achieved in 90 per cent of the 139 patients with active devices in place. It was necessary to remove the sphincter in 11 patients (7.4 per cent). The reasons for removal were infection and erosion in 8 patients (5.4 per cent), infection without erosion in 2 (1.3 per cent), and erosion due to excess pressure and poor tissues in 1 (0.7 per cent). Comparison of success and failure rates associated with incontinence of different etiologies revealed that patients with incontinence after failure of a conventional antistress incontinence operation and those with incontinence after transurethral resection or radical prostactectomy had the highest success rate, and that patients with incontinence secondary to pelvic fracture or exstrophy and epispadias had the highest failure rates. The deactivation feature (the lock) of the new artificial sphincter model was beneficial for primary deactivation, urethral catheterization or cystoscopy, or for elective nocturnal decompression of the bladder neck or urethral tissues.

Endourological reconstruction of posterior urethral disruption.

While conventional methods of urethroplasty for posterior urethral disruption usually are successful technically, they may be associated with complications and often require the expertise of a specialist. Therefore, the option of an endourological approach to the treatment of the obliterated posterior urethra would be highly desirable if a comparable surgical outcome could be achieved. We describe a closed controlled method of posterior urethral reconstruction following traumatic avulsion of the posterior urethra. Urethral continuity was re-established by endoscopic identification of the true prostatic outlet, its fixation with an angiography wire and a Goodwin sound, retrograde visual urethrotomy through the fibrotic segment and balloon dilation of the entire posterior channel. Postoperative anatomical and functional results were excellent, and were achieved with much less risk and cost to the patient than those of a perineal or transpubic urethroplasty.

Urinary undiversion and implantation of the artificial urinary sphincter in a 73-year-old man.

We report a case of successful urinary undiversion and implantation of an artificial urinary sphincter in a 73-year-old man, who had undergone ileal loop urinary diversion elsewhere for treatment of urinary incontinence secondary to transurethral prostatectomy. The rationale for our decision to perform undiversion is presented. Evaluation of patient history and physical examination are necessary, as well as delineation of the anatomy and function of the upper and lower tracts by laboratory, radiological and urodynamic examinations. Each undiversion case is unique. Treatment must be individualized and should be initiated only after meticulous weighing of the advantages and disadvantages of the different therapeutic alternatives. A complete explanation to the patient is important. Highly satisfying results can be expected in appropriately selected cases.

The role of transrectal ultrasonography in the diagnosis and management of prostatic and seminal vesicle cysts.

Cysts in the region of the prostate and seminal vesicles are interesting because of their differential diagnosis and embryological relevance. We present our experience with 5 cases that include a müllerian duct cyst, diverticulum of the spermatic tract, seminal vesicle cyst and 2 prostatic cysts. Transrectal ultrasonography had a significant role in the diagnostic evaluation of these cysts. Ultrasonographically guided transperineal needle aspiration added significant diagnostic information and might have a therapeutic value. After a review of the literature, we propose an algorithm for the evaluation and management of prostatic and seminal vesicle cysts.

Combined transrectal ultrasonography and urodynamics in the evaluation of detrusor-sphincter dyssynergia.

Thirty-one combined transrectal ultrasonographic and urodynamic studies were performed in 24 patients with spinal cord lesions at different levels between C4 and T12. Ultrasonography provided accurate real-time imaging of the bladder neck, prostatic urethra and external sphincter during the bladder filling phase as well as during the voiding phase. Bladder and rectal pressures, sphincter EMG and uroflow were recorded simultaneously. Transrectal ultrasonography contributed significantly to the accuracy of diagnosing detrusor-sphincter dyssynergia. Sphincter contractions were clearly visualised with ultrasonographic video monitoring. This imaging method was especially helpful in sorting out the problems of 3 patients with poor emptying of bladder after endoscopic sphincterotomy. One had a urethral stricture and the other 2 had sphincters that opened adequately but bladders that emptied poorly because of detrusor hypocontractility. Other problems, such as benign prostatic hyperplasia and false passage, were also easily recognised. Transrectal ultrasonography not only provides accurate information but also involves no exposure to radiation and thus precludes the need for costly lead-shielded examination rooms.

Management of penile zipper injury.

A penile problem that physicians are confronted with in the emergency room is entrapment of the foreskin by a zipper fastener. A case presentation and a simple technique for its management are described.