Endoscopic treatment of urinary incontinence in children with primary epispadias

OBJECTIVE: To evaluate the efficacy of the endoscopic insertion of polydimethylsiloxane particles (Macroplastique, Uroplasty Inc) (MPQ) into the posterior urethral region of boys with urinary incontinence and primary epispadias. PATIENTS AND METHODS: Between 1991 and 1995, 12 boys aged 3-7 years (mean 4.8) received an endoscopic submucosal injection with MPQ into the posterior urethra to correct urinary incontinence; the 12 boys were wet day and night. All patients had undergone a modified Cantwell epispadias repair before injection. The procedure was performed 24 times with a total volume of 83 mL of material injected into 59 sites in the posterior urethra (mean volume per injection 1.4 mL). The mean follow-up after injection was 10.8 months (range 3-22). RESULTS: Three patients became completely dry, the degree of incontinence was improved in six and there was no change in three. CONCLUSION: The preliminary results of this relatively non-invasive treatment are encouraging.     

Fascia lata sling cystourethropexy for the management of female urinary incontinence

Myelodysplastic syndromes (MDS) are clonal hematopoietic disorders which begin in a pluripotential bone marrow (BM) stem cell. This early stem cell is believed to acquire a growth advantage over its neighbors as a result of an initial transforming event, the nature of which has remained obscure. In this paper, we propose that pathogens such as those belonging to the herpesvirus family of DNA viruses may play a role in the initial transformation of the stem cell. The case for cytomegalovirus (CMV) as a representative of this family of viruses is discussed at length and a molecular mechanism which may be involved in the oncogenic activity of CMV is proposed. No proof has been presented to implicate CMV directly in MDS, but circumstantial evidence which supports such a possibility is provided.     

Laparoscopic bladder-neck suspension for urinary stress incontinence in women: our first twenty patients

BACKGROUND: Laparoscopic bladder-neck suspension for women with urinary stress incontinence avoids the problems associated with a large abdominal incision. This study reviews the short-term outcome of this minimally invasive operation. METHODS: Between September 1993 and February 1995, 20 female patients with type II urinary stress incontinence underwent laparoscopic bladder-neck suspension at our institution (mean age, 46.6 years; mean weight, 59.5 kg; mean duration of symptoms, 3.75 years; mean follow-up, 7 months). The extraperitoneal space was created with a preperitoneal distention balloon system; dissection of the bladder and bladder neck was done via 3 working ports. In 16 patients, the paraurethral vagina on either side of the bladder neck was hitched up to the iliopectineal ligament by 2-0 sutures. In the remaining 4 patients, the bladder-neck suspension was performed using hernia mesh and staples. Four patients had intraperitoneal suspension. RESULTS: The operative time ranged from 75 to 205 minutes, with a mean of 111.5 minutes. The period of urethral catheterization ranged from 2 to 7 days, with a mean of 3.1 days. The hospitalization stay ranged from 5 to 15 days, with a mean of 6.35 days. Thirteen patients (65%) had complete resolution of symptoms, 5 patients (25%) reported significant improvement, and 2 patients (10%) did not benefit from the operation. CONCLUSION: Long-term follow-up is necessary to determine the efficacy of this laparoscopic technique. The success rate for any incontinence procedure is usually inversely proportional to the duration of follow-up.     

Periurethral collagen injection for the treatment of urinary incontinence in children

PURPOSE: We assessed the efficacy and safety of periurethral collagen injection for urinary incontinence in children with neurogenic bladder dysfunction. MATERIALS AND METHODS: We treated 11 children (mean age 10.6 years) who had incontinence and neurogenic bladder dysfunction with periurethral injections of glutaraldehyde cross-linked collagen. All patients were on anticholinergics and all but 1 were on clean intermittent catheterization preoperatively. Four patients had previously undergone augmentation cystoplasty. All patients were assessed before and after injection with a subjective continence scale and multichannel urodynamics. Followup ranged from 4 to 20 months from the last injection. RESULTS: Mean group Valsalva leak point pressure was 34.5 cm. water. Four of the 11 patients had an identifiable detrusor leak point pressure. Overall success rate was 55% with 4 patients dry and 2 improved. Success correlated with a minimum increase in Valsalva leak point pressure of 20 to 25 cm. water to greater than 60 cm. water. Three patients had no demonstrable Valsalva leak point pressure after injection. All 5 patients in whom treatment failed had no change in Valsalva leak point pressure, including 2 with small capacity, poorly compliant bladders preoperatively. Because they had a component of sphincteric insufficiency, they underwent injection in the hope of increasing capacity with increased continence. In 3 patients Valsalva leak point pressure was greater than 50 cm. water. Detrusor leak point pressure developed in 3 patients postoperatively, including 1 with significantly increased Valsalva leak point pressure. One patient with significantly increased Valsalva leak point pressure had urethral hypermobility postoperatively. Of the 3 patients who subsequently underwent augmentation cystoplasty 1 is now dry, 1 is wet and 1 died of complications unrelated to urological disease. Patients underwent 1 to 4 procedures (mean 2.5). CONCLUSIONS: Periurethral collagen injection may be effective for urinary incontinence in patients who have adequate capacity with good compliance and low Valsalva leak point pressure. When there is no response to repeat injections or a transient response, one should consider the possibility of bladder decompensation.     

Endoscopic treatment for urinary incontinence in children with a congenital neuropathic bladder

A new method for more timely monitoring of cancer patient survival was employed to assess progress in 5-year survival of breast cancer patients in Saarland, Germany, between 1980-84 and 1990-94. Five-year relative survival gradually increased from 68.8% to 73.5%. Improvements were most pronounced among age groups 50-59 and 60-69. The latter had the highest 5-year relative survival (77.1%) in 1990-94.     

A new treatment procedure in stress urinary incontinence (SUI): suburethral prolene sling under local anesthesia

An original technique for the treatment of USI under local anaesthesia is described. It consists of insertion of a Prolene sling under the middle part of the urethra. This sling is not placed under tension, but simply supports the suburethral region. In a series of 22 patients without prolapse requiring surgical correction and presenting USI confirmed by clinical examination, 20 were totally cured by this technique and the postoperative voiding flow rate was not decreased. This technique therefore appears to be simple, non-dysuric and effective.     

The pathophysiology of stress urinary incontinence in women and its implications for surgical treatment

OBJECTIVES: To estimate the total costs of multiple sclerosis (MS) for all Canadians in 1994. METHODS: Prevalence-based study estimating disease-related societal costs for Canadians with MS in 1994. The human capital approach was used to estimate the value of lost productivity due to illness. Two components were revealed: first, direct costs, in terms of expenditures on hospital care, other institutions, physician services, other health professionals, drugs, and other expenditures; and second, indirect costs, in terms of lost productivity due to premature mortality and disability. RESULTS: The total costs of MS for Canadians were $502.3 million in 1994, with direct and indirect cost components at $188.6 million and $313.7 million, respectively. CONCLUSIONS: This study highlights the scope and magnitude of the economic consequences of MS for Canadians. The costs calculated may be used to provide guidance in the setting of national priorities for research and prevention activities.     

Pubovaginal fascial sling for all types of stress urinary incontinence: long-term analysis

PURPOSE: There is a lack of consensus regarding indications and long-term efficacy of the many surgical techniques for treating stress incontinence. Historically pubovaginal sling has been reserved for cases of intrinsic sphincter deficiency or prior surgical failure. Transvaginal needle and retropubic suspensions have been used mainly for sphincteric incontinence unassociated with intrinsic sphincter deficiency. We report the long-term results of pubovaginal sling for all types of stress incontinence. MATERIALS AND METHODS: A total of 251 consecutive women with all types of stress incontinence who underwent pubovaginal fascial sling by a single surgeon were retrospectively and prospectively reviewed. Patients were evaluated preoperatively with history, physical examination, standardized symptom questionnaire, voiding diary, pad test, uroflow, post-void residual urine, video urodynamics and cystoscopy. Postoperatively women with at least 1-year followup were assessed by an independent third party (J. R.) who had no prior knowledge of them, and who recorded the parameters of the questionnaire, examination with a full bladder, voiding diary, pad test, uroflow and post-void residual urine. RESULTS: Overall stress incontinence was cured or improved in 92% of the patients with at least 1-year followup (median 3.1 years, range 1 to 15). The majority of patients with postoperative incontinence had de novo (3%) or persistent (23%) urge incontinence. Permanent urinary retention developed in 4 patients (2%). CONCLUSIONS: Fascial pubovaginal sling is an effective treatment for all types of stress incontinence with acceptable long-term efficacy.     

Collagen injection therapy in the treatment of urinary incontinence

Impairment from depression and its impact on productivity are of profound societal importance. We report the results of an evaluation of depression and academic impairment in university students, using standardized measures. Sixty-three students completed the Beck Depression Inventory and the work role section from the Social Adjustment Scale-Self Report. Academic impairment, manifested as missed time from class, decreased academic productivity, and significant interpersonal problems at school, was seen in 92% of the students. More severe depression was related to a higher level of impairment. At all levels of depression, affective impairment-inadequacy, distress, and disinterest in school-was more prevalent than was academic impairment. The risk of academic impairment became likely at only moderate-to-severe levels of depression. Discussing the implications of depression with students and aggressively pursuing both medication and nonmedication therapies are essential in preventing the high morbidity associated with untreated depression.     

Recent advances in the surgical treatment of faecal incontinence

STATEMENT OF PROBLEM: Even though assessments of borderline restorative items in terms of accuracy and interexaminer variation have been reported, no attempt has been made to simultaneously evaluate diagnostic and treatment planning decision using objective normative standards. PURPOSE: This study established the accuracy of caries presence assessment as compared with gold standards, interexaminer agreement in assessment of caries presence and restorative needs, and influences of perceived caries status and restoration quality on treatment planning in borderline restorative situations. MATERIALS AND METHODS: Fifteen senior dental students in Mexico City (66% women; mean age 23.2 years) evaluated predetermined areas in 109 restored and unrestored posterior teeth in an in vitro model. Teeth were subsequently assessed for restoration quality and the presence of enamel and dentinal caries by use of histologic and specific dye techniques. Student's t test, Cohen's kappa, and Pearson's correlation analyses were used to analyze the data. RESULTS: There were significant caries misdiagnoses and substantial overtreatment proposed. In a few instances, teeth were left untreated, but usually they were programmed for restoration. Interexaminer agreement varied markedly and was not high. However, performance while correctly detecting lesions was better than in treatment planning. CONCLUSION: There was a high correlation between a diagnosis of caries and restorative treatment in unrestored teeth; the correlation was lower for restored teeth, although they were allocated to restorative treatment more often. This difference hinged on perceived quality of the restoration, an important factor in the frequency of proposed re-restoration.     

Application of biofeedback in the treatment of urinary incontinence.

There is sufficient empirical support to warrant the use of biofeedback for the treatment of common forms of urinary incontinence. However, biofeedback should be provided as a part of a behavioral "package" that includes a functional analysis of the disorder, patient education, a home exercise program, and bladder training strategies when indicated for urge incontinence. Our understanding of the physiologic events associated with clinical improvement will improve with further study. Because incontinence is a symptom of an underlying disorder, a medical evaluation should always be undertaken before a psychophysiological treatment begins. Ideally, biofeedback and other behavioral therapies for incontinence should be offered as an integral part of a multidisciplinary evaluation and treatment program. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Myofascial wrap to treat intractable urinary incontinence in children

OBJECTIVES: The management of intractable urinary incontinence in the patient with cloacal or bladder exstrophy/epispadias, failed bladder neck plasty, or failed augmentation cystoplasty remains a surgical challenge. The myofascial wrap, a modification of the rectus fascial wrap, was developed to treat intractable urinary incontinence due to sphincteric incompetence in these problematic cases. A full-thickness, vascularized pedicle of anterior rectus sheath, rectus abdominis muscle, and posterior rector sheath is incorporated into a bladder neck wrap to provide support, mucosal coaptation, and active muscular tone. METHODS: Eight patients (5 females and 3 males) with total urinary incontinence due to sphincteric incompetence underwent the myofascial wrap. Urinary tract pathology included cloacal exstrophy (2), female epispadias (2), classic bladder exstrophy (1), male epispadias (1), myelomeningocele (1), and a pelvic tumor (1). The procedure is performed by harvesting a full-thickness strip of pedicled rectus muscle along with the anterior and posterior fascial sheaths. The strip is passed underneath and then over the bladder neck in a near 360 degrees wrap. The free end of the wrap is anchored into the pubic bone in an ipsilateral subperiosteal pouch. RESULTS: Six of the 8 patients are completely continent, and 2 patients void spontaneously without the need for catheterization. CONCLUSIONS: The myofascial wrap provides support, mucosal coaptation, and muscular tone to an incompetent sphincter and bladder neck. Favorable results in a very difficult population of pediatric patients warrant its continued use.     

Urethrolysis after surgical cure of stress urinary incontinence using colpopexy: surgical technics

Vitronectin (VN) is an obligatory cofactor for the inhibition of thrombin by plasminogen activator inhibitor 1 (PAI-1). It accelerates the rate of association between thrombin and PAI-1 more than two orders of magnitude. In contrast, VN does not accelerate the association between tissue-type plasminogen activator (t-PA) and PAI-1. Previously, we reported that the anti-PAI-1 monoclonal antibody (MoAb) CLB-2C8 binds to a short stretch of amino acids of PAI-1, located between residues 128 and 145, and prevents PAI-1 binding to VN. Furthermore, MoAb CLB-2C8 fully blocks the inhibitory activity of PAI-1 towards t-PA, emphasizing the importance of this area for the interaction with t-PA. Here, we show that this area is also required for the interaction between thrombin and PAI-1, since MoAb CLB-2C8 fully prevents inhibition of thrombin by PAI-1. In spite of similar structural requirements for the interaction between t-PA, PAI-1 and VN and between thrombin, PAI-1 and VN, the intermediate reaction products are clearly distinct. By employing surface plasmon resonance (SPR), using the BIAcore equipment, and by immunoprecipitation we demonstrate that, in the presence of VN, t-PA and PAI-1 form exclusively equimolar binary t-PA/PAI-1 complexes. Thrombin, PAI-1 and VN generate equimolar, binary thrombin/PAI-1 complexes and in addition equimolar, ternary complexes and multimers.     

Follow-up of long-time treatment with intravesical oxybutynin for neurogenic bladder in children

Functional imaging of a language task using positron emission tomography was performed as part of the preoperative assessment of a patient with a left supplementary motor area (SMA) tumor. Positron emission tomography scans were obtained during language tasks (verb generation and word reading of visually presented nouns) that normally lead to increased blood flow in the SMA relative to a control condition (visual fixation). In the patient, the normal SMA response was an order of magnitude larger in the region of the tumor. Other regions, such as left inferior frontal cortex and right cerebellum, showed equivalent activation in the patient and normal subjects. Histopathologic study revealed an anaplastic astrocytoma. Thus, this exaggerated vascular response to local neuronal activation occurred in the setting of a proliferation of glial cells. This is consistent with models of coupling of regional CBF and neuronal activity that implicate glia as the mediator between neurons and vasculature. The concept that tumoral disruption of normal vascular responses could, in some cases, potentially enhance rather than dampen the response is proposed.     

Faecal incontinence in children with spina bifida: the best conservative treatment

We report the case of a 75-year-old woman with an uneventful medical history who presented with sudden-onset diplopia immediately after neck trauma in a traffic accident. Clinical and ophthalmological examinations were consistent with bilateral abducens nerve palsy. The causal relationship, including the medicolegal implications and the pathophysiological mechanism are discussed. The case demonstrates that exceptionally benign trauma can cause severe diplopia. The delay to recovery may be very long, suggesting caution concerning the decision of surgical care.     

Stamey-Lorenz operation for treatment of stress urinary incontinence in women

The Stamey-Lorenz operation was presented as a new method for treatment of stress urinary incontinence in women. During operation the urethra is suspended by using special needles and under cystoscopic control, thus proper vesico-urethral angle is restored. 10 incontinent women were cured using this method, 8 with good results. In two cases we failed.     

Behavioral treatment of urinary incontinence: a complementary approach

When treating urinary incontinence, the first choice for treatment should be the least invasive and with the fewest side effects. Behavioral intervention is one such treatment modality. Behavioral interventions are defined as a change in the relationship between the patient's symptoms and his/her environment. Behavioral interventions include fluid and dietary management, toileting assistance, bladder retraining, urge suppression, and pelvic muscle rehabilitation. Intermittent self-catheterization is also considered a behavioral intervention when combined with fluid/dietary or toileting changes. Before selecting a treatment option, a detailed history, physical examination, and environmental assessment should be taken. In addition, to effectively employ behavioral interventions, the patient's goals should be determined, the patient should be taught about the underlying causes of his/her problem, and he/she should be provided with not only motivation, but also support. Finally, behavioral interventions recognize the significant contribution that the patient makes in his/her own recovery.     

Nitrofurantoin prophylaxis for bacteriuria and urinary tract infection in children with neurogenic bladder on intermittent catheterization

OBJECT: This study was undertaken to determine the efficacy of preoperative erythropoietin administration in infants scheduled for craniofacial surgery and, in so doing, to minimize problems associated with blood transfusions. METHODS: Families were offered the option of having their children receive erythropoietin injections before undergoing craniofacial surgery. The children whose families accepted this option received daily iron and 300 U/kg erythropoietin three times per week for 3 weeks preoperatively. Weekly complete blood counts with reticulocyte counts were measured and transfusion requirements were noted. Blood transfusions were administered depending on the clinical condition of the child. A case-matched control population was also evaluated to compare initial hematocrit levels and transfusion requirements. Thirty patients in the erythropoietin treatment group and 30 control patients were evaluated. The dose of erythropoietin administered was shown to increase hematocrit levels from 35.4 +/- 0.9% to 43.3 +/- 0.9% during the course of therapy. The resulting hematocrit levels in patients treated with erythropoietin at the time of surgery were higher compared with baseline hematocrit levels obtained in control patients at the time of surgery (34.2 +/- 0.5%). Transfusion requirements also differed: all control patients received transfusions, whereas 64% (19 of 30) of erythropoietin-treated patients received transfusions. CONCLUSIONS: The authors conclude that treatment with erythropoietin in otherwise healthy young children will increase hematocrit levels and modify transfusion requirements. Erythropoietin therapy for elective surgery in children of this age must be individualized according to the clinical situation, family and physician beliefs, and cost effectiveness, as evaluated at the individual center.