Prospective biochemical study of the antioxidant defense capacity in retinopathy of prematurity]

We reviewed our experience with 17 cases of posterior urethral disruption due to traumatic pelvic injuries. In all cases, a suprapubic cystostomy was performed at first. For blunt injuries, urethroplasty was delayed for 6 months in average. For most of the penetrating injuries (3/4), we performed immediate debridement and primary repair. Resulting bulbous or membranous strictures less than 3 cm long were treated with one-stage perineal excision-reanastomosis urethroplasty. Membranous strictures longer than 3 cm were managed with a combined transpubic-perineal repair, while bulbous defects longer than 3 cm were treated with a scrotal pedicled island flap. The overall restricture rate was 25%. Those having had initial repeated urethrotomies displayed a 100% restenosis rate. Incontinence rate was 12.5% Erectile dysfunction occurring in 42% of our patients is a sequela of the pelvic injury and was found to be directly related postoperatively to its presence at the time of surgery.     

Quenching the thirst in dialysis patients

OBJECTIVE: To review the results of the operative treatment of posterior urethral injuries in children. PATIENTS AND METHODS: A total of 29 children (25 boys and two girls, age range 3-14 years) with injuries to the posterior urethra were admitted to this department over 14 years. Twenty-three patients presented immediately after trauma and six were referred after unsuccessful attempt(s) at surgical repair. RESULTS: Fourteen patients underwent suprapubic diversion and primary realignment over a catheter. Urethral continuity with normal urinary continence was achieved in seven of these patients. Four patients underwent a re-operation; urethral reconstruction was successful in these patients, but one patient remained incontinent. Primary realignment with anastomosis was performed in nine patients; the results were satisfactory in six. Urethral stricture developed in all of four patients who were managed with a suprapubic cystostomy alone; a staged repair using the transpubic approach was carried out in two of them and one improved. Partial urethral tears in two patients healed with urethral catheterization alone. CONCLUSION: Primary realignment of the urethra with anastomosis and suprapubic diversion resulted in the highest rate of success for normal urethral continuity. Urethral strictures or urinary incontinence were not major problems in this group. Therefore, we recommend this approach for the initial management of urethral injuries in childhood. Transpubic urethroplasties may be reserved for secondary repair.     

Simple reaction time as a measure of global attention in Alzheimer''s disease

Urethral obliteration is an uncommon complication of urethral injury and is usually associated with pelvic fracture. Until recently, surgical reconstruction was the only means available to restore urethral continuity. Although formal urethroplasty may be associated with excellent success rates, impotence and incontinence are potential complications. Endoscopic urethroplasty has recently evolved into a suitable alternative to surgical reconstruction in selected cases. We review here the technique of endoscopic urethroplasty and include our initial results.     

Arguments against the involvement of Borrelia burgdorferi sensu lato in Alzheimer''s disease

The posterior prostatomembranous urethral stricture or distraction defect has historically been the most formidable challenge of stricture surgery. This uncommon lesion occurs most often as the sequelae of pelvic fracture injuries, or straddle trauma, and is associated with serious urethral disruption and separation--an injury that is often complicated by inappropriate initial management using substitution skin flap techniques with the development of recurrent stenosis, irreversible impotence, and occasional incontinence. Management by endoscopic techniques may be possible in patients with short strictures or in those after prostatectomy, but they rarely play a role in resolving the complex obliterated urethra with a significant defect [1]. Resolution of post-traumatic posterior urethral distraction defects and other posterior urethral pathologic conditions has dramatically improved over the past two decades despite an inaccessible subpublic location involving exposed sphincter-active and erectile neurovascular anatomy. The contemporary, perineal, one-stage bulboprostatic anastomotic operation as popularized by Turner-Warwick [20] with selective scar excision is a versatile procedure with a high patent lumen success. Patients undergoing anastomotic urethroplasty have a substained patent urethral lumen success rate approaching 100% versus those who have undergone urethral skin flap or patch repair, where the restricture rate in 5 and 10 years increases twofold to threefold [1, 20]. A patent urethra after an anastomotic urethroplasty at 6 months is free from further recurrent stricture and gives credence to Mr. Turner-Warwick's admonition that "urethra is the best substitute for urethra".     

Blood pressure, renin activity and heart rate changes during propranolol therapy of hypertension

Seven boys with fracture(s) of the bony pelvis and associated partial or complete rupture of the posterior urethra were managed by the time-honored technique of early suprapubic cystostomy and concomitant primary realignment of the urethra over a catheter. Of the 4 children who had a functionally significant urethral stricture 3 were cured within a few months by 1 or 2 simple urethral dilatations and 1 by subsequent transperineal lysis of the angulated urethra from its surrounding fibrous tissue. Followup data for 8 to 22 years (mean 14 years) indicate that all 7 patients void with an excellent stream and are continent, free of infection and potent. In fact, 3 of the 4 married boys have fathered children.     

Obliterative vesicourethral strictures following radical prostatectomy for prostate cancer: reconstructive armamentarium

PURPOSE: We report the reconstructive techniques used to correct obliterative vesicourethral strictures related to prostate cancer surgery. MATERIALS AND METHODS: Four men with anastomotic obliteration after radical prostatectomy underwent primary excision with end-to-end anastomosis, penile fasciocutaneous flap, free-graft urethroplasty with rectus muscle flap or anterior bladder tube with omental pedicle flap procedure. RESULTS: At mean followup of 33.8 months all patients had urethral patency but none was continent. CONCLUSIONS: Single stage reconstruction of the obliterated vesicourethral anastomosis after prostatectomy successfully restored urethral patency. No technique was applicable in all cases. Sphincteric function is likely to be compromised after the primary procedure, resulting in incontinence after successful urethral reconstruction. Subsequent artificial sphincter placement appears to be safe and helpful in restoring continence.     

Urethral duplication in children: surgical treatment and results

PURPOSE: Urethral duplication is a rare congenital anomaly. We report the clinical presentation, imaging findings and surgical treatment in 7 boys with incomplete sagittal duplication of the urethra. MATERIALS AND METHODS: Duplication involved hypospadias in 5 cases (group 1) and a bifid urethra with an accessory preanal tract (Y duplication) in 2 (group 2). Group 1 was treated with 1-stage urethroplasty, including marsupialization of the dorsal orthotopic urethra, ventral-to-dorsal urethrourethrostomy and penile island flap onlay repair to cover the open dorsal urethra. In contrast, group 2 was treated with 2-stage urethral reconstruction with detachment and mobilization of the accessory preanal branch in association with a scrotal tubed neourethra followed by urethroplasty, as in group 1. In all cases the dorsal penile urethra was located between the corpora cavernosa and surrounded by the tunica albuginea. RESULTS: A urethrocutaneous fistula developed in 1 of the 5 group 1 patients. In group 2, 1 patient had recurrent penoscrotal meatal stenosis after the 1-stage procedure and 1 had a urethral diverticulum with calculi at the scrotal tubed neourethra 7 years after urethral reconstruction. Six of the 7 patients now void spontaneously through a meatus located normally at the tip of the glans. The remaining patient with a neurogenic bladder is on intermittent catheterization via appendicovesicostomy due to difficult catheterization of the irregular and sensitive neourethra. CONCLUSIONS: While the ideal surgical management of urethral duplication anomalies remains uncertain, we used a combination of surgical techniques to correct this severe malformation.     

Potential alternatives to erythrocyte transfusion in hemoglobinopathies: hydroxyurea (HU), erythropoietin (EPO), butyrate derivatives, blood substitutes

OBJECTIVE: To evaluate the invaginated sleeve technique for continent cystostomy in humans. PATIENTS AND METHODS: Over the past 5 years six patients have undergone this operative procedure. An essential principle utilized in the technique is the property of partial thickness bladder grafts to stretch longitudinally, so that each tubularized pedicle graft could be directed transmurally and extended extravesically to reach the skin of the lower abdominal wall. As a consequence a urothelial-lined tract, both extravesically and through the bladder wall, was provided for intermittent self-catheterization. RESULTS: Apart from one woman, whose cystostomy tract was disrupted by inappropriate catheterization in the immediate post-operative period to attempt to stop leakage through exposed fenestrations in the suprapubic stent, this procedure provided robust, continent catheterizing routes for all patients for periods of 63, 52, 12, 7 and 1.5 months respectively. Two patients developed discrete stenoses at their mucocutaneous junctions at 3 and 5 months which were corrected easily. CONCLUSION: This simple, minimally morbid technique, which avoids the use of non-urinary tract epithelial structures and maintains bladder capacity, is strongly recommended for patients who need to practise clean intermittent self-catheterization and for whom the urethral route is impracticable.     

Trace elements in egg contents and egg shells of slider turtles (Trachemys scripta) from the Savannah River Site

OBJECTIVES: Stricture of the vesico-urethral anastomosis is a well-known complication after radical prostatectomy. Dilatation, stricture incision or resection have been proposed for endoscopic treatment. METHODS: In a retrospective study of 340 patients with prostatic cancer who underwent a radical retropubic prostatectomy from 1988 until 1996, we looked at the incidence of anastomotic strictures. RESULTS: An anastomotic stricture was found in 24 cases (7%) requiring endoscopic treatment. Based on prospective X-ray studies, we were able to show that the site of stricture is located below the bladder neck musculature in most cases well above the distal urethral sphincter and pelvic floor. No continence problems were encountered following structure resection in a follow-up of 12-72 months determined by a questionnaire and pad test. CONCLUSION: The transurethral resection of anastomotic stricture allows for a rather generous tissue resection, which is preferable to incision or dilatation in our hands.     

Immunohistochemical identification of prostate-specific antigen in a parameatal urethral cyst of the glans penis

PURPOSE: We conducted a retrospective study of patients with strictures after hypospadias repair to identify factors contributing to the development of strictures and to attempt to define an optimal strategy for management. MATERIALS AND METHODS: Patients with the diagnosis of hypospadias who had undergone direct vision internal urethrotomy, urethral dilation or urethroplasty were identified. The original location of the meatus, type of initial repair, subsequent procedures and outcome of the interventions were recorded. RESULTS: A total of 38 patients were identified. Of the 29 patients who were initially treated with direct vision internal urethrotomy or urethral dilation 23 (79%) ultimately required open urethroplasty and did well. Of the 8 patients treated with initial urethroplasty 7 had successful outcomes. Overall success, defined as asymptomatic voiding without fistula or residual stricture, was 78% at a mean followup of 6.3 years. CONCLUSIONS: Stricture disease continues to be a significant complication of hypospadias reconstruction. Initial therapy should be urethral dilation but it should be recognized that the majority of these patients will ultimately require open urethroplasty.     

One-stage hypospadias repair with stent or suprapubic diversion: which is better?

PURPOSE: The authors report on 105 consecutive patients who underwent one-stage hypospadias repair based on use of suprapubic diversion or transurethral drainage with stenting. METHODS: The surgical procedures included 52 metal-based flap urethroplasty (Mathieu) for coronal, subcoronal, and distal shaft hypospadias; 32 transverse island pedicle graft (Duckett) for mid and proximal shaft hypospadias; 21 transverse island pedicle (Duckett) plus rolled midline tube (Thierchs) for penoscrotal and scrotal hypospadias. To accomplish urinary drainage, suprapubic diversion (cystofix) was used in 28 of 52 Mathieu operations, in 17 of 32 Duckett operations, and in 11 of 21 transverse island pedicle graft plus rolled midline tube operations. In the rest of the cases, transurethral drainage with stenting was used. RESULTS: All children had excellent cosmetic and functional outcomes. But the rates of complications such as fistula and meatal stenosis were significantly different between the groups in which suprapubic tube or urethral stent was used. In 56 of the 105 patients in whom suprapubic diversion was used, four (7.14%) had fistulas and three (5.35%) had meatal stenosis, in contrast to a fistula rate of 14.28% and meatal stenosis rate of 12.24% in patients that urethral stent is used for urinary drainage. CONCLUSION: The authors believe that the use of suprapubic diversion is advantageous for the outcome of one-stage hypospadias repair in relation to fistula occurrence and meatal stenosis.     

Inlay-onlay flap urethroplasty for hypospadias and urethral stricture repair

PURPOSE: The absence of a segment of the urethral plate renders the onlay urethroplasty procedure impossible. The plate may be too short (in hypospadias), or scarred after previous repair or due to a dense urethral stricture. A modified approach with restoration of urethral plate continuity is proposed instead of the tubularized island flap associated with higher complication rates. MATERIAL AND METHODS: In 12 of 20 patients with a partially deficient urethral plate the inlay-onlay preputial island flap was used. The wider part of the flap is inlaid in place of the missing plate and anastomosed to the residual plate. Formation of the urethra is then completed with standard onlay overlapping of the flap. In another 8 patients the combined (partially tubularized in advance) tube-onlay flap was used. RESULTS: The inlay-onlay flap technique was used in 3 new hypospadias patients, in 4 with a scarred, hair-bearing plate after previous operations and in 5 with virtually no urethral plate because of a dense urethral stricture. No urethral complications were encountered. Of the 8 patients undergoing the combined tube-onlay repair 3 had complications, including meatal stenosis (2) and partial dehiscence (1). CONCLUSIONS: Inlay-onlay flap urethroplasty allows correction of complex cases of hypospadias or urethral stricture with a partially deficient urethral plate in 1 stage with a low complication rate.     

The endoscopic treatment of extensive urethral strictures and obliteration of the urethra and bladder neck

Extensive urethral strictures, obliteration of the urethra and bladder cervix are thought to be the most complicated urological diseases. They occur more frequently in young and middle-aged persons consequently to pelvic and perineal traumas or they are complications of surgical interventions. Open surgery often cause complications such as suppuration of the operative wound, emergence of urinary fistulas, enuresis, recurrence of the structure or obliteration. Negative results of these operations are also shortening of the penis, erectile dysfunction causing serious social dysadaptation. Current advances in endoscopic instruments and imaging provided design of endoscopic techniques able to represent an effective alternative to open surgical interventions in urethral strictures, obliteration of the urethra and bladder cervix. The experience gained in the Clinic of the Research Institute of Urology in the practice of updated and novel endoscopic interventions aimed at recovery of urethral patency (strictures longer than 1 cm--inner optic urethrotomy, obliteration of the urethra and bladder cervix--endoscopic recanalization) has proved the advantages of the endoscopic techniques over open operative interventions. They are most cost-effective, result in better outcomes, bring about no erectile dysfunction.     

Fetal biparietal diameter as a predictor of a mature lecithin/sphingomyelin ratio

There was a 20 per cent mortality rate of 193 patients with bladder injury and in 94 percent of all patients there were associated injuries that caused the deaths. Blunt external trauma was responsible for 95 per cent of the injuries. Cystography revealed a falsely negative result in 3 patients with extraperitoneal rupture. Management of the 29 intraperitoneal, 36 extraperitoneal and 2 intraperitoneal and extraperitoneal ruptures comprised vesical repair and drainage in 60 patients, urethral catheter alone in 1 patient and no treatment in 6 in whom the rupture was found at autopsy. The advantages and disadvantages of urethral catheter drainage are discussed. Early diagnosis and treatment of bladder rupture are important if the significant mortality is to be reduced.     

Helical computed tomography of the liver: evaluation of the different circulatory phases

Perineal war wounds involve the anterior perineum or urogenital perineum and posterior perineum or ano-sphincteric perineum. They are rare in civilian practice and in war practice, as only a small and hidden surface of this anatomical region is exposed to damaging agents. An isolated wound of the perineum is rarely life-threatening, but always threatens the functional prognosis of these patients, who have a mean age less than 30 years. In war practice, these wounds are often associated with lesions of adjacent of sacral, buttock or abdomino-pelvic regions. This article is confined to perineal war wounds in men. Lesions of the urethra and anus and rectum, as well as lesions of the genital appendages and pelvic nerves, leave micturating, gastrointestinal and sexual sequelae, which are sometimes permanent. These sequelae must not be exacerbated during investigation and surgical repair, despite the unfavourable emergency context, associated lesions and the time required to repair them. The basic principles of surgical treatment remain urinary diversion by a large cystostomy tube for urogenital lesions, faecal diversion by terminal colostomy for ano-sphincteric lesions, conservative debridement of the margins of the anal or urethral wound, debridement and drainage of contaminated soft tissues and connective tissue spaces. First-line immediate suture of the urethra or edges of the anal wound must be considered according to the defect, and the septic and haemorrhagic context. When ideal repair cannot be performed, alignment over an urethral catheter, urethrostomy, fixation-identification of the urethral or anal extremities constitute intermediate procedures allowing secondary urological and proctological specialized procedures in these patients.     

Abdomino-pelvic-gluteal war injuries. Principles of treatment

From a series of 316 cases of war wounds, the authors selected those cases in which the entry or exit wound was situated between the iliac crests and the inferior gluteal fold and report a series of 21 wounds (including 17 assault gunshot wounds) involving the perineal, pelvic and/or gluteal regions. Wounds of these regions are characterized by their immediate severity (10% mortality in this series), due to the complexity of combined lesions (urethra, rectum, hip, abdominal and vascular lesions) and the severity of sequelae. This series included 5 anorectal wounds, 5 urethral wounds and 4 hip wounds. Based on this series and a review of the literature, the authors discuss diagnostic problems (risk of missing abdominal penetration, a retroperitoneal rectal wound or an articular wound). Principles of treatments are also described (wide debridement and drainage, systematic colostomy for wounds of the rectum and large soft tissues wounds, systematic cystostomy for bladder and urethral wounds and alignment of urethral wounds whenever possible, articular lavage and immobilization by external fixation of hip wounds).     

Periurethral polytetrafluoroethylene paste injection in incontinent female subjects: surgical indications and improved surgical technique

We present the results with 2 techniques for periurethral polytetrafluoroethylene (Polytef) injection in 21 female subjects with type III stress urinary incontinence. The standard technique included the use of a stainless steel needle for injection, paste "sopping" and a Wolff, Storz or Lewy syringe as an injecting element. Postoperatively, no catheters were left indwelling and all patients were encouraged to urinate following recovery from the anesthesia. The modified technique included the use of a 14F angio-catheter for injection of the paste, paste heating and a Lewy syringe or Mentor gun as injector. Postoperatively, all patients were left with an indwelling suprapubic catheter for 3 to 5 days. A total of 27 injections was performed, including 9 with the standard technique and the last consecutive 18 with the modified technique. Average followup has been 11.4 months. Cure, improvement and no change rates from the preoperative condition were 11%, 22% and 67% with the standard technique and 39%, 17% and 44% with the modified technique, respectively. In the latter group 3 patients had received pelvic radiotherapy as definitive treatment for pelvic malignancies. The overall failure rate in patients with a stable detrusor was 42% compared to 75% in the group with bladder instability and low compliance. Advantages of the modified technique include avoidance in the formation of intraoperative and postoperative fistulas, and easier handling and injection of the heated paste to achieve urethral compression. Improved short-term results with the modified technique indicate that a larger group of patients and long-term followup are essential requirements to determine the true efficacy of this technical modification. Based on these preliminary results, we now prefer the modified technique to the standard technique in the management of type III stress urinary incontinence.     

Management of obliterative posttraumatic posterior urethral strictures after failed initial urethroplasty

PURPOSE: We evaluate the problems encountered during surgery and assess the results of different endoscopic and open surgical methods following failed urethroplasty for posttraumatic posterior urethral stricture. MATERIALS AND METHODS: Since 1992 we have treated 23 patients in whom urethroplasty for posterior urethral strictures failed. Of these patients, 3 had undergone 2 previous repairs and 6 had additional complicating factors, such as fistula, periurethral cavity and false passage. End-to-end anastomosis was done in 14 patients via a transperineal (7) or transpubic (7) approach. In 1 patient substitution urethroplasty using a radial artery based forearm free flap was performed. In 3 patients a 2-stage urethroplasty was done, 4 underwent core-through optical internal urethrotomy and 1 underwent endoscopic marsupialization of a false passage. RESULTS: At 1 to 5-year followup 3 of the 23 patients had restenoses (13%), including 2 in whom previous treatment failed. The remaining 87% of the patients void well and are continent, and there is no worsening of the preexisting potency status. CONCLUSIONS: Previous failed urethral stricture repair complicates management due to fibrosis, impaired vascularity and limited urethra available for mobilization. Recurrent strictures less than 1.5 cm. can be managed successfully with core-through internal urethrotomy. End-to-end anastomosis is possible in the majority with generous use of inferior pubectomy or the transpubic approach with certain modifications. When residual inflammation or long strictures are present a 2-stage procedure is a safer option. Overall, reoperation can offer a successful outcome for the majority of these complex strictures.     

Does prostate transitional cell carcinoma preclude orthotopic bladder reconstruction after radical cystoprostatectomy for bladder cancer?

PURPOSE: We determined if urethral preservation and orthotopic bladder replacement in patients with transitional cell carcinoma within the prostatic urethra or prostate placed these patients at risk for urethral recurrence or death. MATERIALS AND METHODS: The clinical course of all patients undergoing urethral preservation and orthotopic bladder replacement was reviewed. The urethra was sacrificed only if the distal prostatic urethral margin was positive for transitional cell carcinoma. The pathological T stage and the grade of the primary malignancy, local recurrence, site of recurrence (urethral, pelvic, distant) and death were documented. RESULTS: Of 81 patients 70 were evaluable (June 1996) with a mean followup of 35 months. Of the 70 patients 48 were alive without evidence of disease for a mean of 38 months (range 8 to 107) and 5 died without evidence of disease. Eight of these 53 patients (15%) had prostatic involvement (carcinoma in situ in 6, intraductal carcinoma in 1 and stromal invasive transitional cell carcinoma in 1). Of the 70 patients 17 had disease recurrence (13 died of disease and 4 are alive, 1 of whom had urethral recurrence without initial prostatic transitional cell carcinoma). Of the 17 patients (35%) 6 had transitional cell carcinoma prostatic involvement (carcinoma in situ in 4 and stromal invasion in 2), and 5 of these 6 died, none with or of urethral recurrence but of the primary bladder pathology. Of these 5 patients 1 had stromal invasive transitional cell carcinoma of the prostate and experienced a bulbar urethra recurrence at 1 month and a pelvic recurrence at 3 months, and died at 5 months. Death was not secondary to the urethral recurrence. Thus, of the 14 patients who had prostatic transitional cell carcinoma, only 1 had urethral recurrence (7%), and this recurrence did not present as the cause of death. CONCLUSIONS: The guidelines for urethral resection can be relaxed, increasing the opportunities for orthotopic reconstruction, without placing the patients at increased risk for death of transitional cell carcinoma.     

Four-hour voiding observation in young boys with posterior urethral valves

PURPOSE: We evaluated 4-hour voiding observation as a method of basic assessment of bladder dysfunction in young boys with posterior urethral valves. MATERIALS AND METHODS: Voiding pattern, including number of voids, voided and residual urine volume, and bladder capacity, was determined noninvasively in 24 boys younger than 4 years with posterior urethral valves and compared to that of healthy age matched controls. Results were then compared to those of standard cystometry. RESULTS: The number of voids was higher, voided volume was smaller and residual urine volume was higher in the posterior urethral valve group. There was no difference in voiding pattern before and after removal of the anatomical obstruction. Voided and residual urine volume, and bladder capacity were higher on standard cystometry than on voiding observation. CONCLUSIONS: Four-hour voiding observation is an easy noninvasive method that focuses on emptying difficulties and clearly detects differences in voiding patterns between boys with posterior urethral valves and healthy, nontoilet trained children. We recommend the method as a complement to standard cystometry for the diagnosis and followup of bladder dysfunction in young boys with posterior urethral valves to identify the need for treatment.