The effect of urinary tract reconstruction on neurologically impaired women previously treated with an indwelling urethral catheter

PURPOSE: We investigated the changes in sexuality and quality of life that evolve after lower urinary tract reconstruction in neurologically impaired women previously treated with an indwelling urethral catheter. MATERIALS AND METHODS: A total of 18 neurologically impaired women treated with an indwelling urethral catheter underwent bladder reconstruction. Pubovaginal sling urethral compression was required to restore perineal dryness in 13 patients and was the only operation required in conjunction with intermittent catheterization in 3. Eight patients underwent ileocystostomy, that is creation of a "bladder chimney," and 4 underwent augmentation cystoplasty with creation of a continent catheterizable stoma. In 3 patients ileocystoplasty alone with intermittent urethral catheterization was performed. All patients were followed 6 to 40 months (mean 18) after reconstructive surgery using a 9-part questionnaire to score numerically the effect of surgical reconstruction on sexuality and quality of life issues. RESULTS: On a scale of 0 (worst) to 5 (best) mean score for self-esteem improved from 1 preoperatively to 4 postoperatively, self-image from 1 to 4, sexual desire from 2 to 4 and ability to cope with disability from 1 to 4, respectively. In 4 of the 15 women who were sexually active preoperatively the frequency of sexual intercourse doubled from a mean of 3 to 6 times per month, respectively, and all 4 women reported improved sexual satisfaction. All 13 patients with pelvic pain and 5 with symptoms of autonomic dysreflexia noticed significant improvement if not complete resolution of the symptoms. CONCLUSIONS: Neurogenic lower urinary tract dysfunction treated with an indwelling urethral catheter is detrimental to sexuality and quality of life in neurologically impaired women. Urinary tract reconstruction restores not only quality of life but also sexuality by improving self-image, self-esteem and the ability to cope. Indwelling catheterization as a method of long-term urinary treatment should be avoided in women.     

Induction of early and bioeffective antibody response in rodents with the luteinizing hormone-releasing hormone vaccine given as a single dose in biodegradable microspheres along with alum

Total urinary incontinence is a difficult problem faced by the urologist. Several techniques to increase ureteral resistance have been described. The majority of them rely on intermittent catheterization for bladder emptying, especially in neurogenic incontinence. We have developed a new procedure in which a bladder flap is used to create a neourethra. This urethral extension acts as a flap valve to provide continence. Bladder emptying is accomplished by clean intermittent catheterization. Urethral lengthening with an anterior bladder-wall flap was performed in 18 patients aged a mean of 8.9 years who had neurogenic incontinence (14) or exstrophy (4). Patients with previous bladder interventions received a lateralized anterior flap. Bladder augmentation was performed in 14 of the 18 patients [detubularized ileum (11), detubularized colon (3)]. The average follow-up period is currently 29.3 months. Continence was achieved in 13 of the 18 patients (72%). Complications included urethrovesical fistulae, which developed in two patients. Two patients could not perform catheterization due to pain but had no obstruction to passage of catheter (exstrophy). Ureteral lengthening with an anterior bladder-wall flap is a useful alternative for the surgical treatment of urinary incontinence. This technique achieves a good continence rate and presents few problems with catheterization.     

Somatosensory evoked potential monitoring used to compare the effect of three asymmetric sternal retractors on brachial plexus function

OBJECTIVES: Patients with spinal cord injury (SCI) and chronic indwelling catheters are known to be at increased risk of bladder malignancy. "Decatheterization" by clean intermittent catheterization, external condom catheterization, or spontaneous voiding is thought to reduce the risk by decreasing the chronic mucosal irritation and rate of infection. We examined two Department of Veterans Affairs (DVA) data bases to test this theory. METHODS: A population-based retrospective analysis of invasive treatments for carcinoma of the bladder in all DVA hospitals was conducted using computerized inpatient files from fiscal years 1988 to 1992. RESULTS: One hundred thirty patients with bladder malignancy were identified from a pool of 33,565 patients with SCI (0.39%). All 130 patients underwent either radical cystectomy (n = 63, 48%) or transurethral resection of bladder tumor (n = 67, 52%). The 30-day perioperative mortality and overall 5-year survival rates were 2 (1.5%) and 49 (38%) of 130, respectively. Of the 130 patients analyzed, 42 (32%) had adequate data available regarding tumor pathologic findings and method of bladder management for analysis. The average age at diagnosis was 57.3 years. The histologic finding was transitional cell carcinoma in 23 (55%), squamous cell carcinoma in 14 (33%), and adenocarcinoma in 4 (10%) of 42. Bladder management was an indwelling urethral catheter in 18 (43%), suprapubic catheter in 8 (19%), clean intermittent catheterization in 8 (19%), and condom catheter in 6 (14%) of 42 patients. Squamous cell carcinoma was more common in patients with indwelling urethral catheters and suprapubic tubes (11 of 26, 42%) than in those using clean intermittent catheterization, condom catheterization, or spontaneous voiding (3 of 16, 19%). CONCLUSIONS: Bladder cancer was diagnosed in approximately 0.39% of this large SCI population during a 5-year period. Most cancers (55%) were transitional cell carcinomas. Squamous cell carcinoma was more common in patients with SCI and indwelling catheters than those without chronic catheterization. These data continue to suggest that avoidance of indwelling catheters, when feasible, is the preferred method of bladder management in patients with SCI.     

Bladder cancer and squamous metaplasia in spinal cord injury patients

The influence of long-term indwelling urethral catheterization was studied by random bladder and urethral biopsies in 62 spinal cord injury patients. Six patients (10 per cent) had diffuse squamous cell bladder carcinoma, 4 of whom had no tumor visible endoscopically. Five of the patients with cancer were among 25 patients (20 per cent) managed with an indwelling urethral catheter for more than 10 years (average 21 years, range 15 to 30 years). The other cancer patient had been free of the catheter for 27 years after suprapubic cystotomy for 4 years. Gross and microscopic hematuria was associated with cancer. Squamous metaplasia of the bladder was significantly greater in patients who had been catheterized for more than 10 years (80 per cent), compared to those catheterized for less than 10 years (42 per cent) and patients without catheters (20 per cent). Urethral squamous metaplasia increased slightly in long-term catheterization patients. Urinary infection was universal and did not distinguish patients with inflammation, metaplasia or cancer. Therefore, the duration of indwelling catheterization seems to be the major factor in squamous changes in these patients.     

Endoscopic repair in 154 cases of urethral occlusion: the promise of guided optical urethral reconstruction

PURPOSE: We determined whether optical urethral reconstruction, with the use of a Béniqué bougie in the proximal urethra and transrectal digital guidance, is effective for the treatment of long and severe urethral occlusions. However, with some skill the procedure can be done without the bougie for the treatment of short occlusions. MATERIALS AND METHODS: During a 9-year period 154 men with complete urethral occlusion underwent core through optical urethrotomy via transrectal digital guidance, using the Béniqué bougie in 89 (58%). A total of 400 urethrotomies was performed. All lesions were in the posterior urethra except 8 in the pendulous portion. There were 64 war related injuries (41.6%). Combined voiding and retrograde urethrography was not useful to measure the length of the occlusion due to failure of proximal urethral filling. Guided optical urethral reconstruction consisted of optical urethrotomy performed with a Béniqué bougie introduced proximally through the suprapubic catheter site and into the proximal urethra with the index finger of the operator in the rectum. The same procedure was performed blindly without use of the bougie in 65 patients (42%), and in 43 with lesions shorter than 1 cm. and 4 with multiple annular lesions. We also used the blind technique successfully to reestablish 18 occlusions longer than 1 cm. For optimal epithelialization of the urethral tract we suggest leaving a silicone catheter indwelling for 3 months. No prophylactic antibiotics were given. RESULTS: Of the patients 54 (35%) were cured after 1 procedure, whereas the remaining 100 (65%) required 1 to 9 additional urethrotomies (mean 3). Patients with an uninstrumented urethra who were treated initially with suprapubic catheterization required 1 to 6 urethrotomies (mean 2), compared to 1 to 10 (mean 3) for those who had undergone a prior procedure. Hematuria occurred in 9% of the patients, symptomatic urinary tract infection in 7% and slight extravasation in 3.2%. One patient had stress incontinence. CONCLUSIONS: Our procedure is effective, simple, safe, repeatable, inexpensive and minimally invasive, and it does not require special or sophisticated guiding instruments, which are necessary for previously described techniques. It can be performed with or without use of a Béniqué bougie depending on the extent of the lesion and skill of the surgeon. The outcome can be judged from the symptomatic response of the patient, and flow studies and urethrography are not mandatory during routine followup.     

Transvaginal urethrolysis for urethral obstruction after anti-incontinence surgery

PURPOSE: Urethral obstruction following a stress incontinence procedure occurs in 5 to 20% of patients. We examine the success of transvaginal urethrolysis in resolving voiding dysfunction. MATERIALS AND METHODS: A retrospective chart review was performed on 39 patients who had undergone transvaginal urethrolysis for urethral obstruction following an anti-incontinence procedure. Preoperatively, a history was taken, and pelvic examination and either video urodynamics or cystoscopy were done. RESULTS: All 39 patients complained of urge incontinence, 13% had urinary retention, 51% had incomplete bladder emptying and 36% voided to completion but had irritative voiding symptoms. Previous surgery included retropubic urethropexy in 41% of the cases, pubovaginal sling in 38% and bladder neck suspension in 21%. Mean length of followup after urethrolysis was 16 months. Of the 39 patients 33 (85%) had resolution of urge incontinence but 5 still required occasional intermittent catheterization. The remaining 6 patients had continued urge incontinence. An augmentation procedure was performed in 4 patients with improvement of symptoms. CONCLUSIONS: Our data support transvaginal urethrolysis for the treatment of iatrogenic urethral obstruction. It is a rapid, effective and minimally invasive technique that should be considered if voiding dysfunction does not resolve spontaneously.     

Malone antegrade continence enema for adults with neurogenic bowel disease

PURPOSE: We describe the outcomes of adults with neurogenic bowel disease who underwent a Malone antegrade continence enema procedure with or without concomitant urinary diversion. MATERIALS AND METHODS: Consecutive adult patients with neurogenic bowel disease who underwent an antegrade continence enema procedure (continent catheterizable appendicocecostomy for fecal impaction) were retrospectively reviewed. RESULTS: Of the 7 patients who underwent an antegrade continence enema synchronous urinary procedure (ileal conduit, augmentation ileocystoplasty with continent catheterizable abdominal stoma or augmentation ileocystoplasty) was also performed in 6. Mean patient age was 32 years and mean followup was 11 months. Of the 7 patients 6 who self-administered antegrade continence enemas regularly were continent of stool per rectum and appendicocecostomy, using the appendicocecostomy as the portal for antegrade enemas. All 6 compliant patients reported decreased toileting time and improved quality of life. Preoperative autonomic dysreflexia resolved postoperatively in 3 patients. All urinary tracts were stable. In 4 patients 5 complications occurred, including antegrade continence enema stomal stenosis requiring appendicocutaneous revision (1), antegrade continence enema stomal stenosis requiring dilation (1), superficial wound infection (1), small bowel obstruction requiring lysis of adhesions (1) and urinary incontinence (1 who underwent continent urinary diversion). CONCLUSIONS: Patients with neurogenic bladder and bowel disease may benefit from antegrade continence enema performed synchronously with a urinary procedure. Antegrade continence enema may be indicated alone for neurogenic bowel. Patient selection is important.     

Genetic association of bovine lymphocyte antigen DRB3 alleles with immunological traits of Holstein cattle

PURPOSE: Orthotopic lower urinary tract reconstruction has revolutionized urinary diversion following cystectomy. Initially performed solely in male patients, orthotopic diversion has now become a viable option in women. Currently, the orthotopic neobladder is the diversion of choice for women requiring lower urinary tract reconstruction at our institution. We evaluate and update our clinical and functional experience with orthotopic reconstruction in female patients. MATERIALS AND METHODS: Since June 1990, 34 women 31 to 86 years old (median age 67) have undergone orthotopic lower urinary tract reconstruction following cystectomy. Indications for cystectomy included transitional cell carcinoma in 29 patients, urachal adenocarcinoma in 1, mesenchymal tumor of endometrial origin in 1, cervical carcinoma in 1 and a fibrotic radiated bladder in 1. In addition, 1 woman underwent undiversion to the native urethra following a previous simple cystectomy and cutaneous diversion for eosinophilic cystitis. Data were analyzed according to postoperative early and late complications, survival, tumor recurrence, pathological evaluation of the cystectomy specimen, continence status, voiding pattern and patient satisfaction. The median followup in this group of patients was 30 months (range 17 to 70). RESULTS: There were no perioperative deaths, and 4 early (11%) and 3 (9%) late complications. Four patients died, none with a urethral recurrence, including 3 of metastatic bladder cancer and 1 of unrelated causes. In another patient with an extensive mesenchymal tumor of the uterus a sigmoid tumor recurred requiring conversion of the orthotopic reservoir to a cutaneous diversion. All of the remaining 29 patients are alive without evidence of disease. Intraoperative frozen section of the distal surgical margin (proximal urethra) accurately evaluated (confirmed by permanent section) the proximal urethra prospectively for tumor in all 29 specimens removed for transitional cell carcinoma, including 28 specimens (97%) without evidence of tumor and 1 specimen with carcinoma in situ. Complete daytime and nighttime continence was reported by 29 (88%) and 27 (82%) of 33 evaluable patients, respectively. A total of 28 patients (85%) void to completion, while 5 (15%) require some form of intermittent catheterization to empty the neobladder. Patient satisfaction is overwhelming. CONCLUSIONS: The excellent clinical and functional results demonstrated with further followup confirm our initial experience with orthotopic diversion in women. Careful selection of appropriate female candidates for orthotopic diversion is critical, and includes preoperative evaluation of the bladder neck and intraoperative frozen section analysis of the distal cystectomy margin. Furthermore, close monitoring of the retained urethra is mandatory in all women undergoing orthotopic diversion. We believe that the orthotopic neobladder is the urinary diversion of choice in women following cystectomy.     

Injuries to the sexual skin of female chimpanzees at Mahale and their effect on behaviour

We undertook this study to evaluate the mechanism of continence in women who underwent modified radical cystectomy and creation of an ileal neobladder. Our surgical technique was modified in accordance with detailed anatomic dissection of female pelvises with attention to the innervation of the pelvic musculature and urethral sphincter. Ten women aged 41-71 years (mean 64.3 years) underwent nerve-sparing radical cystectomy and creation of an orthotopic neobladder with detubularized ileum. Videourodynamic evaluation was performed 6 months postoperatively to evaluate sphincteric and reservoir function. Seven of the ten patients were totally continent after the procedure, requiring no protective pad. Of these, one requires intermittent self-catheterization. Videourodynamic evaluation revealed a low-pressure reservoir with a mean capacity of 467 ml, and leakage did not occur during Valsalva maneuver. Three patients reported significant incontinence (more than one pad per day) after orthotopic reconstruction. These patients demonstrated intrinsic sphincteric deficiency with a low mean abdominal leak-point pressure of 48.3 cmH2O. Two of these women had stress incontinence preoperatively. In conclusion, continence can be preserved in most women after modified radical cystectomy and orthotopic bladder replacement. Success results from preservation of the intrinsic sphincteric mechanism and the creation of a low-pressure, compliant reservoir. A history of stress incontinence preoperatively appears to predispose to sphincteric weakness postoperatively.     

Linking critical care nursing and genetics with research funding opportunities

OBJECTIVE: To assess the long-term (3-9 years) results of augmentation ileocystoplasty for non-neurogenic female urge incontinence in terms of continence, the need for intermittent self-catheterization and the need for additional or auxiliary treatment, to define the long-term complications and to assess the patients' satisfaction with the outcome. PATIENTS AND METHODS: The study comprised 51 women who underwent augmentation ileocystoplasty for non-neurogenic urge incontinence between November 1987 and December 1993; 27 patients had associated interstitial cystitis. All patients had exhausted conservative methods, with an unsatisfactory outcome. All patients were interviewed about the results of the procedure, and their charts reviewed and updated with relevant information. RESULTS: Within a mean (range) follow-up of 75.4 (36-109) months, 27 patients (53%) were completely continent, 13 (25%) had occasional leaks and nine (18%) continued to have disabling urge incontinence frequently requiring pads. Regular self-catheterization was needed by 20 (39%) patients while the rest emptied adequately with no or minimal residual volumes. Additional pharmacotherapy had to be used by 12 (24%) patients. Three patients later developed stress urinary incontinence and were managed with fascial sling procedures. The patch was revised in two patients and excised from four others because they had high residual volumes and uncontrollable infections. Two patients had an ileal conduit diversion for persistent incontinence. The most common complication was recurrent urinary tract infections, seen in 22 patients using intermittent self-catheterization. Mucus retention occurred regularly in 10 patients, six had chronic diarrhoea, four had latent bowel obstruction, one developed a bladder stone, one an incisional hernia and one developed patch necrosis and perforation. Twenty-seven patients (53%) were happy with the outcome of the procedure while 20 (39%) were not; four patients were unsure whether a change had occurred. CONCLUSION: Augmentation ileocystoplasty is a valuable alternative for women with intractable urge incontinence. However, these patients and their physicians should be aware of its limitations, specifically the possibility that incontinence may persist and the high probability of the need for self-catheterization, with potential subsequent urinary tract infection.     

Urinary incontinence in neurogenic defects and urogenital anomalies in childhood

Dysraphic defects may cause neurogenic incontinence in childhood. Constipation and encopresis are often associated. Depending on the involved segment of the spinal cord hyperreflexia or atonia of the detrusor is observed. Similar findings, without anatomic correlation, can be seen in occult-neurogenic voiding dysfunctions. Therapeutic means aim at preservation of kidney function and the best possible continence. If the symptoms cannot be treated by anticholinergic drugs in a low-capacity, hypertonic bladder, augmentation by bowel segments or continent urinary diversion (e.g. Mainz I pouch) is performed. In the last years modalities of clean intermittent self-catheterization in high-capacity, atonic bladders could be enhanced by the development of new atraumatic catheter systems. Urogenital malformation e.g. proximal epispadias and exstrophic bladder can cause incontinence as well. Recently, new therapeutic concepts were introduced. Ectopic ureter (extraurethral incontinence) in girls or posterior urethral valves in boys as a reason for incontinence must not be forgotten.     

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.     

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.     

The effect of urethral introducer tip catheters on the incidence of urinary tract infection outcomes in spinal cord injured patients

PURPOSE: We attempted to determine whether an introducer tip catheter reduces urinary tract infection in spinal cord injured patients on intermittent catheterization. MATERIALS AND METHODS: The introducer tip catheter bypasses the colonized 1.5 cm. of the distal urethra. Enrolled patients were prospectively entered into the study in alternate groups depending on whether they reflex voided: group 1--on intermittent catheterization with the introducer tip catheter but not voiding spontaneously or wearing an external urinary catheter, group 2--same as group 1 but using a nonintroducer tip catheter; group 3--on intermittent catheterization with the introducer tip catheter, voiding by reflex and wearing an external urinary catheter, and group 4--same as group 3 but using a nonintroducer tip catheter. RESULTS: Statistical significance was shown when comparing patients using versus not using the introducer tip catheter regardless of whether an external urinary catheter was worn (p = 0.0121). A greater difference was noted between patients using and not using the introducer tip catheter in the intermittent catheterization only group (p = 0.0093). CONCLUSIONS: The introducer tip catheter decreased urinary tract infections in hospitalized men with spinal cord injury on intermittent catheterization.     

Urinary bacteria in elderly patients with urinary incontinence and low levels of daily activity

The results of bacteria isolated from the urine of inactive elderly patients with urinary incontinence in 1982, 87, 93 and 95 were compared and the chronological changes of urinary bacteria were analyzed. The following results were obtained: (1) The most common bacteria isolated from the patients in 1995 were D-group Enterococcus, followed by Providencia rettgeri, E. coli, Pseudomonas aeruginosa and Proteus mirabilis. It is thought that the main cause of the more frequent isolation of Enterococcus is an abuse of cephems and fecal contamination. (2) The most common bacteriaisolated from the patients who were managed with an indwelling urethral catheter were Proteus and Providencia species, and their incidence tended to decrease from 1982 to 1995. (3) Infection with Pseudomonas species tended to increase, as did that Staphylococcus species, especially Methicillin-resistant Staphylococcus aureus and then decreased. Based on these findings, it is important to assess and treat dysuria before inserting an indwelling urethral catheter, and to select an antibacterial agent that is effective in elderly patients with urinary incontinence and limited activity.     

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.     

Urologic complications following abdominoperineal resection of the rectum

Perusal of the records of 111 consecutive patients who underwent abdominoperineal resection of the rectum for malignant diseases of the rectum or anal canal for postoperative urologic complications revealed that the urethra had been injured in two patients, the bladder in none, and the ureter in five. In only two of these last five patients was the late result of treatment of the ureteric injury satisfactory. The late result of treatment of the two urethra injuries was good. All the patients had been treated with an indwelling catheter for at least ten days after the operation. About one third of the patients still had disturbances of micturition two weeks after the operation, but only one required a permanent indwelling catheter.     

Responses of natural killer cell activity to acute laboratory stressors in healthy men at different times of day

BACKGROUND: Five renal recipients with neurovesical dysfunction (NVD) were retrospectively reviewed focusing on anatomical and urodynamic abnormalities of the lower urinary tract and their management prior to kidney transplantation. METHODS: The underlying anomalies in these 5 patients were a posterior urethral valve (1 with an imperforate anus; n = 2), meningomyelocele (n = 2) and a congenital short urethra with an imperforate anus (n = 1). Their urinary tracts were evaluated prior to transplantation with voiding cystourethrography, urethrocystoscopy, cystometrography and electromyography of the external urethral sphincter to identify a possible focus of urinary tract infection, urine storage and voiding function. RESULTS: All 5 patients had NVD proven by urodynamic studies or by documentation of urinary retention in the absence of mechanical outlet obstruction. Bilateral high grade vesicoureteral reflux was noted in all patients, requiring ureteroneocystostomy. Clean intermittent catheterization (CIC) was ultimately employed for bladder emptying in all patients. Two patients with poor bladder compliance underwent augmentation cystoplasty before transplantation. The Mitrofanoff procedure was used in 2 patients with structural urethral abnormalities to access the bladder for catheterization. After eradication of possible sources of infection and establishment of a low-pressure urine storage system with bladder emptying by CIC, kidney transplantation was performed. Following kidney transplantation, all of the recipients were asymptomatic for urinary tract infections using CIC. Although 1 patient lost his graft due to chronic rejection, the other 4 other patients have good renal function. CONCLUSION: Kidney transplantation in patients with NVD can be performed provided that their urinary tract problems are properly resolved.     

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.     

Value of transrectal ultrasonography in the assessment of failures of stress urinary incontinence surgery in women

OBJECTIVES: To describe the role of transrectal ultrasonography as an alternative imaging technique in the evaluation of women who continue to be incontinent following surgical management of female stress urinary incontinence. METHODS: The means of independent samples of transrectal ultrasound parameters of two groups of patients (group I, patients who were continent after surgery; group II, patients who remained incontinent after surgery) were compared. RESULTS: Patients who were continent after surgery showed scanty caudal and dorsal mobility of the bladder neck and proximal urethra during the periods of increased intraabdominal pressure. The US finding in this group of patients is characterized by a funnel surrounding the bladder neck and the proximal urethra. The existence of an intrinsically incompetent sphincter can also be determined with this technique. CONCLUSIONS: Transrectal ultrasonography constitutes an alternative imaging technique in the evaluation of women who continue to be incontinent following surgical management of female stress urinary incontinence. It permitis determining whether incontinence is due to a failed procedure, the existence of an intrinsically incompetent sphincter, or whether other causes of incontinence should be investigated.