Prostatitis and bladder neck obstruction

BACKGROUND AND OBJECTIVES: Development in surgical technology must demand not only improved efficacy and risk reduction but also a reduction in costs and efficient use of human resources. For 25 years we have discussed the development of optical access trocars and their probable benefits. They are now available in the form of the OPTIVIEW by Ethicon and the SURGIVIEW by US Surgical. METHODS: Between December 1996 and March 1997, we utilized the optic obturator trocar, OPTIVIEW, in 104 cases of gynecological operative laparoscopy. The instrument was equipped with an axial grip to facilitate ergonomic handling. RESULTS: The optical trocar was used with a Z-incision techniques in 16 cases; a vertical incision was used in 58 cases. In all of the gynecological procedures, the optical trocar was more advantageous than classic trocars placed without direct vision. Our estimation was that separation of tissue layers was very good in 71 cases, good in 26 cases and problematic in 5 cases. No complications occurred with the use of this trocar. The Z-incision was preferable to the vertical incision although it required a longer time of insertion of up to 5 seconds. Altogether, the OPTIVIEW presented an easy way of avoiding intestinal and vascular injury during initial trocar entry. CONCLUSIONS: The application of this new tool is practical, safe and handy. However, it requires training in its appropriate use. Vertical incisions should be sutured after removal of the instrument. Additional trocars need not be optical trocars as they can be placed under direct vision and laparoscopic control. It is our opinion that a combination of sophisticated new technologies such as the OPTIVIEW trocar, robotic arm, harmonic scalpel and 3-D vision would provide safe and efficient means to accomplish gynecologic laparoscopic surgical procedures.     

Transurethral prostatic thermotherapy with microwaves (prostatron system) in bladder obstruction secondary to benign prostatic hypertrophy

Since April, 1992, 178 patients with symptomatic benign prostatic hyperplasia were treated by TUMT (363 treatments). Before entering the study, all patients had a Madsen symptom score of > 8, peak flow rate of < 15 ml/s, or average flow rate of < 10 ml/s, and post voiding residual urine of < 300 ml/s. The prostatic length was classified into group I < 50 mm (101 patients) and group II < 50 mm (77 patients). TUMT with the Prostatron device (Technomed) was performed in one, two or three session(s) of one or two hour(s) with analgosedation and on an outpatient basis. After treatment all patients were catheterized for 1-3 weeks; the morbidity rate was very low. Three and six months after treatment, the Madsen symptom score, peak flow rate, average flow rate and postvoiding residual urine improved to a high statistical significance in both groups. TUMT for benign prostatic outflow obstruction proved to be an effective treatment throughout the study period, with minimum morbidity. It must be emphasized that the degree of prostatic enlargement or the severity of the symptoms does not indicate clinical success or failure. However, the degree of bladder outflow obstruction and the quality of treatment achieved are very important: a) In patients with severe obstruction, TURP or open surgery continues to be the treatment that affords rapid relief of their symptoms. b) The clinical response to TUMT is dose-dependent; i.e., higher thermal dose, longer session (2 h) and the use of different catheters enhance the therapeutic efficacy.     

Neuroanatomical changes in the rat bladder after bladder outlet obstruction

OBJECTIVE: To evaluate the perinatal and 2-year outcomes in pregnancies complicated by preterm premature rupture of membranes (PROM) during the second trimester. METHODS: Fifty-three consecutive singleton pregnancies with PROM at 14 to 28 weeks of gestation were studied retrospectively. Management goals were to prolong the pregnancies to 32 weeks through expectant management and to avoid fetal compromise through closer monitoring and active intervention, when necessary, after 23 weeks. Outcome of the surviving infants was based on neurologic, audiometric, and ophthalmologic examinations at 2 years of corrected age. RESULTS: Rupture of membranes occurred at 14-19 weeks (mean 17.4 weeks) in 10 women, at 20-25 weeks (mean 24.0 weeks) in 24, and at 26-28 weeks (mean 27.6 weeks) in 19. The median latency periods to delivery were 72 days, 12 days, and 10 days when rupture of membranes occurred at 14-19 weeks, 20-25 weeks, and 26-28 weeks, respectively. The overall incidence of chorioamnionitis was 28%. There were no fetal deaths and nine neonatal deaths. When rupture of membranes occurred at 14-19 weeks, 20-25 weeks, and 26-28 weeks, the perinatal survival rates were 40%, 92%, and, 100%, respectively. Pulmonary hypoplasia accounted for seven deaths. Of the live-born infants, 81% were alive at 2 years of corrected age. Survival without major impairment was observed in 75%, 80%, and 100% of the survivors when rupture of membranes occurred at 14-19 weeks, 20-25 weeks, and 26-28 weeks, respectively. CONCLUSION: Expectant management of second-trimester PROM offers better perinatal and long-term survival than previously thought.     

Use of ultrasonography in the bladder neck suspension

From 1988 to 1992, 78 patients with genuine stress urinary incontinence underwent bladder neck suspension under ultrasonic monitoring. Tightness of suspension was adjusted by setting posterior urethrovesical angle to approximately 90 degree by transrectal ultrasonography during operation. Urinary continence was achieved in 68 of 78 patients. In the remaining 10 patients, slight incontinence recurred within 6 months after operation. In 60 patients undergoing postoperative chain cystourethrogram, the posterior urethrovesical angles set during operation were about the same as those after operation. In 39 patients undergoing uroflowmetry under the condition that micturition volume was 200 ml or more, urinary flow rate did not decrease after operation. In 20 patients whose posterior urethrovesical angles were measured by transperineal and transabdominal as well as transrectal ultrasonography, angles measured by each ultrasonography were almost identical and neither manipulation could change the configuration of the bladder neck. The posterior urethrovesical angles set during operation were kept postoperatively and provided proper tightness of the suspension suture to achieve urinary continence without any difficulty of urination. Therefore, a posterior urethrovesical angle can be set by transperineal and transabdominal ultrasonography as well as transrectal ultrasonography. While transrectal approach provides the clearest image among the three approaches, transperineal and transabdominal approach carried out with a transabdominal convex or sectorial probe are more convenient than transrectal approach which needed a special probe.     

Dynamics of obstruction in acontractile bladder: attempt at management

Five patients with acontractile bladders were observed during lateral voiding cystourethrography in the resting and straining states. Two abnormalities were noted: (1) posterior displacement of the bladder with closure of the posterior vesicourethral angle on straining, and (2) plication of the bladder over the symphysis pubis, resulting in the formation of an anterior pseudodiverticulum. Two other abnormalities are discussed: closure of the anterior vesicourethral angle, and descent of the bladder and prostate in flaccid paraplegia, causing plication at the prostatic apex. Surgical techniques for the correction of the abnormalities are described.     

Results of radiotherapy of ureteral obstruction in invasive bladder cancer

Retrospective evaluation of the records of 574 patients with muscle-invasive bladder cancer revealed 90 patients (16%) with ureteric obstruction; the obstruction was bilateral in 24%. The effect of radiotherapy was assessed in 55 patients with 68 obstructed kidneys. Six patients with eight obstructed kidneys required percutaneous nephrostomy or ureteric catheters in addition to radiotherapy. Drainage improved in only 20% of kidneys and the diverting catheter could be withdrawn permanently in only one (17%) of the diverted patients. The median survival was 11 months. Irradiation was followed by significant complications in 37 patients (67%). This raises doubts about the assumed beneficial effect of irradiation on ureteric obstruction due to muscle invasive bladder cancer. The short median survival of 11 months confirms that ureteric obstruction is a poor prognostic factor in muscle invasive bladder cancer.     

Dynamic activity of bladder neck and external sphincter in ejaculation

Macroamylasemia and acute pancreatitis are both associated with a high serum amylase. The former is an incidental laboratory finding and seems to have no apparent clinical significance or specificity. On the other hand, acute pancreatitis is a serious illness demanding recognition and treatment. Persistently normal pancreatic scans convincingly exclude acute pancreatitis and should alert one to the possible presence of macroamylasemia.     

Giant bladder diverticulum in Ehlers-Danlos syndrome type I causing outflow obstruction

A series of 33 patients with juvenile dermatomyositis was reviewed in terms of their prognosis in relation to their drug therapy. This retrospective study was intended to help clarify the use of various therapies in this rare, heterogeneous disease from our hospital's experience in the last 24 years. The results confirmed that oral corticosteroids should remain the undisputed first line of treatment. For more refractory, chronic patients, the results suggest that azathioprine should be the favored drug of first choice (in addition to corticosteroids). There may be a role for cyclosporine as a "rescue" treatment, but this needs to be further defined.     

A prospective randomized trial evaluating endoscopic Nd:YAG laser prostate ablation with or without potassium titanyl phosphate (KTP) laser bladder neck incision

OBJECTIVE: The purpose of this investigation was to study the correlation between diagnostic delay and the stage of the lung cancer at the time of operation. A second objective was to study differences in symptoms between the patients grouped according to stage. METHODS: A total of 172 patients consecutively admitted for surgery between 1 January 1994 and 1 June 1995 at the Department of Thoracic and Cardiovascular Surgery of Rigshospitalet National Hospital of Denmark were included in the retrospective study. Two groups of patients were compared, one group with good prognosis (patients in Stages I and II) and one group with poor prognosis (patients in Stages III and IV). The time-spans studied were: (1) interval from the patient's perception of the first symptom to operation; and (2) the time from first contact with the healthcare-system to operation. The median delay between the patient-groups was compared using the Mann-Whitney U-test. To compare the symptoms which brought the patients in contact with the healthcare-system, the chi2-test was used. RESULTS: In the time interval between appearance of the first symptom and operation, a significantly shorter median delay was found for patients with Stages I and II compared to Stages III and IV (P = 0.037). Concerning the interval from first contact with the healthcare system to operation a significantly shorter median delay was found for the group of patients in Stage I and II compared to the patients-group in Stage III and IV (P = 0.017). It was found that the cancer was an accidental finding, significantly more often in patients in Stages I or II compared to patients in Stages III or IV (P = 0.0002). CONCLUSIONS: A few months delay before final treatment of a non-small-cell lung cancer seems to have an impact on the perioperative stage of the cancer, and thereby on the patients prognosis. A screening of asymptomatic risk-group patients will result in recognition of early lung cancer.     

Ureteral obstruction due to primary localized amyloidosis

Localized amyloidosis of the ureter is a rare condition. There are only 27 cases reported. Because of the difficulty in differentiating between localized amyloidosis or other benign conditions and a malignant tumor many cases have led to nephroureterectomy. We report a case of a middle aged woman who had an almost complete obstruction of the right ureter caused by amyloidosis. Biopsies were taken via a ureteroscope prior to exploration of the ureter enabling the patient to be treated with local excision and ureteroneocystostomy instead of nephroureterectomy.     

Usefulness of posterior capsulectomy in the treatment of bladder neck disease

RATIONALE: Presentation of 12-year experience accrued in the surgical treatment of the acquired bladder neck disease. Based on Riches' experience (1961), posterior capsulotomy, although exceptional in terms of indication, was effective in the treatment of 26 patients with early failure of standard endoscopic techniques. MATERIALS AND METHOD: Over a 12-year period, 945 prostatectomies were entered in a protocol, 305 (32.2%) open surgery and 640 (67.8%) transurethral resections. Incidence of sclerosis was 5.03% (48 patients). Treatment of second group with TUR and/or cervicotomy failed in 26 (45-58%) patients. Posterior capsulotomy was effective in 100% patients. RESULTS: Mean follow-up has been productive, and exceeds 4 years based on clinical, radiologic, endoscopic and urodynamic parameters.     

Perioperative bladder management after primary total hip arthroplasty

A retrospective review of 95 consecutive primary total hip arthroplasty patients was performed to assess the clinical outcome of two postoperative bladder management protocols. The first 49 patients (group 1) were treated with a pro re nata straight catheterization protocol. The next 46 patients (group 2) were treated with an indwelling catheterization protocol. There were no differences between the groups with respect to sex or age. The patients in group 2 had significantly lower incidences of urinary retention (P < .0005) and bladder distention (P < .0005) than those in group 1. Preoperative systemic diseases and urologic symptoms did not correlate with the occurrence of postoperative urinary retention or bladder distention. There were no infections in group 1. In group 2, one patient (2%) had bacteriuria and one patient (2%) had a urinary tract infection (P > .1). This trend of increased contamination in the catheterization group may be related to a mean catheterization duration of 72 hours.     

Few patients with "chronic prostatitis" have significant bladder outlet obstruction

Apolipoprotein E (apoE) is one of the amyloid associated proteins that is found in the amyloid plaque of Alzheimer's disease and systemic amyloidosis. ApoE might play an important part in the etiology of Alzheimer's disease by functioning as a "pathologic chaperone" to promote the formation of amyloid filaments. In this study, we investigated whether apoE is associated with amyloid deposits of primary localized cutaneous amyloidosis using immunohistochemistry, immunogold electron microscopy, and immunoblotting. The subjects consisted of 12 patients with lichen amyloidosus and one patient with macular amyloidosis. Light microscopically, amyloid deposits in the dermal papillae were round in shape and stained with Congo red. Immunohistochemically, apoE was detected in amyloid deposits in all the cases examined. Immunogold electron microscopy showed apoE immunoreactivity on the amyloid deposition. Immunoblots of amyloid-positive skin showed 35K and 14K proteins, which were taken to be apoE and its fragment, respectively. In normal skin extract, only the 35K protein was detected by the anti-human apoE. Moreover, the intensity of the amyloid-positive skin sample was stronger than that of the normal skin sample. Monoclonal anti-cytokeratin antibody reacted with the 45K protein of the amyloid-positive skin extract. These results indicate that apoE is a component of primary localized cutaneous amyloidosis, and that it might play an important role in primary localized cutaneous amyloidosis.     

Experimental pyeloureterectomy and calyceal neck transection with autotransplantation and bladder advancement

OBJECTIVE: To determine whether Dexon mesh, closely applied to the kidney, provides purchase for sutures to permit bladder/parenchymal apposition on autotransplantation and that, if this line of apposition were some distance from but surrounding renal papillae, urothelium would proliferate to cover exposed parenchyma to form a widely patent lumen; this should facilitate removal of the whole of an upper tract collecting system, retaining renal parenchyma alone. MATERIALS AND METHODS: To test this possibility and explore the practicability of the concept, nine dogs underwent bilateral nephrectomy followed by unilateral autotransplantation: the other kidney was discarded. Because the canine renal pelvis is intrarenal, the ureter was stretched maximally before passing fine scissors into the renal hilum to transect the collecting system as close to the kidney as possible in six of the nine dogs. In the remaining three dogs, partial nephrectomy was performed with division of the calyceal necks under vision. Thinned bladder wall was sutured to Dexon mesh some distance from the collecting tubules; omentum was applied to the suture line. RESULTS: Three dogs were killed prematurely at < 2 weeks because of perioperative complications. Four were killed at 2, 4, 5 and 8 weeks and two at 12 months. Dexon mesh proved to be an effective anchoring fabric, providing close apposition of bladder wall and parenchyma. There was no adhesion of the kidney to peritoneal contents. Urothelial proliferation to cover exposed parenchyma occurred early and by 12 months, a thin stroma was interposed between parenchyma and epithelium. The kidney was preserved in all but one removed electively, this dog having both cystitis and pyelonephritis at 12 months. CONCLUSIONS: This study showed that autotransplantation of a kidney after removal of its collecting system and advancement of thinned bladder wall to renal parenchyma is practicable, with regenerated urothelium bridging the deficiency by covering exposed parenchyma, to create a widely patent lumen.     

Management of neck pain: a primary care approach

Among the many disorders that cause neck pain, biomechanical stress is the most common. Nonoperative therapies offer relief in most patients within three months. Those with chronic or radicular pain require additional evaluation and multiple therapies for effective relief. Systemic illness and spinal compression require prompt intervention to prevent serious complications.     

Transurethral resection of partially obstructed ejaculatory ducts: seminal parameters and pregnancy outcomes according to the etiology of obstruction

PURPOSE: We determine how transurethral resection of the ejaculatory ducts performed for infertility affects seminal parameters and pregnancy outcomes in patients with partial ejaculatory duct obstruction due to a congenital or acquired etiological factor. MATERIALS AND METHODS: Based on history and physical examination, hormonal profiles, semen analyses, transrectal ultrasonography and vasography findings partial ejaculatory duct obstruction was diagnosed in 14 men a mean of 30 years old who presented for infertility evaluation. Patients were grouped according to congenital or acquired cause of obstruction. Transurethral resection of the ejaculatory ducts was performed using the standard resectoscope loop technique. Clinical outcome was assessed by postoperative analyses of seminal parameters and pregnancy reports. RESULTS: Transurethral resection of the ejaculatory ducts significantly improved semen quality (ejaculate volume and percentage of sperm motility) in all patients in the congenital group, while all but 1 (83%) had an improved sperm count. Pregnancy was achieved via sexual intercourse by 66% of the patients an average of 5.7 months postoperatively. Of the acquired etiological factor group 37.5% had improved semen quality after transurethral resection of ejaculatory duct and 12.5% achieved pregnancy via sexual intercourse. Postoperative complications occurred at a similar rate in each group (33%). However, complications in the congenital etiology group were minor, while 25% of the men in the acquired group had significant impairment of seminal parameters after transurethral resection of the ejaculatory ducts. CONCLUSIONS: Semen quality improvement and pregnancy outcome after transurethral resection of the ejaculatory ducts for partial ejaculatory duct obstruction differ significantly according to the main etiological cause of obstruction. An equivocal diagnosis of partial obstruction and technical problems during transurethral resection of the ejaculatory ducts may contribute to failure. However, in some cases the reason for failure remains unclear.