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Biomedical subjects

G D Webster

Publications and source records attributed to G D Webster.

At least 19 recordsLinked to original sources
PubMed1998

Dorsal onlay urethroplasty for urethral stricture repair.

Full-thickness penile skin grafts have long proved to be valuable in substitution urethroplasty. However, occasional cases of poor graft take, sacculation, or shrinkage of the repairs have mitigated their success. A determining factor in the outcome of grafts is their mechanical support. Historically, ventral placement of the graft has been used, primarily because of the simplicity of access and the excellent graft bed offered by the spongy tissue. However, mechanical support in this location is suboptimal in comparison with that offered by the corpora cavernosa. Recently, dorsal placement of the graft has been proposed, allowing the skin patch to be spread fixed on the tunica albuginea of the corporal bodies overlying the stricture. Fixation of the graft may minimize its retraction and increase its neovascularization. To date, this innovation has proved to be very promising.

Graft Survival↗
PubMed1998

Transvaginal repair of vesicovaginal fistulas after hysterectomy by vaginal cuff excision.

PURPOSE: When repairing vesicovaginal fistulas after hysterectomy there is often reluctance to excise totally the fistula tract for fear of enlarging the tissue defect. It has been suggested that consequent tension on suture lines may cause recurrence of an even larger fistula. On the other hand, a basic surgical principle is that scar tissue margins will not heal as quickly or at all compared to fresh viable margins. We reviewed whether our technique of total excision of the fistula tract and vaginal cuff scar provides an efficient cure rate. MATERIALS AND METHODS: We retrospectively analyzed the outcomes of 20 women who underwent vaginal cuff excision repairs of a vesicovaginal fistula after total hysterectomy. Women who had complex fistulas and/or prior radiation therapy were excluded from study. RESULTS: Of the 20 patients 3 (15%) sustained a bladder lesion that was repaired intraoperatively and 7 (35%) underwent 1 or more attempts at secondary repair. All fistulas were at the vaginal cuff. Mean fistula size was 0.7 cm. (11 women). All repairs were performed as soon as possible after presentation except 2 (10%) that were delayed because of the fistula appearance. The fistula tract was excised totally in all patients. All patients were cured. There were no postoperative complications and no significant or symptomatic vaginal shortening. CONCLUSIONS: Transvaginal vaginal cuff excision repair is an effective first attempt cure of vesicovaginal fistulas after hysterectomy. Excision of the fistula tract and vaginal cuff scar enables the surgeon to suture viable tissues in every layer, thereby providing conditions optimal for wound healing. This procedure obviates the need to wait for tissue readiness and to interpose a flap in the majority of patients.

Adult↗
PubMed1998

Pubovaginal sling using cadaveric allograft fascia for the treatment of intrinsic sphincter deficiency.

PURPOSE: Pubovaginal sling is the definitive management of female stress urinary incontinence due to intrinsic sphincter deficiency. Customarily, autologous fascia has been used, although synthetic material has its proponents. Harvesting autologous fascia at surgery is associated with postoperative discomfort, and synthetic material has a history of infection and erosion. To assess whether allograft fascia is free from these drawbacks, we retrospectively compared the outcome of women undergoing pubovaginal sling using either autologous or cadaveric allograft fascia. MATERIALS AND METHODS: We reviewed our experience during the last 28 months with patients treated with the pubovaginal sling for intrinsic sphincter deficiency. All patients underwent preoperative video urodynamics. The outcome was assessed using the SEAPI scoring system. Special attention was devoted to local sling tolerance. Operative time and length of hospital stay were compared between patients with allograft and autograft pubovaginal sling. RESULTS: A total of 92 women (mean age 60 years) underwent allograft (59) or autograft (33) pubovaginal sling. Preoperative parameters, such as percent of patients who had had previous incontinence surgery, mean leak point pressure and SEAPI incontinence score, were similar in both populations. Mean followup was 11.5 months (range 1 to 28) for the overall population. The SEAPI scoring system showed that patients were markedly improved, with no significant difference between the allograft and autograft groups. Allograft and autograft pubovaginal slings were equally well tolerated, and no infection or erosion was encountered. Mean operative time and hospital stay were significantly shorter when using allograft compared to autograft fascia. CONCLUSIONS: The success rates of allograft and autograft pubovaginal sling were equally high, and no complications related to the cadaveric origin of the allograft fascia were observed. Allograft pubovaginal sling was well tolerated, and its use significantly shortened operative time and hospital stay.

Adolescent↗
PubMed1997

Voiding dysfunction following incontinence surgery: diagnosis and treatment with retropubic or vaginal urethrolysis.

PURPOSE: A retrospective analysis was done of women undergoing urethrolysis for post-cystourethropexy voiding dysfunction to identify possible predictors of outcome. MATERIALS AND METHODS: The charts of 51 sequential women who underwent 54 urethrolysis procedures between 1986 and 1996 were reviewed. The most common presenting symptoms were irritative in 38 patients, obstructive in 31, de novo urge incontinence in 28 and persistent retention in 12. Onset was immediate after suspension in 84% of the patients. Median time from last cystourethropexy or sling to urethrolysis was 15 months (range 4 to 268). Initial evaluation consisted of multichannel video urodynamics and cystoscopy in all women. The techniques of urethrolysis were retropubic in 35 cases, vaginal in 15 or infrapubic in 4, with simultaneous repeat suspensions performed in 63%. RESULTS: A successful outcome with complete resolution of symptoms or significant improvement was achieved in 86% (retropubic), 73% (vaginal) and 25% (infrapubic) of the cases with a median followup of 10 months. No parameter examined, namely urodynamic variables, number of previous suspensions, time from suspension to urethrolysis or surgical approach, was a statistically significant predictor of outcome. CONCLUSIONS: Urodynamics may not show classic obstructive voiding in women who benefit from urethrolysis. Our only absolute selection criterion for offering urethrolysis is a clear temporal relationship of symptoms to cystourethropexy. Retropubic and vaginal techniques for urethrolysis provide similar results but morbidity is seemingly less with the vaginal approach. Omental or Martius fat pad interposition may be of benefit.

Adult↗
PubMed1997

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.

Aged↗
PubMed1997

Treatment of complex anterior urethral stricture disease with mesh graft urethroplasty.

PURPOSE: Treatment of complex anterior urethral strictures complicated by a lack of sufficient penile skin for primary flap repair has generally consisted of 2-stage scrotal inlay urethroplasty. Scrotal skin has shortcomings, most notably hair formation, diverticula and stricture recurrence from urine induced dermatitis. As an alternative, we present our results with staged mesh graft urethroplasty using split-thickness skin, which is nonhair-bearing, easier to size and seemingly less permeable to urine penetration. MATERIALS AND METHODS: Between 1990 and 1995, 20 men underwent mesh graft urethroplasty for complex strictures, most after failed urethroplasty. Meshed split-thickness skin graft from the thigh (17 men) or full-thickness foreskin (3) was used. RESULTS: Overall median time to closure was 5.5 months, and 6 men required revision before closure (revision of ostia in 3, chordee release in 2 and lysis of graft adhesions in 1). A successful outcome, as evidenced by retrograde urethrography and history, was achieved in 12 of 15 men (80%) with a median followup of 38 months. Five men have not undergone closure due to patient refusal (2) or because the graft is not ready to be closed (3). Of the failures 2 men had retrograde urethrographic evidence of stricture at the proximal anastomosis and 1 had recurrent stenosis of the entire neourethra by 2 years. CONCLUSIONS: Mesh graft urethroplasty is not a panacea but it is a valuable adjunct in the treatment of complex urethral strictures, offering comparable results to and benefits over scrotal inlay procedures. In a significant percentage of cases it is a multistage rather than a 2-stage procedure.

Adolescent↗
PubMed1997

Favorable outcome of pubovaginal slings for geriatric women with stress incontinence.

PURPOSE: Traditionally pubovaginal slings have been associated with a greater risk of immediate morbidity and prolonged voiding dysfunction compared to other stress incontinence repairs. Because elderly patients already have inherently greater perioperative risk and prevalence of innate voiding dysfunction, there is some reluctance to construct slings in this age group. We examined the outcome of pubovaginal sling in elderly women versus younger controls to determine whether this concern is justified. MATERIALS AND METHODS: We retrospectively analyzed the outcome of 19 geriatric women older than 70 years who underwent a pubovaginal sling procedure between 1992 and 1995, and compared the findings to those of 77 younger control women with a mean followup of 22 months. All women had video urodynamically proved stress incontinence due to intrinsic sphincter deficiency and many had coexistent bladder instability symptoms. Women with neurogenic causes for incontinence were excluded from the study. RESULTS: Stress incontinence resolved in 100% of geriatric and 97% of control women. Preoperative instability symptoms, including urge incontinence, improved in more than 50% of patients in both groups. De novo instability symptoms arose in 10% of women in each group but were generally controlled with anticholinergics. Efficient voiding resumed within a mean of 16 days in both groups. CONCLUSIONS: The morbidity and success rates of pubovaginal sling surgery in the elderly compare favorably to those in younger women. Advanced age alone would not dissuade us from constructing a pubovaginal sling when indicated.

Adult↗
PubMed1996

Kock versus right colon continent urinary diversion: comparison of outcome and reoperation rate.

OBJECTIVES: To compare one surgeon's sequential experience with two types of continent cutaneous diversion; namely, the Kock pouch (KP) and the right colon pouch (RCP). METHODS: Outcomes for the final 30 KP patients seen during the period 1989 to 1992 and the initial 30 RCP patients seen between 1992 and 1995 were analyzed retrospectively. Patients differed in median age (KP 52.5, RCP 63.5 years), in number in whom malignancy was the reason for diversion (KP 18, RCP 25), and median follow-up period (KP 50, RCP 16 months). RESULTS: No intraoperative complications or perioperative deaths occurred. Immediate postoperative complications were mild and self-limited in both groups, with the exception of 1 RCP patient who developed life-threatening hemorrhage from a ruptured splenic artery aneurysm. KP patients had a statistically higher (P < 0.05) surgical revision requirement (16 patients, 26 revisions) than RCP patients (4 patients, 4 revisions). The majority of KP revisions were for efferent limb problems. Of the 14 KP patients not requiring revision, 4 have mild incontinence not warranting surgery. Three renal units showed new mild hydronephrosis (2 KP, 1 RCP) and are being observed. Prolonged diarrhea was present in 1 patient in each group, and vitamin B12 supplementation was required in 1 KP and 2 RCP patients. CONCLUSIONS: The markedly higher rate of surgical revision with the Kock pouch has led to our change in practice in favor of the right colon pouch for continent cutaneous urinary diversion.

Colon↗
PubMed1996

Bladder outlet obstruction in women.

While voiding dysfunction is relatively common in women, true bladder outlet obstruction is a rare condition and may be present in a misleading manner. To make an accurate diagnosis and tailor appropriate treatment, urodynamic investigation is required. However, even sophisticated urodynamic studies have limitations in predicting obstruction as a complication of anti-incontinence surgery and response to ureterolysis.

Female↗
PubMed1996

Endoscopic management of the obliterated anastomosis following radical prostatectomy.

PURPOSE: We evaluated an endoscopic technique to treat the challenging problem of an obliterated anastomosis following radical prostatectomy. MATERIALS AND METHODS: Four men with a mean 2.25 cm. obliterative defect underwent visual internal urethrotomy along a sternal guide wire passed under direct antegrade and retrograde vision. Men then performed self-dilation according to an increasing interval protocol. RESULTS: All 4 men maintained anastomotic patency for a mean followup of 12.5 months and 1 no longer requires self-calibration. There were no complications of this procedure. CONCLUSIONS: Endoscopic management coupled with self-dilation offers a safe, minimally invasive option for difficult, long obliterative anastomotic defects following radical prostatectomy.

Aged↗
PubMed1995

Impotence following pelvic fracture urethral injury: incidence, aetiology and management.

OBJECTIVE: To evaluate the potency status of patients undergoing delayed perineal repair following a pelvic fracture urethral injury to determine the incidence and aetiology of impotence. PATIENTS AND METHODS: Long-term potency (> 6 months post-operatively) was subjectively evaluated in 92 patients and correlated with their pre-operative and intra-operative findings. The management of their impotence was aso reviewed. Thirty original pelvic radiographs were assessed independently to determine if the pattern of bony injury was associated with the development of impotence. RESULTS: Fifty-seven patients (62%) remained impotent in the long term with a median follow-up of 48 months (range 12-128) and the operation did not render any potent patient impotent. Self-injection with vasoactive agents was successful in 24 of 27 (89%), suggesting a neurogenic aetiology in the majority. Bilateral pubic rami fracture was also associated with a high incidence of impotence. CONCLUSION: Disruption of the cavernosal nerves lateral to the prostatomembranous urethra behind the symphysis pubis is the most likely cause of impotence in this injury.

Adolescent↗
PubMed1995

Detrusor instability.

Detrusor instability is a common cause of urgency and urge incontinence in neurologically normal patients. It is defined as an involuntary phasic detrusor contraction of any pressure associated with symptoms of urge or leakage while the patient is attempting to inhibit micturition. The etiology is unknown but it has been associated with congenital causes, aging, stress incontinence, and bladder outlet obstruction. Diagnosis relies on a urologic history and physical examination, a voiding diary, and a urodynamic evaluation. Treatment is primarily pharmacologic and behavioral, with surgical options being reserved for selected patients.

Humans↗
PubMed1994

Performance of four computer-based diagnostic systems.

BACKGROUND: Computer-based diagnostic systems are available commercially, but there has been limited evaluation of their performance. We assessed the diagnostic capabilities of four internal medicine diagnostic systems: Dxplain, Iliad, Meditel, and QMR. METHODS: Ten expert clinicians created a set of 105 diagnostically challenging clinical case summaries involving actual patients. Clinical data were entered into each program with the vocabulary provided by the program's developer. Each of the systems produced a ranked list of possible diagnoses for each patient, as did the group of experts. We calculated scores on several performance measures for each computer program. RESULTS: No single computer program scored better than the others on all performance measures. Among all cases and all programs, the proportion of correct diagnoses ranged from 0.52 to 0.71, and the mean proportion of relevant diagnoses ranged from 0.19 to 0.37. On average, less than half the diagnoses on the experts' original list of reasonable diagnoses were suggested by any of the programs. However, each program suggested an average of approximately two additional diagnoses per case that the experts found relevant but had not originally considered. CONCLUSIONS: The results provide a profile of the strengths and limitations of these computer programs. The programs should be used by physicians who can identify and use the relevant information and ignore the irrelevant information that can be produced.

Analysis of Variance↗
PubMed1994

Synchronous management of anastomotic contracture and stress urinary incontinence following radical prostatectomy.

Of 77 patients presenting for artificial urinary sphincter implantation due to incontinence following radical prostatectomy 26 had a significant associated urethrovesical anastomotic contracture. Synchronous endoscopic contracture incision with electrocautery and implantation of an artificial urinary sphincter (AMS800) were performed in all cases. A total of 25 patients void with a good subjective flow, with an average followup of 32 months. In 1 patient symptomatic stenosis recurred 6 months after incision and reincision was successful at the time of sphincter revision. No infection or erosion developed and 24 patients are socially continent (0 to 1 thin pad per day). During this time 5 patients underwent 8 revisions of the artificial sphincter. Synchronous contracture incision with electrocautery and artificial urinary sphincter implantation are safe and provide satisfying results in patients with complex post-prostatectomy incontinence.

Anastomosis, Surgical↗