Biomedical subjects
Publications and source records attributed to R A Appell.
Urinary incontinence should not be accepted as inevitable, and is not solely the province of urologic specialists. A through history and physical examination, performed by the primary care physician, is the cornerstone of evaluation Most cases respond to behavioral and medical therapy.
OBJECTIVES: To determine the potential utility of glutaraldehyde cross-linked collagen (GAX-collagen) administered in an antegrade fashion into the submucosa of the bladder neck in patients who present with postprostatectomy urinary incontinence. METHODS: Twenty-four men aged 59 to 76 years (mean 69.0) with stress type urinary incontinence after radical prostatectomy were evaluated in this study. All patients had previously received retrograde collagen (mean number of treatments 4.33; amount of collagen was 25.72 mL) and had failed to develop further improvement by this approach alone. These patients subsequently received antegrade collagen via a suprapubic approach. An average of 7.1 mL of GAX-collagen was used for the procedure. RESULTS: Minimal follow-up was 12 months (range 12 to 15). Patients were considered cured if they were dry and wore no pads or were socially continent with less than one pad per day. Eighteen of 24 patients (75%) were dry at the 6-month follow-up. With longer follow-up at 12 months, however, only 9 of 24 patients (37.5%) were totally dry. All patients experienced symptomatic improvement as manifested by lower pad usage. CONCLUSIONS: With proper patient selection, antegrade administration of GAX-collagen in patients who have failed standard retrograde collagen injection may salvage many patients from eventual failure of the conservative treatment approach. As newer injectables become available, the overall results may improve.
The Vesica percutaneous bladder neck stabilization (PBNS) represents a minimally invasive surgical procedure for the treatment of stress incontinence caused by hypermobility of the proximal urethra and bladder neck. Since the initial description of the procedure, technique and instrumentation modifications have added to the reproducibility of this operation. Three specific modifications have been incorporated: strong attachment of the stabilization suture to the pubic bone utilizing a bone anchor; incorporation of a full-thickness broad segment of tissue including the endopelvic, pubocervical, and subvaginal fascia as well as vaginal wall in a Z suture; and loose resuspension of the proximal urethra to stabilize the continence mechanism. Cystoscopic verification of suture location precludes bladder entry or distal suture placement. This procedure has been utilized in 71 women with an overall cure rate (no stress incontinence) of 94% at follow-up of 12 months. One retropubic abscess required drainage, and a second patient required excision of a skin sinus tract caused by an infected bone anchor. Urinary retention longer than 3 weeks has not been encountered. Overall morbidity has been minimal. Long-term follow-up of continence status and other procedure-related complications is ongoing. The PBNS provides continence results and complication rates equivalent to those of other retropubic and transvaginal procedures using a minimally invasive outpatient technique.
PURPOSE: We reviewed our experience with Le Bag orthotopic urinary diversion in 38 cases. MATERIALS AND METHODS: Between April 1990 and January 1995, 38 men underwent radical cystectomy and Le Bag urinary diversion for treatment of bladder cancer. Approximately 20 cm. each of detubularized ileum and cecum were used to construct the pouch. A total of 22 pouches was fashioned with absorbable staples. In 21 cases freely refluxing Bricker ureterointestinal anastomoses were used. RESULTS: There was no significant difference in major complication rates in the hand sewn versus stapled anastomosis groups, and there were no complications specifically related to the use of staples. There were 3 episodes of febrile urinary tract infection: 2 in the Bricker group and 1 in the tunneled anastomosis group. There was no significant difference between the 2 groups with respect to ureteral obstruction. The daytime continence rate was 91%, and 80% of the patients are completely dry or have only mild incontinence at night. Most patients had mild hyperchloremic metabolic acidosis postoperatively as evidenced by a decrease in median serum bicarbonate level (28 versus 24 mmol./l.). This difference appears to be related to pouch length (r = 0.58, p = 0.0002). CONCLUSIONS: We conclude that the Le Bag technique is a technically feasible form of urinary diversion with functional results similar to other forms of orthotopic diversion. Use of absorbable staples simplifies pouch construction without increasing complications. This form of urinary diversion is associated with hyperchloremic metabolic acidosis, which is related to pouch length.
OBJECTIVE: Our purpose was to determine the efficacy of transvaginal electrical stimulation in treating genuine stress incontinence. STUDY DESIGN: This was a multicenter, prospective, randomized, double-blind, placebo-controlled 15-week trial comparing the use of an active pelvic floor stimulator with a sham device. Thirty-five women used an active unit and 17 control subjects used sham devices. Weekly and daily voiding diaries were recorded throughout the trial. Urodynamic testing, including pad test and subtracted cystometry, was done before and at the end of device use. Pelvic muscle strength was measured at baseline and at the end of the trial. Patients scored their symptoms on visual analog scales and completed quality-of-life questionnaires before and after therapy. RESULTS: Significant improvements from baseline were found in patients using active devices but not in controls. Comparisons of changes from baseline between active-device and control patients showed that active-device patients had significantly greater improvement in weekly (p = 0.009) and daily (p = 0.04) leakage episodes, pad testing (p = 0.005), and vaginal muscle strength (p = 0.02) when compared with control subjects. Significantly greater improvement was also found for both visual analog scores of urinary incontinence (p = 0.007) and stress incontinence (p = 0.02), as well as for subjective reporting of frequency of urine loss (p = 0.002), and urine loss with sneezing, coughing, or laughing (p = 0.02), when compared with controls. Pad testing showed that stress incontinence was improved by at least 50% in 62% of patients using an active device compared with only 19% of patients using sham devices (p = 0.01). Voiding diaries showed at least 50% improvement in 48% of active-device patients compared with 13% of women using the sham device (p = 0.02). No irreversible adverse effects were noted in either group. CONCLUSIONS: Transvaginal pelvic floor electrical stimulation was found to be a safe and effective therapy for genuine stress incontinence.
The failure to store urine resulting from bladder outflow incompetence requires a method to increase outflow resistance. Peri- and intraurethral injection is one form of treatment capable of accomplishing this need. The best results are obtained in those women who do not have detrusor abnormalities, who have adequate bladder capacity, who have no anatomic abnormality, and have demonstrable intrinsic sphincteric deficiency of function. The technique is tolerated well by patients and reduces the need for alternative major open surgical procedures.
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We investigated the effectiveness and associated complications of treatment with an endoluminal urethral sphincter prosthesis in 153 spinal cord injury men (mean age 36 years, range 16 to 74 years) with urodynamically diagnosed detrusor-external sphincter dyssynergia. These patients were prospectively treated with a urethral sphincter stent at 15 centers in North America. Followup ranged from 2 to 33 months. Voiding pressures averaged 76 +/- 28, 42 +/- 21, 44 +/- 38, 35 +/- 18 and 32 +/- 20 cm. water, respectively, before prosthesis insertion in 153 patients and at 3 months in 123, 6 months in 114, 12 months in 98 and 24 months in 22. A significant decrease in voiding pressure was noted in the 22 patients at 24 months compared with matched preoperative data (80 +/- 25 cm. water, p = 0.03). The residual urine decreased from 181 +/- 154 ml. before insertion to 82 +/- 93 ml. at 24 months (p = 0.01). Maximum cystometric capacity remained constant, with a mean of 195 +/- 158 ml. before insertion to 248 +/- 122 ml. at 24 months (p = 0.17). No significant differences were apparent after 24 months of followup in any of the urodynamic parameters between 44 patients with and 109 without previous external sphincterotomy. Hemorrhage requiring blood transfusion, obstructive hyperplastic epithelial overgrowth and soft tissue erosion did not occur. No deleterious effects were observed on renal or erectile function. Of the patients 43 (28.1%) required 2 prostheses to bridge the external sphincter completely. Stent removal was required in 10 patients. Seven explantations were required for prosthesis migration, 1 for pain and urethral edema, 1 for inability to maintain a condom catheter, and 1 for nonepithelialization and secondary bladder neck obstruction. A total of 13 patients (8.5%) required a subsequent operation for bladder neck obstruction. Therefore, the sphincter prosthesis is an attractive modality for the treatment of external sphincter dyssynergia in patients with and without previous external sphincterotomy because of its ease of deployment and minimal associated morbidity.
This is simultaneously an exciting and confusing time for those caring for patients with BPH. For years we thought we had the answer, TURP, but costs and complications have opened this area for further study in alternative methods for the management of BPH. The pathogenesis and the maintenance of BPH is poorly understood and the natural history of BPH has not been well characterized. The bothersome level of symptoms to individual patients varies widely as well as the expectations of patients to the outcome of treatment. Satisfaction and cure are not necessarily identical, especially in patients with BPH, in which there seems to be great variability in the clinical course. Perhaps, in the future, this will be able to be related to the equally variable histological picture of BPH. There are problems in designing appropriate clinical trials for the evaluation of new treatments for BPH to take into account these variabilities in patient cases and histology (Table 9). The proper evaluation of new approaches to the management of patients with BPH takes years to complete, and physicians must resist the temptation to rush into any new treatment without reasonable caution for proven safety and efficacy when compared with existing modalities of treatment.
The goal of treatment in patients with ISD is to allow for coaptation of the urethral mucosa without obstruction. Urodynamically this means that the pressure necessary to open the urethra (leak point pressure) is increased but no appreciable change occurs in the closure pressure of the urethra. Periurethral injections have the potential to accomplish this need. Contigen appears efficacious and safe in the properly chosen patient. The cross-linking of the bovine collagen has enhanced the durability of the substance when injected and reduced the potential to produce local immune-type reactions. None of the patients in the multicenter trial (many of whom have been followed for more than 5 years) have had an adverse event related to immunogenicity. The technical aspects of the actual injection process are easily learned, and no special equipment is needed. More important than technique is patient selection. The best results are attained in those patients who do not have detrusor problems, have an adequate bladder capacity, and have minimal anatomic abnormality (urethral hypermobility). Because injection of Contigen can usually be done with local anesthesia alone, a significant number of patients who are not acceptable candidates for open surgical procedures (slings and artificial sphincters) may benefit from this treatment. It is anticipated that Contigen will be a valuable adjunct in the management of both adult and pediatric incontinence problems.
Urinary incontinence affects millions of elderly American men and women. This paper reviews the causes of urinary incontinence and the evaluation that can be easily accomplished as an outpatient with minimal expense and morbidity.
Urinary incontinence is a common problem that affects millions of elderly men and women and their caregivers. Evaluation of incontinence is easy and inexpensive and does not require hospitalization. A basic evaluation consists of history taking (including a review of drug use), physical examination, and appropriate laboratory testing. Urodynamic evaluation may also be necessary. Treatment may consist of behavior modification techniques (eg, Kegel exercises, biofeedback, bladder retraining), use of a mechanical device or pharmacologic agent, or surgery. Should medical and surgical methods fail, alternatives are available to ensure patients' well-being and comfort.
The Magnetip* double J type ureteral stent has been used in a wide variety of clinical urological settings. We reviewed the use of the stent in 50 patients. In 45 patients stents were placed in conjunction with extracorporeal shock wave lithotripsy, stone manipulation, obstruction due to pregnancy or malignancy, pyeloplasty and ureteroneocystostomy. In 83 per cent of the attempts the stent was placed successfully. Retrieval with the Magnetriever* was accomplished in 86 per cent of the cases (100 per cent in female and 76 per cent in male patients). Details of stent use are described.
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Explore the source record for details and available documents.