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Biomedical subjects

R A Appell

Publications and source records attributed to R A Appell.

At least 55 records · Page 3Linked to original sources
PubMed1998

Surgery for the treatment of overactive bladder.

OBJECTIVES: To describe surgical options that may be indicated when conservative management of overactive bladder is unsuccessful. METHODS: The literature on current endoscopic and open surgical procedures is reviewed. RESULTS: The endoscopic approach of hydrodistention under anesthesia may be therapeutic, but normally offers only temporary relief of symptoms. Among open surgical procedures, cystolysis has not withstood the test of time and is no longer used. Partial rhizotomy can reduce reflex bladder contractility while preserving other important urogenital functions. Peripheral denervation via a vaginal approach appears effective in as many as 70% of patients with motor instability, but is not effective in interstitial cystitis or other sensory bladder disorders. Transvesical phenol injection is most effective for detrusor instability (DI) caused by multiple sclerosis. Enterocystoplasty is more helpful in intractable DI than in interstitial cystitis. Detrusor myomectomy has yielded excellent results in patients with neurogenic causes of DI. Urinary diversion is rarely required in DI, but may be preferable to enterocystoplasty when severe pelvic pain is present. CONCLUSIONS: When appropriately chosen, surgical procedures can substantially improve the quality of life of some individuals with overactive bladder.

Cystoscopy↗
PubMed1998

Teloscopy.

Explore the source record for details and available documents.

Cystoscopy↗
PubMed1998

Collagen injection therapy for post-prostatectomy incontinence.

PURPOSE: Post-prostatectomy incontinence has an incidence of 5 to 12% and greatly affects quality of life. Since the approval of glutaraldehyde cross-linked collagen there is a renewed interest in injectable urethral bulking agents. We investigated the long-term efficacy and prognostic criteria for transurethral collagen injection therapy for men with post-prostatectomy incontinence. MATERIALS AND METHODS: From November 1993 to May 1995, 62 men with post-prostatectomy incontinence (54 after radical prostatectomy and 8 after transurethral resection of the prostate) were treated with collagen via a transurethral approach. Median followup was 29.0 months from the date of the last injection procedure. RESULTS: Social continence was defined as dry or minimal leakage requiring at most 1 pad daily with activity. Of 62 patients 38.7% achieved social continence and 8.1% became totally dry. The success rate was 35.2 for radical prostatectomy versus 62.5% for transurethral prostatic resection patients. Of the patients who achieved social continence with at least 1-year followup 23 (60.9%) remained so with no further treatment. At 2-year followup 21 patients (42.8%) maintained social continence. The success rate was 27.3% for those who wore a penile clamp or condom catheter before treatment (3 of 11 patients), and only 21.4% for those who underwent transurethral incision of a bladder neck contracture (3 of 14). A median of 4 injection procedures and 20.0 ml. collagen were required to achieve social continence. CONCLUSIONS: Transurethral collagen injection therapy is a reasonable treatment option for post-prostatectomy incontinence in select patients in whom more conservative therapy has failed. However, patients who have required a penile clamp, experienced continuous leakage or undergone transurethral incision of a bladder neck contracture are unlikely to respond well to this treatment.

Activities of Daily Living↗
PubMed1997

The use of bone anchoring in the surgical management of female stress urinary incontinence.

Recent reviews have noted failures of transvaginal surgical procedures designed to cure female stress urinary incontinence (SUI). Modifications continue to be applied to improve the transvaginal approach, including anchoring of the supporting sutures to the pelvic bones, reduction of the transvaginal dissection to help reduce further prolapse, and simpler techniques to allow a wider use of sling procedures. This paper reports on the use of a bone-anchoring technique and preservation of the endopelvic fascia in both transvaginal suspension surgery for hypermobility and sling surgery for intrinsic sphincteric deficiency. Results show an 81.7% cure rate in 71 patients who underwent the bone-anchor suspension and were followed for at least 3 years; a 97.5% cure rate in 40 patients who underwent an in situ sling procedure with bone anchoring and were followed for at least 2 years; and a 94% cure rate in 78 patients who underwent a sling procedure with autologous or synthetic material and bone anchoring and were followed for at least 2 years. The use of this bone-anchoring technique and preservation of the endopelvic fascia appears to enhance the success rate without increasing the risk to the patient and, as minimally invasive procedures, reduce the surgery time and the length of hospitalization, thus reducing costs.

Female↗
PubMed1997

Clinical efficacy and safety of tolterodine in the treatment of overactive bladder: a pooled analysis.

OBJECTIVES: To examine the safety, efficacy, and tolerability of tolterodine in four randomized, double-blind, parallel, multicenter, 12-week studies of patients with overactive bladder. METHODS: Two of the four studies compared tolterodine (2 mg twice daily) to oxybutynin (5 mg three times daily) and placebo, one study compared tolterodine (2 mg twice daily) to oxybutynin (5 mg three times daily), and one study compared two dosages of tolterodine (1 and 2 mg twice daily) to placebo. Efficacy was determined from micturition diaries and patient perception of their bladder condition. Safety and tolerability were assessed from adverse events and laboratory measures. RESULTS: A total of 1,120 patients were randomized and treated at 134 centers. For the primary efficacy variable, the number of micturitions/24 hours, pooled results showed a significant decrease from baseline for the 1 mg tolterodine (P < 0.001), 2 mg tolterodine (P < 0.001), and 5 mg oxybutynin (P < 0.01) groups, compared to placebo. Both tolterodine doses and oxybutynin significantly decreased incontinence episodes/24 hours and significantly increased volume voided/micturition, compared to placebo. Tolterodine at a dose of 2 mg twice daily and 5 mg oxybutynin twice daily were significantly more effective in improving patient perception of bladder condition than placebo. Tolterodine at a dose of 2 mg and 5 mg oxybutynin were equivalent in their effectiveness. Tolterodine at doses of 1 mg and 2 mg were tolerated significantly better than oxybutynin when adverse events, dry mouth (both frequency and intensity), dose reductions, and patient withdrawals were considered. CONCLUSIONS: Although oxybutynin is highly effective, its clinical utility is limited by systemic side effects that lead to frequent discontinuation of treatment or dose reductions. Patients receiving tolterodine should not experience these limitations and instead will get safe and long-term effective treatment for their condition.

Adult↗
PubMed1997

Female Stress Urinary Incontinence Clinical Guidelines Panel summary report on surgical management of female stress urinary incontinence. The American Urological Association.

PURPOSE: The American Urological Association convened the Female Stress Urinary Incontinence Clinical Guidelines Panel to analyze the literature regarding surgical procedures for treating stress urinary incontinence in the otherwise healthy female subject and to make practice recommendations based on the treatment outcomes data. MATERIALS AND METHODS: The panel searched the MEDLINE data base for all articles through 1993 on surgical treatment of female stress urinary incontinence. Outcomes data were extracted from articles accepted after panel review. The data were then meta-analyzed to produce outcome estimates for alternative surgical procedures. RESULTS: The data indicate that after 48 months retropubic suspensions and slings appear to be more efficacious than transvaginal suspensions, and also more efficacious than anterior repairs. The literature suggests higher complication rates when synthetic materials are used for slings. CONCLUSIONS: The panel found sufficient acceptable long-term outcomes data (longer than 48 months) to conclude that surgical treatment of female stress urinary incontinence is effective, offering a long-term cure in a significant percentage of women. The evidence supports surgery as initial therapy and as a secondary form of therapy after failure of other treatments for stress urinary incontinence. Retropubic suspensions and slings are the most efficacious procedures for long-term success (based on cure/dry rates). However, in the panel's opinion retropubic suspensions and sling procedures are associated with slightly higher complication rates, including longer convalescence and postoperative voiding dysfunction.

Clinical Trials as Topic↗
PubMed1997

Evaluation and medical management of female urinary incontinence.

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.

Female↗
PubMed1997

Collagen injection therapy for female intrinsic sphincteric deficiency.

PURPOSE: Since glutaraldehyde cross-linked collagen was approved for use, studies have reported success or improved rates of 63 to 86%. Long-term efficacy with strictly defined outcome criteria has not been reported. We report our experience with collagen injection therapy for female patients with intrinsic sphincteric deficiency to establish efficacy, duration of response and clinical predictors of success. MATERIALS AND METHODS: A total of 96 women underwent collagen injection via a periurethral approach with local anesthesia. In all patients history, physical examination and video urodynamics documented intrinsic sphincteric deficiency without urethral hypermobility. Continence success was defined as dry or socially continent (minimal leakage requiring 1 or no pad daily even with strenuous activity). Median followup was 14.0 months. RESULTS: Of 94 patients 67.0% achieved continence, 38.3% became dry and 28.7% became socially continent. Of 35 patients who achieved continence with at least 1 year of followup 6 had regression. Therefore, 82.9% of those successfully treated remained so at 1 year and none had de novo detrusor instability. An average of 2.1 procedures and 11.9 ml. collagen were required to achieve continence. The 31 patients not achieving success underwent an average of 3.2 procedures with 16.1 ml. collagen. No major complications have occurred to date. CONCLUSIONS: Collagen injection achieves a reasonable rate of continence and good durability at 1 year of followup in female patients with intrinsic sphincteric deficiency and no urethral hypermobility.

Aged↗
PubMed1996

Percutaneous antegrade collagen injection therapy for urinary incontinence following radical prostatectomy.

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.

Aged↗
PubMed1996

Vesica percutaneous bladder neck stabilization.

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.

Endoscopy↗
PubMed1996

The Le Bag orthotopic urinary diversion.

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.

Anastomosis, Surgical↗
PubMed1996

Collagen injection therapy in the treatment of urinary incontinence.

Patients with intrinsic sphincteric deficiency (ISD) require a procedure to create urethral compression or coaptation by employing a sling procedure, the artificial urinary sphincter, or intraurethral injections. Collagen, marketed under the trade name Contingen, is the most commonly used injectable in the United States currently. When a patient exhibits poor urethral function, lack of detrusor instability, and good anatomic support, she/he is considered an ideal candidate for intraurethral injections. Methods of injection are described for male and female patients. The only adverse effects of collagen injections have been transient and treatable, including urinary retention in up to 8% and urinary infection in 4%. The treatment response in female patients using collagen is similar to surgical procedures to correct ISD; newer approaches and techniques for needle localization appear promising in improving the results of implantation in male patients postprostatectomy.

Biocompatible Materials↗
PubMed1996

Percutaneous bladder neck suspension: technique and results.

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 into this procedure: strong anchoring of the suspension suture to the symphysis pubis using a bone anchor, incorporation of a broad segment of vaginal wall with a Z suture, and loose resuspension of the proximal urethra. Cystoscopic verification of suture location precludes bladder entry or distal suture placement. This procedure has been currently used in 71 women with an overall cure rate of 94% (no stress incontinence) at follow-up of 12 months. One retropubic abscess required drainage. A second patient required excision of a skin sinus tract cause by an infected bone anchor. Urinary retention of > 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. PBNS provides equivalent continence results and complication rates as compared with other retropubic and transvaginal procedures with a minimally invasive outpatient technique.

Female↗
PubMed1995

Pelvic floor electrical stimulation in the treatment of genuine stress incontinence: a multicenter, placebo-controlled trial.

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.

Double-Blind Method↗
PubMed1995

Injectables in the treatment of female 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.

Drug Implants↗