Outcomes and consequences: the therapeutic index redefined.
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Female↗
Biomedical subjects
R Dmochowski
Publications and source records attributed to R Dmochowski.
Urethral diverticula: evolving diagnostics and improved surgical management.
Urethral diverticula remain problematic from both diagnostic and therapeutic standpoints. Recent developments in pelvic imaging with computed tomography, sensitive ultrasonography, and magnetic resonance imaging have greatly advanced diagnostic acumen and improved the clinician's ability to stage lesions as to location, size, and coexistent pathology. Coupled with improved recognition has come advancements in surgical technique, reflective of improved understanding of urethral anatomy and function. Better use of concomitant procedures, such as pubovaginal sling or soft tissue interposition, has continued a steady trend toward improved surgical outcomes when considering urethral function and urinary continence. This article reviews these mutually complementary trends.
Diverticulum↗
Prospective randomized controlled trial of extended-release oxybutynin chloride and tolterodine tartrate in the treatment of overactive bladder: results of the OBJECT Study.
OBJECTIVE: To compare the efficacy and tolerability of extended-release oxybutynin chloride and tolterodine tartrate at 12 weeks in participants with overactive bladder. SUBJECTS AND METHODS: The OBJECT (Overactive Bladder: Judging Effective Control and Treatment) study was a prospective, randomized, double-blind, parallel-group study conducted between March and October 2000 at 37 US study sites. Participants who had between 7 and 50 episodes of urge incontinence per week and 10 or more voids in 24 hours received extended-release oxybutynin, 10 mg/d, or tolterodine, 2 mg twice daily. The outcome measures were the number of episodes of urge incontinence, total incontinence, and micturition frequency at 12 weeks adjusted for baseline. RESULTS: A total of 315 women and 63 men were randomized and treated, and 332 participants (276 women, 56 men) completed the study. At the end of the study, extended-release oxybutynin was significantly more effective than tolterodine in each of the main outcome measures: weekly urge incontinence (P=.03), total incontinence (P=.02), and micturition frequency episodes (P=.02) adjusted for baseline. Both drugs improved symptoms of overactive bladder significantly from baseline to the end of the study as assessed by the 3 main outcome measures (P<.001). Dry mouth, the most common adverse event, was reported by 28.1% and 33.2% of participants taking extended-release oxybutynin and tolterodine, respectively (P=.32). Rates of central nervous system and other adverse events were low and similar in both groups. CONCLUSIONS: Extended-release oxybutynin was more effective than tolterodine as measured by end-of-study urge incontinence, total incontinence, and micturition frequency episodes. Both groups had similar rates of dry mouth and other adverse events.
Aged↗
Editorial comment. Experience with synthetic slings.
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Biocompatible Materials↗
Erosion of woven polyester pubovaginal sling.
PURPOSE: Various materials have been used for pubovaginal slings to correct female stress urinary incontinence. Use of synthetic materials provides a theoretical advantage in that no graft harvesting is necessary. Major risks of synthetic material use are erosion and infection of the sling. We report on erosion of woven polyester slings treated with pressure injected bovine collagen (ProteGen) which required removal. MATERIALS AND METHODS: Office records of patients who had ProteGen slings removed at 5 centers during the last 24 months were retrospectively reviewed. Presenting symptoms, interval between sling placement and removal, subsequent procedures and continence status following sling removal were evaluated. RESULTS: A total of 34 women required removal of the polyester sling secondary to erosion, infection or pain. The most common presenting complaints were delayed vaginal discharge in 21 patients (62%), vaginal pain or pressure in 21 (62%), suprapubic pain in 11 (32%) and recurrent urinary tract infection in 5 (15%) at a mean of 7.95 months (range 1 to 22) after sling placement. Of the patients 17 (50%) had vaginal erosion only, 7 (20%) isolated urethral erosion and 6 (17%) urethrovaginal fistulas. In 4 patients no erosion was obvious but slings were removed secondary to vaginal pain. Before sling removal 16 patients (47%) were totally dry, 13 (38%) had some degree of urinary incontinence and 3 (8%) had retention. Following sling removal 7 patients (20%) remained dry, 25 (74%) had mild to severe stress urinary incontinence with or without urgency and urge incontinence, and 2 (6%) are pending followup. CONCLUSIONS: Woven polyester slings treated with pressure injected bovine collagen are prone to erosion. Although the ProteGen sling was recalled in January 1999, patients who have had the sling placed must be followed closely.
Female↗
Multivariant analysis of men from infertile couples with and without antisperm antibodies.
PROBLEM: Research studies in animal and human systems have demonstrated conclusively that antisperm antibodies can interfere with fertilization. In the male, autoantibodies to sperm can be detected both in the sera and seminal plasma. METHOD OF STUDY: Ninety-seven men who were tested for antisperm antibodies as a part of an infertility evaluation were identified. Complete medical history was obtained, including information related to events suspected of being associated with antisperm antibodies. History of surgery (varicocele repair, hernia repair, and vas reversal) and infection (epididymitis, sexually transmitted disease, and orchitis) were compared with semen parameters (motility less than 60%, concentration less than 20 x 10(6), and volume less than 2 cc). These were compared to antisperm antibody results of mixed agglutination reaction (MAR) and direct immunobead binding test (IBT) for immunoglobulin G (IgG). Statistical analysis was performed using Fishers exact two-tailed test. RESULTS: As expected, prior vas reversal was significantly associated with the presence of antisperm antibodies (P = 0.0002) by MAR or IBT with a fivefold increased relative risk (95% confidence interval, 1.97-12.38). Other surgeries manipulating the cord structures independent of vas reversal were not associated with antisperm antibodies (P = 0.09). Prior infections, independent of vas reversal, were significantly associated with antisperm antibodies by MAR (P = 0.04) with a 3.8-fold increased relative risk (95% confidence interval, 1.06-13.87) but not by IBT. Sperm concentration less than 20 x 10(6), motility less than 60%, and a volume less than 2 cc were not associated with antisperm antibodies by MAR or IBT. CONCLUSION: These findings suggest that manipulation of the cord structures excluding the vas were not associated with antisperm antibodies; however, vas reversal and prior infection are significant risk factors for the development of antisperm antibodies.
Adult↗
[The variability of the leakage pressure threshold due to exertion "the Valsalva Leak Point Pressure" as a function of the filling volume of the bladder].
OBJECTIVE: To determine the influence of the bladder filling volume on the Valsalva Leak Point Pressure (VLPP) in patients investigated for urinary stress incontinence. PATIENTS AND METHODS: 50 patients investigated for urinary stress incontinence were included in this prospective study. Evaluation consisted of clinical examination, urodynamic examination with simultaneous fluoroscopic assessment and cystoscopy. VLPP was measured while standing every 100 cc during filling until the cystomanometric bladder capacity. RESULTS: We observed a significant reduction of VLPP as a function of bladder filling volume. The VLPP measured at 200 cc constituted the reference value in view of its sensitivity and specificity for the diagnosis of type III urinary stress incontinence (Blaivas' classification). CONCLUSION: Measurement of VLPP must be standardized and interpreted as a function of bladder filling volume.
Adult↗
Primary bladder neck obstruction: urodynamic findings and treatment results in 36 men.
PURPOSE: We reviewed the urodynamic findings and treatment outcomes of a large series of men with primary bladder neck obstruction. MATERIALS AND METHODS: A retrospective review was done of the presenting symptoms and urodynamic findings of 36 men with primary bladder neck obstruction. Outcomes after treatment with alpha-blockers, transurethral incision of the bladder neck and prostate, or no long-term therapy were determined by chart review and patient survey in the majority of cases. RESULTS: Mean age of the men was 41 years. Patients had significant lower urinary tract symptoms, decreased peak urinary flow rates, elevated post-void residual, markedly elevated peak voiding pressures and poor funneling of the bladder neck during voiding. Although most patients initially chose alpha-blocker therapy, only 30% of those beginning alpha-blockers continued them long term, usually due to inadequate symptomatic improvement. A total of 18 men underwent transurethral incision, which resulted in significant improvements in symptom scores, peak urinary flow rates, post-void residual and peak voiding pressures. Patients reported a mean 87% overall improvement in symptoms after transurethral incision. CONCLUSIONS: Video urodynamics facilitate diagnosis of primary bladder neck obstruction. Transurethral incision is the most effective therapy for primary bladder neck obstruction.
Adrenergic alpha-Antagonists↗
Cystometry.
Cystometry provides crucial information on which therapy for voiding dysfunction is predicated. The technique of cystometry can be altered to address specific clinical questions; however, the goal of the study is to reproduce the clinical situation being investigated. Specific areas remain to be clarified, including the estimation and interpretation of compliance and the utility of standard versus natural filling methods.
Compliance↗
[Diverticulum of the female urethra].
The diagnosis and successful treatment of female urethral diverticulum can be facilitated by a heightened clinical awareness coupled with appropriate evaluation and perioperative management. In particular, it is important to address all the preoperative factors to avoid complications de treatment such as recurrence of the diverticulum or urethro-vaginal fistula. The authors also report their clinical experience of evaluating 59 women with urethral diverticula over the last 11 years and describe the technique and complications of diverticulectomy in 49 women.
Diverticulum↗
Peyronie's disease: surgical treatment based on penile rigidity.
Operative treatment of Peyronie's disease has the risk of penile shortening and/or loss of erection. To avoid these complications, we used plaque incision together with polytetrafluoroethylene (Gore-Tex) graft insertion in men with preserved penile rigidity and only implanted a penile prosthesis in men with erectile failure. Between August 1986 and July 1992, 24 men 36 to 72 years old (mean age 53 years) underwent surgery. Of the men 16 with adequate penile rigidity by history and/or RigiScan study, and severe curvature underwent plaque incision and polytetrafluoroethylene graft insertion. Eight men had erectile failure, including 4 with distal flaccidity as demonstrated by RigiScan study. These 8 men received a penile prosthesis (semirigid in 6 and inflatable in 2). In addition, 2 of these men also required plaque incision because of persistent curvature. With a mean followup of 47 months (range 20 to 92), all 16 men with incision and a polytetrafluoroethylene graft had excellent erections with satisfactory intercourse. Minimal curvature away from the plaque incision site, not causing any difficulty with sexual performance, occurred in 7 patients. The men with a penile prosthesis engage in normal intercourse without residual or recurrent curvature. Incision of Peyronie's plaque and polytetrafluoroethylene graft insertion is associated with an excellent functional result in men with normal preoperative penile rigidity. A penile prosthesis should be reserved for men with erectile failure.
Adult↗
Outpatient visual laser-assisted prostatectomy under local anesthesia.
OBJECTIVE: Visual laser-assisted prostatectomy (VLAP) with a noncontact right-angle delivery system recently has been introduced as a new treatment option for symptomatic outlet obstruction secondary to benign prostatic hyperplasia. The right-angle laser technology has numerous potential advantages over traditional transurethral resection of the prostate. These advantages include the feasibility of performing the VLAP procedure under local anesthesia without bleeding. We summarize our experience with VLAP performed with local anesthesia administered with periprostatic block. METHODS: This technique was employed in 46 men with symptomatic BPH as an outpatient procedure. All men were evaluated prior to surgery with flow rates, residual volume determinations, and AUA-6 symptom score analyses. Follow-up occurred at three and six months and included repeat measures of flow rates, residual volumes, and symptom scores. RESULTS: Mean AUA symptom scores and uroflow parameters significantly improved with six months' follow-up. No significant complications were encountered. CONCLUSIONS: VLAP under local anesthesia as an outpatient procedure is a promising treatment alternative for men with symptomatic benign prostatic hyperplasia.
Aged↗
Experience with the management of urethral diverticulum in 63 women.
The presentation and management are reviewed of 63 women with urethral diverticulum seen at a single institution in 10 years. Of the women 36 (61.9%) had urinary incontinence as a presenting symptom and 20 (31.7%) had incontinence as the only presenting complaint. Diverticula were suspected in 57 cases (90.5%) based on the presence of a periurethral mass during pelvic examination. Investigations included voiding cystourethrogram, excretory urogram, urodynamic studies and recently transvaginal ultrasound. Voiding cystourethrography adequately demonstrated the diverticulum in 60 of the 63 women (95.2%). Urodynamic studies performed in 58 women revealed abnormal findings in 36 (62%), including genuine stress urinary incontinence in 28 (48.3%). The location/number/size/configuration, communication, continence classification was used to define the characteristics of the diverticula. Seven women either refused operation or had small asymptomatic diverticula not requiring treatment. Transvaginal diverticulectomy was performed using a 3-layer closure in 56 women. Concomitant bladder neck suspension was performed in 27 women with documented stress urinary incontinence and/or urethral hypermobility. With a mean followup of 70 months (range 6 to 136) 48 women (85.7%) were completely relieved of the presenting complaint. Complications of diverticulectomy included 2 small distal recurrent diverticula, 1 urethrovaginal fistula and 6 transient early urinary tract infections. None of the women had urethral stricture or recurrent urinary tract infection. Six women (22.2%) who underwent diverticulectomy and bladder neck suspension, and 3 (10.3%) treated with diverticulectomy alone had minimal urinary incontinence requiring less than 2 pads a day.
Adult↗
Bladder contracture following intravesical doxorubicin therapy: case report and a review of the literature.
Intravesical doxorubicin rarely has been implicated as a cause of bladder contracture. We present a case of severe bladder contracture, documented radiographically and urodynamically after 8 weekly intravesical instillations of doxorubicin. The patient subsequently underwent cystectomy because of voiding dysfunction and the specimen demonstrated marked fibrosis in the bladder wall. We postulate that a benign, recurrent bladder ulceration during doxorubicin therapy may have potentiated the fibrotic response in the bladder to the doxorubicin. Objective monitoring of bladder capacity should be considered in patients treated with intravesical chemotherapy.
Administration, Intravesical↗
Ileal conduit in era of systemic chemotherapy.
The records of 62 patients with invasive transitional cell carcinoma of the bladder whose planned treatment was radical cystectomy with ileal conduit urinary diversion and postoperative systemic chemotherapy were reviewed. Seven of the patients received radical cystectomy but not postoperative chemotherapy as planned, 3 of them (5%) for reasons directly related to complications from the urinary diversion. Fifty-five patients received the planned postoperative chemotherapy. Complications during chemotherapy that were related to the ileal conduit were urinary tract infection in 37 percent and stenosis at the ureteroileal anastomosis requiring percutaneous nephrostomy in 3.6 percent. Chemotherapy was not discontinued in any patient, however, because of complications specifically related to the urinary diversion. We conclude that the ileal conduit is well tolerated by patients who require systemic chemotherapy and is, today, the simplest, safest, and best diversion method when systemic chemotherapy is to follow radical cystoprostatectomy.
Antineoplastic Combined Chemotherapy Protocols↗
Pelvic recurrence after radical cystectomy without preoperative radiation.
Between March 1, 1983 and December 31, 1985, 178 patients underwent radical cystectomy without preoperative radiation on the urology service at our university hospital and tumor institute. Of the patients 33 per cent received postoperative adjuvant chemotherapy. Over-all, the pelvic recurrence rate was 6 per cent. The recurrence rate by stage was stage O/A 2 per cent, stage B 5 per cent, stage C 6 per cent and stage D 15 per cent. The results demonstrate that adequate local control can be achieved without routine use of preoperative radiation.
Antineoplastic Combined Chemotherapy Protocols↗