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PubMedDate not supplied

[The late results of organ-preserving operations in acute hemorrhages in patients with bladder cancer].

Surgical aid in acute hemorrhage due to cancer of the urinary bladder was rendered within 1986-1994 to 65 patients (53 males and 12 females) aged 30-50, 51-60, 61-70 and over 70 years (10, 11, 24 and 20 cases, respectively). The majority had the disease stage T2 and T3. In 42 (64.6%) patients with profuse hematuria complicated by bladder tamponade an urgent resection was performed: segmental in 22, hemiresection in 8, open bladder electroexcision of the tumor in 10 patients. 2 patients had sigmoid cancer with bladder involvement managed by subtotal resection of the bladder and resection of the sigmoid colon. Nephro- or cystostomy was performed because of grave condition (purulent pyelonephritis, azotemia) in 23 patients (35.4%). Total postoperative lethal outcomes made up 33.3% (14 patients): 6 patients died early after surgery, 8 patients 6 months to 8 years later. 27 patients (64.3%) are alive. Of them 10 are 5-8-year survivors. These patients had cancer stage T2 and T3 with tumor location on the lateral wall. In three 4-year survivors there were tumor recurrences 2 and 3 years after surgery which were treated by transurethral resection and electroexcision on the open bladder. Long-term outcomes of urgent surgery show that different kinds of resection of the bladder may be effective in the treatment of acute hemorrhages from bladder tumors.

Acute Disease↗
PubMedDate not supplied

[The transurethral microwave thermotherapy of benign prostatic hyperplasia].

Treatment outcomes are available for 502 patients with benign prostatic hyperplasia exposed to transurethral microwaves (TUMW) on Prostatron unit. Of the patients whose age ranged from 55 to 84, 328 had stage I disease, the rest stage II. 32 patients had previously undergone cystostomy. Acute urine retention was registered in 67 patients on day 1-4 after microwave therapy because of edema of the tumor. To remove the urine, cystostoma and catheter were placed in 18 and 49 patients, respectively. In half a year a positive effect occurred in 80% of cases. As microwave therapy relieves symptoms, increases the quality of life, improves urine flow and reduces the tumor size it can be recommended for the treatment of benign hyperplasia of the prostate.

Aged↗
PubMedDate not supplied

[Late results of local transrectal hyperthermia in patients with benign prostatic hyperplasia and its complications].

LTH on Yakhta-4M unit was used in benign prostatic hyperplasia (BPH). The prostate was heated transrectally by directional radiation. The course of treatment comprised 5 sessions for 60 min twice a week. The efficacy of the treatment was assessed 3 years later in 78 patients which were divided into 4 groups: 31 patients with BPH, 30 patients with BPH in combination with chronic prostatitis, 9 patients with acute urine retention and 8 patients with cystostomy fistula. 5 patients underwent surgery. LTH is safe in relation to side effects, may be used both at early stage of the disease and in risk of operative intervention.

Aged↗
PubMed1995

[Gangrene of the external genitalia].

The term gangrene of the male external genital organs is applied to two different entities : Primary gangrene of the external genital organs (5% of cases), also called Fournier's disease, first described in 1883 : gangrene of the integument of the external genital organs in the absence of a local cause, according to an unknown mechanism and with inevitable progression towards a specific distribution of necrosis, regardless of treatment. "Secondary" gangrene of the external genital organs (95% of cases) related to a local, cutaneous, urogenital or gastrointestinal cause, whose course can be modified by early application of appropriate treatment. An early diagnosis is essential : in true Fournier's disease to avoid the systemic complications of this necrosis, and in secondary gangrene to limit the local extension and to prevent systemic complications. In view of the galloping course of the disease and in order to very rapidly reach the diagnosis, many authors recommend : local aspiration, biopsy or search for subcutaneous gas by ultrasound or radiology. Treatment consists of : Antibiotic therapy using two or three antibiotics to cover the usually mixed bacterial flora (Gram positive cocci, Gram negative bacilly and anaerobes). Surgical debridement as required, possibly repeated to excise necrotic zones, to drain collections and for irrigation of cavities. Hyperbaric oxygen therapy. Urinary diversion (cystostomy) or gastrointestinal diversion (colostomy) may be required when either of these two tracts are responsible for the infection, or when diversion facilitates management. Surgical reconstruction (grafts or flaps) as required. The mortality is high, of the order of 20% : < 10% in young patients with a good general condition who are correctly treated after an early diagnosis; > 50% in elderly patients with other concomitant diseases, when diagnosis and treatment are delayed.

Diagnosis, Differential↗
PubMed1996

[Anterior vaginal wall and pelvic floor sling for stress incontinence].

There is considerable doubt as to whether the intra-abdominal position of the urethra is the critical factor in maintenance of continence. Recent studies have suggested that a firm, supportive, suburethral layer is required for urethral closure during effort. The surgical procedure we describe is performed by vaginal approach and involves creation of a sling from the vaginal wall and underlying musculofascial layer, that provides compression and support for the urethra and resuspends the bladder neck. 20 women (37-70 years, mean 48.4) with severe stress incontinence (average of 5 wet pads per day) underwent the sling procedure between October 1994 and July 1995. 10/20 had had previous pelvic surgery (6 anti-incontinence procedures and 4 hysterectomies). 3/20 had intrinsic sphincter dysfunction and the rest a hypermobile urethra. The surgical technique was easily performed. Postoperative complications were minimal, and included blood transfusion in 3 and in 5 suprapubic pain which subsided spontaneously or after oral diclofenac. The cystostomy was closed after 10.5 days (range 3-49) when voiding resumed and urine residual became less than 60 ml. The median follow-up was 9.4 months (range 3-12). All patients were cured and satisfied. 2/20 reported onset of urge incontinence which was found urodynamically to be de-novo detrusor instability due to urethral obstruction. On the other hand, all 3 patients with associated urge incontinence reported its disappearance postoperatively. These results are encouraging and this surgical procedure seems to provide a good solution for all types and grades of stress incontinence. Long-term follow-up is required to determine persistence of the good results.

Adult↗
PubMedDate not supplied

[Surgical repair of vesico-vaginal fistulae with abdominal-transvesical approach. Comments on this technique and long-term results].

OBJECTIVES: We reviewed our series of vesicovaginal fistula that had been treated by the abdominal-transvesical approach, which we have also utilized in complex relapsed fistulas of the posterior aspect of the bladder in all but one case of triple fistula associated with lithiasis of the bladder. METHODS: 6 patients with vesicovaginal fistula secondary to pelviogynecological surgery were treated by the abdominal-transvesical approach. One patient had been referred to our hospital for a triple fistula that had relapsed for the fifth time. This patient was submitted to cystolithotomy during the same session. Another patient with urinary incontinence and cystocele prior to the fistula underwent unrethrocervicopexy following the Marshall-Marchetti-Krantz technique after fistula repair. All the cases were treated by the same surgeon without omental interposition. RESULTS: Excellent results were achieved in all 6 cases, with no fistula relapse. The urinary infection disappeared in those patients with this complication prior to fistula repair. Patient control evaluation was performed 6-12 months postoperatively and at 4 years. All 6 patients are currently urologically asymptomatic and continent. CONCLUSIONS: In our view, vesicovaginal fistula repair can be done via the vaginal, abdominal or combined approach. We do not believe that one technique is superior over the other. Although the 6 cases described herein are not significant statistically, the abdominal-transvecial approach has been successful in these 6 cases, despite the difficulty that is always encountered in some cases of vesicovaginal fistula, regardless of the technique utilized. Omental interposition may be useful in those cases with a large fistulous defect. Some advocate fistulectomy in all cases. The time to surgical correction following diagnosis was always more than three months. The crossed or x-shaped suture achieves minimal superpositioning. Postoperative bladder drainage should not lie on the suture of the bladder mucosa to prevent decubitus through placement of a cystostomy tube. The foregoing points are essential in this procedure.

Adult↗
PubMed1997

[Perineal-genital wounds in war medicine. Apropos of 18 cases].

Perineo-genital wounds involving the anterior perineum or the urogenital perineum are uncommon; 1-4% of all war wounds. We report 18 cases observed in war situations. Isolated uretrogenital wounds are rarely life-threatening, but the functional prognosis is always compromised in these men whose mean age is under 30 years. Debridements should be limited and all isolated lesions should be repaired early with tight suture of the cavernous body albuginea, preservation of viable testicular and adnexal tissue (but the rate of orchidectomy is greater than 50%), and immediate suture of any wound to the urethra rather than simple alignment. In war situations, these wounds are usually caused by perforating or blast trauma. The wounds are complex, with damage to the soft tissues, sometimes involving lesions to the anal sphincter, the gluteal masses or the abdomino-pelvic structures. Laparostomy for hemostasis is justified. The risk of sepsis is high, requiring triple antibiotics, cystostomy, careful debridement, discharge drainage or possibly colostomy. Treatment of urogenital lesions is a secondary operation in these cases but must not be neglected if the mictional and sexual functions are to be preserved.

Adult↗
PubMed1997

[Should one perform supravesical urinary diversions with excluded bladder in patients with cancer?].

OBJECTIVE: To review our experience in 37 patients who had undergone supravesical urinary diversion with defunctionalized bladder left in situ. METHODS: The pathological conditions that indicated surgery were advanced infiltrating bladder carcinoma and bladder irradiation due to other pelvic organ malignancies. RESULTS: The analysis showed 70.25% of the patients had complications, the most common being hemorrhage (27.07%), followed by pyocyst (13.51%). Four patients (10.81%) required rehospitalization for treatment of complications. The patients were treated with a combination of parenteral antibiotics and continuous bladder irrigations using a variety of antiseptic solutions. One patient required a permanent cystostomy. CONCLUSION: There is a need to evaluate the benefit of the supravesical urinary diversion with defunctionalized bladder left in situ in patients with advanced infiltrating bladder carcinoma and bladder irradiation due to other pelvic organ malignancies. The type of diversion is unrelated to the complications that develop in the defunctionalized bladder. Patients with positive urine cultures and/or urethral stricture preoperatively have an increased risk of developing pyocyst.

Adult↗
PubMed1997

[Firearm wounds of the lower urinary tract in men. Surgical management in emergency context].

The lower urinary tract is injured in less than 1% of all firearm wounds in men. In war medicine, blast wounds occur in 75% of the cases while in civil medicine ballistic injuries are more frequent. When the bladder and the posterior urethra is involved, the projectile usually follows a path through the gluteal muscles and pelvis. A perineal genital path is usually found for injuries to the anterior urethra. This explains the frequency of associated vascular and colorectal lesions in pelvic wounds and genital injuries in perineal wounds. Bone and muscle injuries occur in both situations. A mental reconstruction of the projectile path is required for a precise diagnosis of the lesions, together with the clinical examination (urine outlet, miction impossible with or without bladder extension, urethral bleeding) and most importantly standard x-ray of the pelvis in search of bone lesions and the projectile. Urethrography should always be performed whenever the urethra is injured in all civil wounds. However, the final diagnosis of the lesions can only be made at surgery. Urology procedures, usually performed by polyvalent surgeons, should be simple, rapid and reliable. It is important to preserve urinary and genital functions in these young subjects usually under 30 years of age. Cystostomy and drainage is the strict minimum. In addition, depending on the infectious and hemodynamic status, conservative excision of damaged tissue is needed prior to primary closure. Wounds involving the bladder can be closed in 95% of the cases. Closure is simple for wounds involving the superior portion of the bladder. For deeper wounds involving the trigone endovesical suture is used after intubing the ureters. Ureteral drainage is mandatory when the bladder is highly damaged and cannot be closed. Urethro-prostato-membranous wounds should also be repaired to avoid inevitable fibrosis of fistulization. However, access to the apex of the prostate causes major bleeding and there is a risk of injuring the sphincter or erection nerves, particularly by surgeons inexperienced in urogenital surgery. When massive bleeding cannot be controlled by clamping the two hypogastrics, symphysiotomy, rather than symphysectomy, is recommended. In other cases, aligning the urethral extremities may be sufficient. Short wounds to the anterior urethra should be cleaned and the extremities spatulated and anastomosed on a guide when they can be closed. In other cases, a perineal or penile urethrostomy is created. Associated wounds involving the anus and rectum require colostomy, emptying the excluded rectum and wide pelvic-perineal drainage. An attempt should be made to repair the rectum or the sphincter. Genital lesions require early repair: tight suture of the albuginea of the cavernous bodies with or without a patch, preservation of viable testicular parenchyma and adnexal tissues (but orchidectomy is necessary in 50% of the cases).

Adult↗
PubMed1998

[Intravesical instillation of trospium chloride, oxybutynin and verapamil for relaxation of the bladder detrusor muscle. A placebo controlled, randomized clinical test].

Therapy of detrusor hyperactivity with anticholinergic agents often is followed by adverse drug reactions. Intravesical application may be an interesting alternative. A randomised, single-blind, placebo-controlled, mono-centre clinical trial was carried out in 84 patients with urgency or urge incontinence. Due to intravesical administration of oxybutynin (CAS 5633-20-5) (n = 21) and trospium chloride (CAS 10405-02-4) (n = 21), respectively, a significant increase in maximum bladder capacity and decrease of detrusor pressure accompanied by an increase of residual urine were found in comparison to placebo in urodynamical investigations. Improvement of uninhibited bladder contractions occurred leading to higher filling volume. Under verapamil (CAS 152-11-4) (n = 21) no marked changes in the efficacy variables were found compared with placebo. All patients completed the study and were assessed with regard to efficacy and safety. No adverse events or marked changes in the vital signs were reported. The immediate onset of effect and the lack of adverse drug reactions suggest that treatment with topical oxybutynin or trospium chloride is an effective alternative in patients with intolerable side effects when orally treated. In addition, intravesical administration may be indicated in patients with bladder spasms due to indwelling catheter or in order to increase bladder capacity before percutaneous cystostomy.

Adult↗
PubMed1998

[Urinary stress incontinence. Comparison of the Raz technique and the Bologna technique. Analysis of a series of 188 patients].

OBJECTIVE: Our purpose was to evaluate and compare the perioperative morbidity and the long-term results of the Raz colposuspension and the Bologna operation for the treatment of stress urinary incontinence in women. STUDY DESIGN: Data of 188 women who underwent either a Bologna operation (group 1) or a Raz colposuspension (group 2) for the treatment of stress urinary incontinence between January 1, 1987 and December 1, 1995 were analysed retrospectively regarding history, preoperative evaluation, associated surgical procedures, complications and cure and failure rate. POPULATION AND METHODS: 80 patients were treated with the Bologna operation and 108 with the Raz colposuspension. Patients with prior anti-incontinence surgery, and patients with a preoperative diagnosis of urge incontinence were excluded from the study. Success was defined both subjectively (complete absence of complaint of stress urinary incontinence) and objectively (no evidence of loss of urine on cough provocation during physical examination). Survival curves were generated in each group for time to event data: "time to recurrent stress incontinence" and compared by the logrank test. A multivariate analysis using a Cox proportional hazards regression model was performed to indentify possible outcome predictors. RESULTS: The success rate of group 1 was significantly higher than that of group 2 (p = 0.00001). The median of success was 51 months in group 1 and 21 months in group 2 (p = 0.00001). The incidence of intraoperative complications in each group (inadvertent cystostomy, hemorrhage) did not differ. The multivariate analyses using the Cox regression model showed that the most highly correlated variable with the surgical cure rate was the type of surgical anti-incontinence procedure adopted: Bologna or Raz (p = 0.00001) CONCLUSION: In our hands, the Bologna operation has a higher cure rate than the Raz colposuspension. For us, when treating patients with stress urinary incontinence by the vaginal route, the Bologna operation is indicated when sufficient anterior vaginal tissue is available to create vaginal bands.

Female↗
PubMedDate not supplied

[The estimation of the degree of surgical risk in patients with prostatic adenoma].

Based on the authors' personal experience of surgical treatment of prostate adenoma an assessment has been carried out of general status and degree of operation-related risk using a simplified "acute physiologic scale" the total score of which is the sum 13 of easily identifiable vital physiologic or biochemical parameters. The assessment is performed by 4-score scheme, with prognosis of lethality being given depending on values obtained. Radical adenomectomy was found out to be indicated in those patients in whom the total score did not exceed 5; electroresection (transurethral or transvesical) can be recommended in those patients having the total score under 11. The score above 11 necessitates cystostomy (including the trochar one) or else indwelling catheter is supposed to be inserted.

Adult↗
PubMed1998

Comparison of short versus long duration of ampicillin and gentamicin for radical hysterectomy.

Prophylactic antibiotic therapy for radical hysterectomy is still controversial. Although the efficacy of antibiotics have been demonstrated, there remains the question of duration of administration. In this study, we retrospectively reviewed 95 patients who underwent radical hysterectomy and pelvic lymphadenectomy for cervical cancer at our institute. The management was uniform except for the duration of antibiotic administration. Group I (34 cases) had ampicillin and gentamicin for 3 days while group II (61 cases) had the same regimen for 7 days. No significant difference was found in terms of postoperative infection (2.9% in group I and 1.6% in group II) or febrile morbidity (32.4% versus 50.8%). Other factors such as the patients' age, body weight, preoperative hemoglobin level, amount of blood loss and blood transfused, operative time, duration of retroperitoneal drain and duration of suprapubic cystostomy. Only operative time had a significant influence on febrile morbidity regardless of the duration of antibiotics administered. In conclusion, the antibiotic administration gave a radical hysterectomy and pelvic lymphadenectomy a very low incidence of postoperative infection. Longer duration of treatment did not appear to lessen postoperative infection nor febrile morbidity. Shorter duration of antibiotic administration needs further evaluation.

Adult↗
PubMed1997

Management of posttraumatic posterior urethral disruption.

We reviewed our experience with 17 cases of posterior urethral disruption due to traumatic pelvic injuries. In all cases, a suprapubic cystostomy was performed at first. For blunt injuries, urethroplasty was delayed for 6 months in average. For most of the penetrating injuries (3/4), we performed immediate debridement and primary repair. Resulting bulbous or membranous strictures less than 3 cm long were treated with one-stage perineal excision-reanastomosis urethroplasty. Membranous strictures longer than 3 cm were managed with a combined transpubic-perineal repair, while bulbous defects longer than 3 cm were treated with a scrotal pedicled island flap. The overall restricture rate was 25%. Those having had initial repeated urethrotomies displayed a 100% restenosis rate. Incontinence rate was 12.5% Erectile dysfunction occurring in 42% of our patients is a sequela of the pelvic injury and was found to be directly related postoperatively to its presence at the time of surgery.

Accidents, Traffic↗
PubMed1998

[Endoscopical reconstruction of traumatic urethral disruption with ureteral resectoscope: a case report].

A 19-year-old man sustained a fracture of the left ischial rami and disruption of the membranous urethra when a car hit him against a wall. A suprapubic tube was placed and was used for reconstruction of the disrupted urethra 3 months later. Eighty days after the injury, an 11.5 F ureteral resectoscope was inserted through the open cystostomy tract. Simultaneously, a 11 F pediatric cystoscope was inserted via urethra. Using the "cut to the light" procedure, the scar tissue was incised with sharp strokes of the ureteral resectoscope revealing the distal urethral lumen. Sequentially, urethral dilatation to 24 F was performed over a 0.038 Teflon-coated guide wire following insertion of a 24 F urethral catheter. The urethral catheter was removed 22 days after the operation. Direct vision urethroscopy was performed at 1- to 2-week intervals for 3 months. At present 13 months after the operation, he performs 18 F urethral self-dilation and has been free of voiding complaints. The ureteral resectoscope is useful for endoscopical reconstruction of urethral disruption.

Adult↗
PubMed1998

[Percutaneous urethral suspension with bone anchorage (Vesica) in the treatment of stress urinary incontinence. Results after a year of follow-up].

OBJECTIVES: Evaluation of efficacy of percutaneous bladder neck suspension with bone anchors in women with stress incontinence with no previous treatment. PATIENTS AND METHODS: Fourteen women (mean age 48, range 37-74) were operated. All had a stable bladder and objective leakage, either by pad test of by physical examination. Ten were evaluated by a incontinence questionnaire. Mean incontinence time before the procedure was 3.9 years. All needed pads (mean 3.3 pads/day). The surgical technique is described. RESULTS: Mean surgical time was 80 minutes. In three patients there was bladder perforation during the procedure, that was solved by delaying the catheter withdraw. Mean postoperative stay was 4.2 days, with good tolerance, and one patient was discharged with a cystostomy. After a minimum follow-up of one year (mean 17.5 months), eleven patients have improved their continence (6 dry, 5 socially acceptable incontinence < pads/day) and 3 have recurrence. Postoperative pad test was < or = 10 g in patients without improvement and over 20 g in patients who failed. Mean postoperative total score in the questionnaire decreased from 10.1 to 2.5 in patients who improved and didn't change in patients who failed. CONCLUSION: Percutaneous bladder neck suspension is a useful alternative to open interventions, due to its low morbidity and lower postoperative stay.

Adult↗
PubMed2000

Approach to urinary diversion in the surgical patient.

Major surgical procedures may remove part or all of the bladder and make an incontinent or continent urinary diversion appropriate. Preoperative consideration must be given to 1) the stoma and its position, 2) the catheterizable channel, 3) the urinary continence mechanism, and 4) the substitute bladder reservoir. Complete bowel preparation and broad-spectrum antibiotics are desirable. The patient's motivation for taking care of a continent urinary diversion is important, since lifelong catheterization and mucous irrigation may be necessary. The status of the native bladder outlet and urinary sphincter is important in cases in which an orthotopic continent urinary diversion is considered. Preoperative evaluation by a stoma therapist is invaluable. Adequate urinary drainage is important in the immediate postoperative period. Patients with urinary diversions must be followed lifelong to rule out asymptomatic deterioration of their upper urinary tracts and to check for potential metabolic and nutritional problems.

Attitude to Health↗