Search

We present long-term observations on photoselective vaporization of the prostate in a prospectively studied cohort of men with obstructive benign prostatic hyperplasia.Obstructive benign prostatic hyperplasia in 94 men was treated with transurethral near contact vaporization with potassium-titanyl-phosphate laser with the patient under general or spinal anesthesia. Baseline characteristics, perioperative data, postoperative outcomes and adverse events were recorded.Mean prostate volume was 45 ml (range 13 to 136). Mean lasing time was 47 minutes (range 10 to 99), and there was minimal blood loss and no evidence of fluid absorption. All 94 men were outpatients and all but 1 became catheter-free in less than 24 hours. Baseline mean American Urological Association symptom index score was 22, quality of life score 4.5, peak urinary flow rate 7.8 ml per second and post-void residual urine volume 197 ml. After surgery percentage changes from baseline in mean values of these parameters, reflecting significant (p0.0001) improvement at 1, 2, 3 and 5 years, ranged from 83% to 88%, 86% to 90%, 170% to 252% and 76% to 89%, respectively. Complications were mild, and included transient dysuria (6%), delayed hematuria (3%), bladder neck contracture (2%) and 2-day retention (1%). No patient had incontinence or newly developed impotence, but up to 26% of the sexually active men experienced retrograde ejaculation. Postoperatively, low stage prostate cancer was detected in 5% of the patients.: Despite limitations our long-term experience and the literature suggest that significant improvements in symptomatic and urodynamic outcomes of photo-selective vaporization of the prostate are achievable and sustainable.

Purpose: We prospectively studied a cumulative cohort of men with obstructive benign prostatic hyperplasia who underwent potassium-titanyl-phosphate (KTP) laser vaporization prostatectomy to determine the safety and efficacy of this procedure.Materials and Methods: A total of 55 men with symptomatic bladder outlet obstruction due to benign prostatic hyperplasia were treated with a 60 W. KTP laser produced by a prototype Laserscope ††Laserscope, San Jose, California. generator and delivered through a side-deflecting fiber with a 22Fr continuous flow cystoscope. Sterile water was used for irrigation. The prostatic lobes were vaporized to within capsular fibers. Mean lasing time plus or minus standard deviation was 44 ± 19 minutes.Results: Mean prostate volume plus or minus standard deviation was 43 ± 14 ml. No patient had any significant blood loss or fluid absorption, or required blood transfusion. Foley catheters did not require irrigation and were removed less than 24 hours postoperatively. All patients ...

The pleotropic cytokine TGF-beta1 which induces connective tissue synthesis, and inhibits the growth of smooth muscle cells, has been implicated in corpus cavernosum fibrosis. The objective of this study was to determine the dose and time dependence of TGF-beta1 as an active agent in penile corporal fibrosis in an animal model.A time release method of delivery was developed using sodium alginate microspheres containing recombinant human (rh) TGF-beta1. New Zealand White rabbits were injected intracorporally with a single alginate microsphere either with or without rh-TGF-beta1. Dosage was varied from 325 to 1500 ng./bead. Animals were sacrificed at either three or five days post injection and the penises removed en bloc, examined, and processed for quantitative histomorphometric analysis, staining the sections with Masson's trichrome.Alginate microspheres containing [125I]-rh-TGF-beta1 showed slow-release kinetics (t1/2 = 10.5 hours). Histomorphometric analysis of 60 sets of high powered fields/treatment/ animal showed dose dependent decreases in percentage of corporal smooth muscle with TGF-beta1 treatment (750 to 1500 ng./bead). Placebo (alginate microspheres alone) had trabecular smooth muscle content comparable to values previously reported for untreated rabbit corpus cavernosum.This study confirms that TGF-beta1 induces fibrosis in situ by altering connective tissue synthesis and hence the structure of the corpus cavernosum. Injection of rh-TGF-beta1 impregnated alginate microspheres into the corpus cavernosum resulted in dose-dependent decreases in percentage of corporal smooth muscle.

Purpose: The majority of impalpable prostate cancers (stage T1c) are biologically significant. We report the interim results in 257 patients with stage T1c prostate cancer treated with radical prostatectomy.Materials and Methods: Prostate specific antigen progression-free survival was assessed by the Kaplan-Meier method. Multivariate analyses were performed to determine which clinical and pathological variables independently correlated with progression. Comparisons among the various clinical substages (T1a to T2b/c) were calculated.Results: Of the patients with stage T1c cancers 51 percent had stage pT2c or less and 91 percent had clinically significant tumors on the basis of pathological grade, deoxyribonucleic acid ploidy and tumor volume. High preoperative prostate specific antigen, poorly differentiated tumors and nondiploid status were strong independent predictors of progression. The 5-year survival rate free of progression was 84 percent. Patients with clinical stage T1c cancers had a signi...

To provide information about long-term outcome after radical prostatectomy for clinically localized prostatic cancer (stage T2c or lower), we undertook a retrospective analysis of 3,170 consecutive patients (mean age 65.3 ± 6.4 years, range 31 to 81) with a mean followup of 5 years. Complication rates for patients who underwent prostatectomy before 1988 were compared with those who underwent radical prostatectomy more recently. Of the patients 49 (1.5%), 178 (5.6%), 897 (28%) and 2,047 (65%) had clinical stages T1a, T1b, T2a and T2b,c disease, respectively. The Gleason score was 3 or less in 292 patients (9%) and 7 or greater in 782 (25%). Overall, 438 patients (14%) died, 159 (5%) of cancer. The crude 10 and 15-year survival rates for all patients were 75% and 60%, respectively, which is comparable to the expected survival of a control group (67% and 46%). The cause specific survival rates were 90% and 82%, respectively, metastasis-free survival rates 82% and 76%, local recurrence-free survival r...

Active alloplastic bladders were implanted into four dogs after cystectomy and were well tolerated. The prosthesis created a vacuum of −90cm. H2O in the upper tracts, which gradually decreased until the bladder filled. Renal function was maintained as long as the prostheses worked effectively. Hydronephrosis developed and renal function deteriorated if the bladder was not emptied, even though the leak pressure was only 3 to 5cm. H2O. Both resolved when active bladder function was restored. Pressures in the ureter were measured percutaneously, at flow rates up to 15ml. per minute (900ml. per hour). At 15ml. per minute, the pressure only reached a maximum of 16cm. H2O. Encrustation did not occur even in the presence of infection.The results achieved with this negative pressure bladder prosthesis, which is emptied actively, are very promising and should provide the impetus for increased research in this field of urology.

Urinary flow rates were measured in a randomly selected community sample of more than 2,000 men 40 to 79 years old with no history of prostate surgery, prostate cancer or certain other diseases known to interfere with normal voiding. Peak urinary flow rates decreased from a median of 20.3ml. per second in men 40 to 44 years old to 11.5ml. per second for men 75 to 79 years old, while voided volumes decreased from a median of 355.5 to 222.5ml. for the same age ranges. Peak flow rates of less than 10ml. per second were found in 6% of the men aged 40 to 44 years, increasing to 35% among men aged 75 to 79 years. Urological standards for peak urinary flow rate should be based on community data, and should account for age and voided volume. Our study may serve as the starting point for the development of community-based flow rate normal ranges. Nomograms are given to permit estimating flow rate percentiles as a function of age and voided volume.

Patient and partner satisfaction with the use of an AMS 700††American Medical Systems, Inc., Minnetonka, Minnesota. inflatable penile prosthesis was evaluated by reviewing the records from 387 patients and questionnaires completed by 272 of these patients. The evaluation demonstrated that 83% of the patients and 70% of the partners were satisfied with use of this device. Couples who reported the lowest levels of satisfaction were characterized by men who required more than 1 procedure for prosthesis implantation. Pain and appearance of the penis were the most common causes for dissatisfaction with the device. Results from this evaluation recognize the importance of careful surgical technique to avoid any surgical complications but, more importantly, they emphasize the need for physician-manufacturer interaction to maximize mechanical reliability of the prosthesis.

The narrow-backed cuff design of the AMS800 artificial urinary sphincter was introduced to improve transmission of cuff pressure to underlying tissue and, theoretically, to decrease the incidence of cuff erosion. The AMS800 urinary sphincter with this design change was implanted in 136 male and 8 female patients (mean age 57 years). Mean followup was 28 months. The cuff was placed around the bladder neck in all 8 female and in 29 male patients, and it was implanted around the bulbous urethra in the remaining 107. The 4.5 cm. cuff in combination with the 61 to 70 cm. pressure balloon was implanted in 109 patients. There were 12 device failures and 12 surgical complications. Five patients required cuff removal and none required reoperation for inadequate cuff pressure. Postoperatively, 132 patients reported satisfactory continence. The design change of the AMS800 and the use of the 4.5 cm. cuff with the 61 to 70 cm. pressure balloon decreased the incidence of cuff erosion and the need for reoperation for inadequate cuff pressure.

Vena caval tumor thrombus in association with transitional cell carcinoma of the kidney is uncommon, with only 9 cases having been reported to our knowledge. We report 3 additional cases and review this subject with particular attention to symptoms, radiographic evaluation and the importance of early diagnosis.

Purpose: We evaluate our experience with de novo reimplantation of the artificial genitourinary sphincter with a particular emphasis on mechanical and nonmechanical failure rates. De novo reimplantation is defined as implantation of an artificial sphincter following removal of a previously placed sphincter for erosion and/or infection and a waiting period of several months.Materials and Methods: A retrospective analysis of more than 400 patients with an artificial sphincter revealed 23 who underwent de novo reimplantation between January 1983 and October 1998. All patients were men with a mean age of 66.5 years (range 16 to 88) and all had a urethral cuff. Reasons for cuff removal were erosion in 12 cases (52.2%), infection in 10 (43.5%) and intraoperative urethral injury in 1 (4.3%). Mean waiting period was 6.8 months (range 1.5 to 32) between explantation and de novo reimplantation. Mean followup was 32.6 months (range 1 to 108).Results: Of the 23 patients 20 (87%) had no mechanical or nonmechanical fai...

Concurrent sphincteric incontinence and organic impotence are not uncommon; they can be caused by many congenital and acquired conditions. In the past simultaneous implantation of the artificial sphincter and penile prosthesis was met with skepticism. Of 65 patients who had concurrent implantation of the artificial sphincter and various categories of penile prosthesis 60 were followed for a mean of 35.74 months (range 8 to 55 months). Continence was graded as good or satisfactory in 95 per cent of the patients and poor in 5 per cent. The penile implants were functional in 98 per cent of the patients. Of the 60 patients 33 required 59 corrections, for an average of 0.98 correction per patient. These results indicate that staged or concurrent implantation of dual prostheses is feasible technically, functionally and cosmetically, and without increased risk for surgical or mechanical problems.

The model AS 800 artificial urinary sphincter was implanted in 100 male and 9 female patients between 7 and 89 years old. Postoperative followup was 1 to 32 months. The indication for implantation was total urinary incontinence in 86 patients (78.9 per cent), stress incontinence in 22 (21.2 per cent) and urgency incontinence in 1 (0.9 per cent). Of the patients 97 (89 per cent) underwent implantation for the first time, 7 (6.4 per cent) had a previous artificial urinary sphincter model replaced by the AS 800 device and 5 (4.6 per cent) underwent reimplantation of a previous model. The cuff was placed around the bladder neck in all 9 female patients, whereas in the male patients the cuff was implanted around the bladder neck in 20 and around the bulbous urethra in 80. Thirty-one patients (28.4 per cent), 29 of whom were continent at night, were practicing nocturnal deactivation of the device. Complete post-activation continence was achieved in 91 patients (83.5 per cent), some leakage occurred in 10 (9.2 per cent) and 8 (7.3 per cent) remained incontinent. A total of 23 patients required 1 or more revisions, the most common indications for the first revision being loss of cuff compression (9), tubing kink (3), cuff erosion (3) and infection (2). At the time of this report 89 patients (81.7 per cent) were continent, 9 (8.3 per cent) still had some leakage, 3 (2.8 per cent) were incontinent, 5 (4.6 per cent) were awaiting reimplantation and 3 (2.8 per cent) had died of unrelated causes.

The genitourinary spheroidal membrane, composed of silicone rubber, has been developed along with a mechanical delivery instrument that allows transcutaneous insertion of the prosthetic sphere in the periurethral tissues to enhance outlet resistance in incontinent patients. An experimental study was undertaken in six female mongrel dogs to evaluate the safety and efficacy of this concept. The leak-point pressure increased from five to 38 cm. H2O (mean increase, 16.8 cm. H2O). This increase is statistically significant (p less than 0.024, two-sided t test). During the 90-day experiment, there was no migration of the spheres, minimal local inflammatory response, and no granuloma formation or inflammatory response in various organs studied. Although the leak-point pressure was increased in all of the dogs, none developed difficulty voiding. We conclude that the design concept is sound and safe, the delivery system is reliable, and it is possible to place the spheroidal membrane into an anatomic location that will increase outlet resistance.

Clinical experience in the selection of patients for implantation of the artificial urinary sphincter and the surgical techniques for sphincter implantation indicate a need to provide suitable guidelines for patient followup and the management of post-implantation urinary incontinence. Two types of post-implantation incontinence are recognized: 1) immediate post-activation incontinence and 2) delayed or recurrent incontinence. The potential causes, and the diagnostic and management techniques are dependent on not only an understanding of device function but also on the use of already available clinical tools. Physical examination, inflate-deflate roentgenograms of the device, cystoscopy and retrograde urethrography each has an important role in determining the cause and, therefore, the appropriate remedy for the restoration of urinary control. Causes that result in loss of urinary control after implantation include improper operation of the device by the patient, detrusor hyperreflexia, occlusive cuff erosion, improper cuff sizing and device malfunction. Proper recognition of the precise cause of post-implantation incontinence and workable guidelines for management will provide for effective assurance that urinary control can be restored successfully.

We report the results of 1,000 consecutive patients who underwent percutaneous removal of renal and ureteral stones. Removal was successful for 98.3 per cent of the targeted renal stones and 88.2 per cent of the ureteral stones. Complications, evolution and technique are discussed. Percutaneous techniques are an effective way to handle the majority of renal calculi and these techniques will continue to be important as shock wave lithotripsy becomes more widespread in the United States.

The usefulness of bethanechol chloride as a therapeutic adjunct in the treatment of patients with residual urine but no obstruction has been questioned. This study, in which oral bethanechol chloride was compared to a placebo in a randomized, double-blind fashion, does not show a significant short-term effect in female patients with persistent elevation in residual urine. No differences were seen in voided volume, residual volume, percentage residual volume, mean flow rate and intravesical pressure at 100 ml. volume and at maximal capacity when the treatment groups were compared to the group receiving the placebo.

In 12 children with membranous urethral strictures transpubic urethroplasty has been performed successfully with minimal morbidity and no mortality. Of the 12 patients 8 are completely continent after transpubic urethroplasty, 2 have partial continence and 2 are incontinent. Wedge resection of the pubic symphysis afforded satisfactory exposure to the prostatic urethra, and none of the 12 patients experienced orthopedic instability, abnormal gaits or pelvic girdle pain. In 3 patients there was loss of erectile function after pelvic injury, which reflects the significant risk of impotence after crush injury to the pelvis with rupture of the posterior urethra.

The model AMS800 artificial urinary sphincter was implanted in 117 patients with urinary incontinence resulting from radical prostatectomy. The indication for implantation was total incontinence in 107 patients and stress incontinence in 10. All patients had bulbous urethral cuff insertion and 20 had previous pelvic irradiation. Followup questionnaire indicated a 90% signifi cantly improved continence rate and a 90% satisfaction rate among patients. There were 64 surgical revisions required in 37 patients: inadequate cuff compression in 21 (33%), tubing kinks in 10 (16%), urethral cuff erosion in 8 (13%), scrotal hematoma in 6 (9%), control assembly malfunction in 4 (6%) and cuff leaks in 4 (6%). Of the 20 patients with previous pelvic radiation 2 (10%) had at least 1 erosion, compared to 5 of 97 (5%) in the nonirradiated group. At followup 5 patients did not have at least 1 component of the AMS800 device indwelling (2 cuffs and 3 entire devices had been removed).

A patient with bilateral localized amyloidosis of the ureters is described. This is the first case to be reported in which anuria was the presenting symptom, the second case with bilateral involvement and the thirteenth case of amyloidosis localized to the ureter. Careful urologic and hematologic followup is indicated.

The 36 patients who underwent radical retropubic prostatectomy for adenocarcinoma after transurethral resection of the prostate were reviewed to evaluate the difficulty of the radical operation, the rate of morbidity and the survival. In 24 patients (67 per cent) the dissection proved to be routine; 18 patients (50 per cent) had perfect urinary control, whereas 4 were totally incontinent. There appears to be no untoward effect on survival, since all patients remain alive, 22 per cent having had followup for 5 years or more.

True detrasor-striated sphincter dyssynergia is seen most characteristically in patients with suprasacral spinal cord transection after a period of spinal shock has passed. Routine cystometry-electromyography records can better define this entity. However, several additional etiologic possibilities may produce cystometry-electromyography records that could be diagnosed erroneously as representing detrusor-sphincter dyssynergia.

An operation was required in 78 children with vesical diverticula in the absence of bladder outlet obstruction. Virtually all diverticula were located in juxtaposition to the ureteral orifice and were associatedwith vesicoureteral reflux in all but 6 of 89 diverticulum-ureteral units. Upper tract changes were seen on excretory urography in 78 per cent of the refluxing units. The surgical procedure of choice was diverticulectomy and ureteroneocystostomy, which yielded a high degree of success. Diverticulectomy alone and vesical neck revision were rarely indicated.

The records of 34 patients with posterior urethral disruptions secondary to blunt pelvic trauma who were treated with primary realignment were reviewed. Among the 29 evaluable patients there was a 38 per cent incidence of stricture (11 of 29), a 3 per cent incidence of incontinence (1 of 29) and a 15 per cent incidence of impotence (4 of 27). Primary realignment has a low morbidity and an acceptable rate of incontinence, impotence and stricture formation, and is recommended in the treatment of posterior urethral injuries.

The complications experienced by 692 consecutive patients who underwent bilateral pelvic lymphadenectomy and radical retropubic prostatectomy from 1978 through 1984 were analyzed. Four patients (0.6 per cent) died in the perioperative or early postoperative period. Pulmonary embolus developed in 19 patients (2.7 per cent) and severe to total urinary incontinence occurred in 34 (5 per cent). Our large series suggests that radical retropubic prostatectomy with staging bilateral pelvic lymphadenectomy can be performed in a safe manner with minimal postoperative morbidity.

Urinary retention may develop in the absence of significant organic disease. Patients with psychogenic retention range from those with episodic acute retention to those who have learned to inhibit urination and have retention with a large residual urine volume owing to myotonic detrusor degeneration. A combination of thorough medical, neurologic, psychiatric and urologic evaluation is indicated for all such patients. Management consists of the implementation of bladder training with or without intermittent catheterization, which generally may be accomplished on an outpatient basis.

We report the unusual occurrence of neurofibromatosis of the bladder in 2 children. The pathologic features and clinical presentation are discussed and the literature is reviewed.