Search

Purpose: We report our experience with auto-expandable metallic stents for treating ureteropelvic junction obstruction., Materials and Methods: We treated 4 patients with a mean age of 45 years who had ureteropelvic junction obstruction with placement of a self-expandable intraureteral metallic stent (Wallstent, Schneider, Zurich, Switzerland). All patients presented with recurrent ureteropelvic junction obstruction after open pyeloplasty. Excretory urography and 3-dimensional reconstruction computerized tomography were performed 1 and 6 months after stent insertion. Virtual endoscopy images were obtained at followup due to the need to define ureteral patency., Results: Mean followup was 16 months (range 9 to 24). Wallstent placement was successful and immediate patency was achieved in all cases. During followup 3 patients required no further intervention and the stented ureteropelvic junction remained patent. In the remaining patient stricture recurred 2 months after initial stent insertion due to the ingrowth of scar tissue through the prosthesis. Additional intervention was deemed necessary after placing a longer 6 cm., completely coaxial overlapping metal stent. Virtual endoscopy and excretory urography findings concurred. Virtual endoscopy allows visualization of the stented ureteropelvic junction lumen cephalad and caudal to the prosthesis. It also enables easy navigation within the stent at different angles of view., Conclusions: The concept of applying metallic stents for ureteropelvic junction obstruction and adjacent adynamic ureteral segments combined with virtual endoscopy is strengthened by the results of this study.

Purpose: We assess the efficacy of intravesical administration of oxybutynin chloride in patients with interstitial cystitis., Materials and Methods: The study included 36 women with a mean age of 45 years with a diagnosis of interstitial cystitis. Patients were treated with gradual intravesical instillation of saline oxybutynin solution (oxybutynin group) or gradual filling of simple saline (control group). Evaluation parameters consisted of symptom problem index, voids per day, volume per void, functional bladder capacity, volume at first sensation, cystometric bladder capacity and cystometric volume at first sensation., Results: Statistically significant improvement of all evaluated parameters was found in both groups. When comparing the outcomes statistically significant improvement of parameters favored the oxybutynin group., Conclusions: Bladder training alone produces a satisfactory result by gradually expanding the bladder, and an additional statistically significant improvement is evident with intravesical oxybutynin.

Purpose: We report our experience with the use of self-expandable metallic stents to bypass anastomotic strictures after ureteroileal urinary diversion., Materials and Methods: We evaluated 3 men and 1 woman with invasive bladder carcinoma who underwent radical cystectomy and ileal conduit urinary diversion. Ureteroenteric anastomotic strictures developed after a mean of 16 months. Self-expandable metallic stents were successfully placed (bilaterally in 2) comprising 6 stented ureters that bypassed strictures. Mean patient age was 64 years and mean followup was 12 months., Results: No restenosis was observed in 3 patients during followup. The stricture recurred 1 month after stent placement in the remaining patient and additional intervention was necessary, consisting of placement of a totally coaxial overlapping metal stent. No sepsis or other complication was observed. One patient died of metastatic disease 12 months after stent placement., Conclusions: We propose the use of metal stents as an adequate, safe and effective alternative treatment for anastomotic strictures after ureteroileal diversion.

Purpose: We investigate the association of clinical and urodynamic findings with corresponding clinical grade and possible predictors of clinical grade of multiple sclerosis (MS)., Materials and Methods: A total of 90 patients, 28 to 62 years old (mean age 45.8 +/- 12.1), with the clinical syndrome of MS were consecutively and prospectively studied. All patients were subjected to detailed video urodynamic evaluation and electromyography of the external urethral sphincter., Results: Urodynamic evaluation revealed detrusor hyperreflexia in 52 patients (57.7%), detrusor external sphincter dyssynergia in 27 (30%) and hypocontractility or areflexia of the detrusor in 15 (16.6%). Residual urine varied widely from 50 to 900 ml. Decreased compliance with areflexia was seen in 5 patients (5.5%) and nonrelaxing sphincter (but not contracting) with bladder hypercontractility was noted in 9 (10%). Statistical analysis followed comparison of 2 proportions. When patients with a less severe form (grades 1 and 2) were differentiated from those with a more severe form of MS (grade 3), we observed a significant difference only in incontinence, high post-void residual, leg spasticity, urinary stones, hydronephrosis, type 3 detrusor external sphincter dyssynergia, no electromyography activity and positive sharp waves. The variables with the highest predictive value between the groups were urinary stones, sepsis, type 3 detrusor external sphincter dyssynergia and no electromyography activity of the external urethral sphincter (100%)., Conclusions: Proper identification of the bladder and external urethral sphincter status, especially exclusion of detrusor overactivity or a dyssynergic response of the external urethral sphincter, will prevent complications that may result in deterioration of quality of life.

Purpose: This study was undertaken to evaluate the immediate and long-term effects of the combination of alpha-blockers and antibiotics in the treatment of chronic prostatitis., Materials and Methods: The patients eligible for study were assigned to 3 groups: group 1--nonprostatodynia, abacterial prostatitis (134), group 2--prostatodynia (72) and group 3--chronic bacterial prostatitis (64). alpha-Blockers were administered to all patients of groups 1 and 2 with demonstrable high maximal urethral closure pressure and typical clinical complaints irrespective of the presence of inflammatory findings in expressed prostatic secretion. alpha-Blockers were given to 50% of patients with bacterial prostatitis. Antibiotics were administered to all patients with positive expressed prostatic secretion cultures, and in half of those with abacterial prostatitis and inflammatory expressed prostatic secretion. Mean followup was 22 months (range 6 months to 3 years). The sign 1-tailed test was used for statistical analysis of data., Results: The recurrence rate of bacterial prostatitis was significantly reduced by alpha-blockade (expressed prostatic secretion culture negative) and symptom relief was achieved for many months. For abacterial prostatitis statistical analysis revealed a lower symptom recurrence rate in patients receiving only alpha-blockers in comparison with those treated with a combination of alpha-blockers and antibiotics., Conclusions: The use of alpha-blockers is justified, not only for prostatodynia, but also for abacterial and bacterial prostatitis. In the latter case alpha-blockade not only caused enhanced clinical improvement but also reduced the recurrences as defined by expressed prostatic secretion positive segmental cultures.

Purpose: We report our experience with the use of metallic self-expandable and balloon expandable stents for the treatment of malignant ureteral obstruction., Materials and Methods: We treated 12 consecutive patients with malignant ureteral obstruction, for a total of 14 ureters with stents placed. We placed metallic balloon expandable stents in 6 patients and self-expandable metallic stents in the remaining 6. Mean patient age was 65 years and mean followup was 9 months (range 8 to 16)., Results: Of the ureters 11 were patent without any additional manipulations during followup of 8 to 16 months. Secondary interventions were needed in 3 cases because of obstructive urothelial hyperplastic reaction, tumor ingrowth and local recurrence of the primary cancer invading the upper end of the stent. Two patients died 2 and 10 months after placement of the stent., Conclusions: Both types of metal stents have advantages and disadvantages that must be balanced against each other when choosing the ideal device for the treatment of obstruction. Implantation of a metal self-expanding or balloon expanding stent is safe and effective for the palliative treatment of malignant ureteral obstruction in late stage cancer patients.

Twenty patients with prostatodynia were studied urodynamically with synchronous video-pressure-flow studies and electromyography of the external urethral sphincter. The most striking finding was a significant increase in maximum urethral closure pressure compared to an age and sex-matched control group. Typically, peak and average urinary flow rates were decreased. Another prominent feature was incomplete funneling of the bladder neck during voiding with an accompanying urethral narrowing at the level of the external urethral sphincter. These findings are not consistent with a diagnosis of tension myalgia of the pelvic floor or detrusor-striated sphincter dyssynergia but suggest a primary abnormality involving the pelvic sympathetic nervous system. We believe that more advanced methods than those available currently are needed to elucidate fully the role of the autonomic nervous system, especially its sympathetic component, in the etiology of prostatodynia.

A total of 13 men underwent synchronous video/pressure/flow electromyography studies after abdominoperineal resection of the rectum. All patients had diminished pressure in the proximal urethra and an incompetent vesical neck suggestive of sympathetic denervation. Five patients (38 per cent) had cystometric evidence of parasympathetic denervation and 7 (54 per cent) had electromyographic evidence of pudendal denervation. These data suggest that denervation owing to surgical injury is an important cause of persistent symptoms after abdominoperineal resection of the rectum.

Normally the bladder neck remains closed except during voiding. We reviewed 550 consecutive patients who underwent synchronous video/flow/pressure/electromyography studies to identify whether neurologic factors are involved in the pathogenesis of an abnormally open bladder neck. A total of 33 patients who had not undergone prior bladder neck surgery had an open bladder neck at rest. The prevalence of neurologic lesions in patients with an open bladder neck was significantly greater than in those with a normal bladder neck. However, there was no correlation between any specific lesion and the incidence of an open bladder neck. Patients with myelodysplasia had an inordinately high incidence of open bladder neck. We conclude that abnormalities of bladder neck innervation may result in a pathologically open bladder neck.

The efficacy of Credé's maneuver to promote voiding was evaluated prospectively in 207 patients with a variety of lower urinary tract disorders. The normal response to Credé's maneuver was a contraction of the external urethral sphincter (the Credé effect), an increase in urethral pressure and maintained closure of the vesical neck. Relaxation of the external urethral sphincter and synchronous opening of the bladder neck during Credé's maneuver were seen in only 4 patients (2 per cent). We conclude that Credé's maneuver is an inefficient method of bladder emptying in the majority of patients and even when voiding is accomplished with Credé's maneuver it usually is grossly inefficient and associated with significant urethral obstruction.

A total of 27 men with multiple sclerosis underwent urodynamic evaluation as part of a prospective study of voiding dysfunction. Of 18 patients with detrusor-external sphincter dyssynergia 9 suffered serious urologic complications, including repeated episodes of urosepsis, vesicoureteral reflux and urolithiasis. None of the 9 patients without dyssynergia suffered any urologic complications. Urologic complications were correlated highly to the presence of detrusor-external sphincter dyssynergia and the severity of multiple sclerosis but not to duration of multiple sclerosis, age of the patient or type of dyssynergia. Although no treatment was without complications it appears that either anticholinergics plus intermittent self-catheterization or condom catheter drainage is superior to an indwelling catheter for initial conservative treatment. External sphincterotomy or urinary diversion may be necessary if conservative therapy fails.

Congenital ureteral valves are a rare cause of obstructive uropathy and the majority of cases are diagnosed only at surgery or autopsy. A case of congenital ureteral valve associated with an incompletely duplicated kidney is reported and the literature on ureteral valves is reviewed. Modern uroradiological and endoscopic diagnostic techniques should result in a more precise preoperative diagnosis. The high incidence of associated genitourinary anomalies, particularly duplication anomalies, suggests abnormal ureteral embryogenesis as an etiological factor in congenital ureteral valve formation.