Urethral leiomyoma: combined vaginal and abdominal approach - a case report / Mioma uretral: abordagem combinada vaginal e abdominal - um relato de caso

Abstract Introduction: leiomyomas are benign mesenchymal tumors of smooth muscle origin that can develop in various locations. Urethral leiomyomas are rare, with approximately only 120 cases reported in the literature. These tumors often occur in the third and fourth decades of life but are rare in menopausal patients. In general, treatment involves surgery, only three recurrence reports in the literature. Description: a case report on a 56-year-old woman; the patient had type II diabetes mellitus and chronic high blood pressure, was overweight (body mass index, 27.1 kg/m2), and a smoker. Besides this, the patient presented symptoms of urinary obstruction and had a large urethral leiomyoma. The tumor was completely removed with no associated urethral lesions using a complex, combined abdominalvaginal surgical approach. Discussion: the management and treatment on urethral leiomyomas is challenging and have not been established yet due to the rarity of these tumors.

Resumo Introdução: os leiomiomas são tumores mesenquimais benignos de origem muscular lisa, podendo manifestar-se em diversas localizações. Os leiomiomas uretrais são raros, tendo apenas aproximadamente 120 casos relatados na literatura. São mais comuns na terceira e quarta décadas de vida, sendo raros em pacientes menopausadas. Em geral, são tratados cirurgicamente, com apenas três relatos de recidivas na literatura. Descrição: relato de caso de uma paciente do sexo feminino, 56 anos, portadora de diabetes mellitus do tipo II, hipertensão arterial crônica, sobrepeso (IMC 27,1Kg/m2) e tabagismo. Além disso, com quadro de sintomas obstrutivos urinários e portadora de um grande leiomioma uretral, este que foi completamente removido, através de uma desafiadora abordagem cirúrgica combinada (abdominal e vaginal), sem lesões uretrais associadas. Discussão: os leiomiomas uretrais são tumores raros e seu manejo é desafiador e ainda não foi estabelecido.

A new surgical technique: transvesical prostate resection

ABSTRACT Objectives: Surgical treatment is indicated in patients where medical therapy fails to prove beneficial or in patients who develop complications related with bladder outlet obstruction. In our study, we developed a new surgical technique which can be defined as Transvesical Resection of Prostate (TVRP) without using the urethra. This method was previously described in our articles (1). Materials and Methods: A 62-years-old male patient, using an alpha blocker agent for 5 years, reported increased discomfort with urination. His findings were as follows: PSA: 1.2 ng/dL, prostate volume: 45 cc, digital rectal examination: benign, IPSS: 30, QoL: 5, Qmax: 6, urine volume: 225 cc, post-mictional residue: 65 cc. Eventually the patient was informed and prostate resection decision was made. Results: Suprapubic catheter was removed 1 day after surgery and the patient was discharged. Urethral catheter was removed 4 days after urine output became clear. No complications developed after the operation. At postoperative 1st month, Qmax was 22, urine volume was 260 cc, post-mictional residue was 40 cc, IPSS was 8, QoL was 1, and the pathology was benign prostate tissue. Conclusions: Urethral stricture is one of the most important postoperative complications of TURP. The incidence of urethral stricture is reported between 2.2% and 9.8% in different series (2-5). In this technique which we developed, urethra is not used and prostate is removed through the bladder, similar to open prostatectomies. For this reason, we suggest that it has an advantage over TURP, regarding urethral stricture development.

Safety and effectiveness evaluation of open reanastomosis for obliterative or recalcitrant anastomotic stricture after radical retropubic prostatectomy

ABSTRACT Purpose: To evaluate safety, efficacy and functional outcomes after open vesicourethral re - anastomosis using different approaches based on previous urinary continence. Materials and Methods: Retrospective study of patients treated from 2002 to 2017 due to vesicourethral anastomosis stricture (VUAS) post radical prostatectomy (RP) who failed endoscopic treatment with at least 3 months of follow-up. Continent and incontinent patients post RP were assigned to abdominal (AA) or perineal approach (PA), respectively. Demographic and perioperative variables were registered. Follow-up was completed with clinical interview, uroflowmetry and cystoscopy every 4 months. Success was defined as asymptomatic patients with urethral lumen that allows a 14 French flexible cystoscope. Results: Twenty patients underwent open re-anastomosis for VUAS after RP between 2002 and 2017. Mean age was 63.7 years (standard deviation 1.4) and median follow-up was 10 months (range 3 - 112). The approach distribution was PA 10 patients (50%) and AA 10 patients (50%). The mean surgery time and median hospital time were 246.2 ± 35.8 minutes and 4 days (range 2 - 10), respectively with no differences between approaches. No significant complication rate was found. Three patients in the AA group had gait disorder with favorable evolution and no sequels. Estimated 2 years primary success rate was 80%. After primary procedures 89.9% remained stenosis - free. All PA patients remained incontinent, and 90% AA remained continent during follow-up. Conclusion: Open vesicourethral re - anastomosis treatment is a reasonable treatment option for recurrent VUAS after RP. All patients with perineal approach remained incontinent while incontinence rate in abdominal approach was rather low.

Outcome of surgical management and pathogenesis of female primary bladder neck obstruction / 北京大学学报(医学版)

OBJECTIVE@#To investigate the effect of transurethral resection of bladder neck on primary female bladder neck obstruction and to analyze the expression of three kinds of sex hormone receptor (SR) in female bladder neck tissues diagnosed as primary bladder neck obstruction by the immunochemistry and statistics.@*METHODS@#The clinical data of 40 female patients, admitted into Peking University People's Hospital for difficulty of voiding during Oct.2008 and Dec.2013 and eventually diagnosed as bladder outlet obstruction (BOO) by urodynamics, were retrospectively reviewed. BOO was defined as a maximum flow rate (Qmax) less than 12 mL/s together with a detrusor pressure at maximum flow rate (Pdet Qmax) more than 25 cmH2O in urodynamic study in the absence of neurological disorders. Diagnosis was confirmed by the cystoscopy. Preoperative and postoperative AUASS scores were recorded and analyzed for observation of curative effects and complications. The immunochemical expression of SR of primary female bladder neck obstruction (PBNO) tissues and normal control was examined and applied to statistical analysis.@*RESULTS@#There were significant changes postoperatively in voiding scores, storage scores and total scores (P<0.001). Postoperatively, 1 patient newly presented with overactive bladder (OAB), 4 patients newly presented with hematuria, and 1 patient underwent cystostomy. The symptoms of urinary retention with overflow incontinence in 2 patients disappeared after the surgery, and 3 patients complicated with OAB complained without urgency. In addition, pre-hydronephrosis improved postoperatively in six patients. The subjective satisfactory rate to the surgery of TURBN was 77.5% (31/40). Sex hormone receptor, including androgen receptor (AR), estrogen receptor (ER), progesterone receptor (PR), expressed in both bladder neck tissues of normal control and PBNO patients. In PBNO group, the expression of PR was significantly lower than that of control group (P<0.05), while the other 2 SRs expressed with no significantly statistical difference. PBNO patients were divided into 2 groups, according to their symptoms scores, and the expression of SRs showed no significant differences among the mild, moderate and severe groups (P>0.05).@*CONCLUSION@#The transurethral bladder neck resection is valid in treating with female PBNO patients, with rarely occurrence of complications. PR expressed less in the female bladder neck tissues, and is possibly correlated with the occurrence of female PBNO.

Oxidative stress in the bladder of men with LUTS undergoing open prostatectomy: a pilot study

ABSTRACT Purpose: This study aims to evaluate the link between preoperative parameters and oxidative stress (OS) markers in the bladder wall of men undergoing open prostatectomy. Materials and Methods: From July 2014 to August 2016, men aged ≥ 50 years and presenting with LUTS were prospectively enrolled. Preoperative assessment included validated questionnaires (IPSS and OAB - V8), lower urinary tract ultrasound and urodynamics. Bladder biopsies were taken during open prostatectomy for determination of OS markers. Increased OS was defined by increased concentration of malondialdehyde (MDA) and / or decreased concentration of antioxidant enzymes (superoxide dismutase and / or catalase). P<0.05 was regarded as statistically significant. Results: Thirty - eight consecutive patients were included. Mean age was 66.36 ± 6.44 years, mean prostate volume was 77.7 ± 20.63 cm3, and mean IPSS was 11.05 ± 8.72 points. MDA concentration was increased in men with severe bladder outlet obstruction (BOO grade V - VI according to the Schaefer's nomogram) in comparison with BOO grade III - IV (p = 0.022). Patients with severe LUTS also had higher MDA concentration when compared to those with mild LUTS (p = 0.031). There was a statistically significant association between increased post - void residual urine (cut off ≥ 50 mL) and not only higher levels of MDA, but also reduced activity of SOD and catalase (p < 0.05). Conclusions: This pilot study showed that severity of LUTS and BOO were associated with increased MDA concentration in the bladder wall of men undergoing open prostatectomy. Further studies are still needed to assess the role of non - invasive biomarkers of OS in predicting bladder dysfunction in men with LUTS.

A new surgical technique: transvesical resection of prostate - case series

ABSTRACT Objective: To protect the urethra from instrumentation related urethra injures and stricture, we developed a new surgical technique which can be defined as transvesical resection of prostate without using urethra. Materials and Methods: Our study included 12 consecutive bladder outlet obstruction patients treated with transvesical prostate resection in our clinic between March 2016 and May 2016. Detailed anamnesis, results of physical examination, digital rectal examination, routine lab tests, international prostate symptoms score, transrectal ultrasound, measurement of prostate-specific antigen levels and uroflowmetry was performed in all patients prior to surgery. Results: Hospitalization period following surgery was 1 day. Foley catheter and suprapubic cystostomy catheters were removed in a median period of 3.6 days and 1 day. Median mass of resected adenomas was measured as 21.8 gr. Median maximum flow rate was measured as 6mL/s. Median postvoid residual urine volume was 70.6 cc and median international prostate symptoms score and quality of life scores were 9 and 1.4, respectively. Conclusion: In this study, we would like to show the possible practicality of transvesical resection of prostate technique in this patient group. However, we think that this technique is very useful in special patient groups such as patients with bladder stones, priapism and penile prosthesis.

Surgical treatment of detrusor underactivity: a short term proof of concept study

ABSTRACT Objectives To compare the surgical outcomes of men with bladder outlet obstruction (BOO) due to benign prostatic obstruction (BPO) to those with detrusor underactivity (DU) or acontractile detrusor (DA). Materials and Methods This retrospective, IRB approved study included men who underwent BPO surgery for refractory LUTS or urinary retention. Patients were grouped based on videourodynamic (VUDS) findings: 1) men with BOO, 2) men with DU and 3) men with DA. The primary outcome measure was the Patient Global Impression of Improvement (PGII). Secondary outcome measures included uroflow (Qmax), post-void residual volume (PVR) and the need for clean intermittent catheterization (CIC). Results One hundred and nineteen patients were evaluated: 1) 34 with BOO, 2) 62 with DU and 3) 23 with DA. Subjective success rate (PGII) was highest in the BOO group (97%) and those with DU (98%), while DA patients had a PGII success of 26%, (p<0.0001). After surgery, patients with BOO had the lowest PVR (68.5mL). Fifty-six patients (47%) performed CIC pre-operatively (47% of BOO, 32% of DU and 87% of DA patients). None of the patients in the BOO and DU groups required CIC post operatively compared to16/23 (69%) of patients in the DA group (p<0.0001). Conclusions BPO surgery is a viable treatment option in men with presumed BOO and DU while DA is a poor prognostic sign in men who do not void spontaneously pre-operatively.

Photoselective vaporization of the prostate in men with a history of chronic oral anti-coagulation

PURPOSE: A considerable percentage of patients with benign prostatic hyperplasia (BPH) also have additional cardiac pathologies, which often require anticoagulant therapy. The aim of this study was to evaluate the efficacy and safety of photoselective vaporization of the prostate (PVP) for BPH in cardiac patients receiving anticoagulant therapy. MATERIALS AND METHODS: A total of 67 patients suffering from BPH and high risk cardiac pathologies were operated on using laser prostatectomy. All patients had cardiac pathologies with bleeding disorders requiring anticoagulant use, and underwent standard urologic evaluation for BPH. Patients were treated with laser prostatectomy for relief of the obstruction using the KTP/532 laser energy at 80 W. RESULTS: The mean patient age was 71.4 years (range 55-80). Mean prostate volume on transrectal ultrasonography was 73.2 mL (range 44-120). Operation time ranged from 40 to 90 min, with an average value of 55 min. The average hospital stay was 48 hours (range 12-72) and the Foley catheters were removed within 48 hours, with a mean catheterization time of 34.2 ± 5.9 hours (0-48). No patient required an additional procedure due to severe bleeding necessitating intervention during the early postoperative phase. Mean International symptoms scoring system (IPSS) values and post voiding residual volume decreased and peak urinary flow rate increased (p < 0.001). Our results showed that the mean prostate volume had decreased by 53 percent at 6 months. CONCLUSIONS: High-power photo selective laser vaporization prostatectomy is a feasible, safe, and effective alternative for the minimal invasive management of BPH, particularly in cardiac patients receiving anticoagulant therapy.

Can bipolar vaporization be considered an alternative energy source in the endoscopic treatment of urethral strictures and bladder neck contracture?

OBJECTIVE: We evaluated the outcome of bipolar energy by using PlasmaKinetic™ cystoscope instruments in the treatment of urethral stricture and bladder neck contracture. MATERIALS AND METHODS: Twenty-two male patients with urethral stricture and five with bladder neck contracture were treated by endoscopic bipolar vaporization. The most common etiology for stricture formation was iatrogenic (85.2 percent) and the mean stricture length was 12.2 mm. All patients were evaluated with urethrography and uroflowmetry one month and 3 months after surgery. Urethroscopy was routinely performed at the end of the first year. Preoperative mean maximum flow rate (Q max) was 4.9 mL/s for urethral stricture and mean Q max was 3.4 mL/s for bladder neck contracture. The results were considered as "successful” in patients where re-stenosis was not identified with both urethrography and urethroscopy. Minimum follow-up was 13.8 months (range 12 to 20). RESULTS: Tissue removal was rapid, bleeding was negligible and excellent visualization was maintained throughout the vaporization of the fibrotic tissue. Postoperative mean Q max was 14.9 mL/s and the success rate was 77.3 percent for urethral stricture at mean follow-up time of 14.2 months. The success rate was 60 percent with a mean follow-up time of 12.2 months for bladder neck contracture and the mean Q max was 16.2 mL/s, postoperatively. CONCLUSIONS: The study suggests that bipolar vaporization is a safe, inexpensive and reliable procedure with good results, minimal surgical morbidity, negligible blood loss, and thus, it could be considered as a new therapeutic option for the endoscopic treatment of urethral stricture and bladder neck contracture.

Transurethral resection versus transurethral incision of the prostate: a subjective and objective analysis

To assess and compare the outcome and complications of transurethral prostatectomy [TURP] versus transurethral incision of the prostate [TUIP] in patients having bladder outlet obstruction. Fifty patients suffering form benign prostatic hyperplasia [BPH] with prostate size of <30 gms were included in this study. Group a [25 patients] underwent TURP while in group B [25 patients] TUIP was performed. The patients were assessed using International Prostatic Symptoms Scoring System [IPSS], uroflownetry, TRUS and postvoid residual urine volume. Follow up was done at 1,3,6 and 9 months intervals. There was no statistically significant difference in the mean age among the two groups. IPSS score dropped by 81.55% for group A and 85.71% for group B at 9 months postoperatively from baseline. The overall improvement in maximum flow rates as recorded for both groups was 172.60% and 249% respectively while it was 182.8% and 279% for group A and B in average flow rates. The mean drop in postvoid residual urine volume for group A was -88.50% and -99.02% for group B. Overall 84% of patients in group A and 92% of patients in group B were well satisfied with the outcome of procedures. TUIP is an effective and comparable treatment modality for BPH with gland size of < 30 grams. Results of TURP and TUIP were comparable, but TUIP was simple and easier to perform, with less morbidity and shorter operation time than TURP

Recurrent vesicourethal stenosis after radical prostatectomy: how to treat it?

Vesicourethral anastomotic stricture and urinary incontinence are severe complications of radical prostatectomy because they cause great impact in the quality of life. Three patients that presented these complications after prostate radical surgery were assessed retrospectively. To treat the stenosis of the vesicourethral anastomosis an urolume was placed and later on, an artificial sphincter AMS 800 was implanted to treat the resulting urinary incontinence.

Bladder neck resection with preservation an antegrate ejaculation

Objective: To evaluate a new method of bladder neck resection and to determine; whether or not antegrade ejaculation can be preserved. Patients and Methods Twenty patients with bladder neck obstruction were treated by bladder neck resection with preservation of more than 1 cm proximal to the verumontanum. The patients were evaluated before and after resection by semen volume; sperm count symptom improvement and urodynamic evaluation. Results With this technique preserving 1 cm of the supramontanal part; we could preserve antegrade ejaculation in 17 out of 20 patients (85); while in two patients only a small amount of semen was ejaculated and in one patient; complete retrograde ejaculation was reported. Conclusion The complication of retrograde ejaculation in young patients who are in need of fertililty may be avoided by preservation of 1 cm of the supramontanal part during bladder neck resection

Incisión transuretral de cuello vesical en el síndrome uretral refractorio / Transurethral incition of bladder neck in strong urethral syndrome

12 pacientes afectadas de Síndrome uretral refractario a terapias médidas fueron intervenidas con una incisión transuretral de cuello vesical. 11 de las 12 enfermas (91,6 por ciento) mejoraron su flujo miccional medio en un 57 por ciento y el flujo máximo en un 23 por ciento y 10 de ellas (83,3 por ciento) mejoraron su sintomatología y su calidad de vida. Ninguna paciente presentó infección urinaria o incontinencia urinaria definitiva en el post-operatorio

Cirugía endoscópica de la uropatía obstructiva por disinergía de esfinter liso / Endoscopic surgery of obstructive uropathy by dyssynergy of smooth sphincter

La obstrucción funcional del cuello vesical es una entidad clínica poco reconocida. Através de nuestra experiencia en Urodinamia hemos aprendido a diagnosticarla. Presentamos un enfoque terapéutico quirúrgico novedoso, a pesar de que sus fundamentos técnicos están descritos hace bastante tiempo en la literatura. Se revisan 25 pacientes tratados por obstrucción funcional del cuello vesical entre 1991 y 1996. El diagnóstico se realizó con estudio completo que incluye estudio urodinámico, endoscópico y radiológíco. Se realizó cirugía del cuello vesical, en 19 de ellos, 12 varones y 7 mujeres. El seguimiento de la serie fue de 37.7 meses en promedio (4 a 67 meses). No hubo complicaciones de importancia y el resultado sintomático fue excelente en 90 por ciento. La flujometría mejoró de 9.8 m]/ seg a 22.8 n-dlseg en los varones. En las mujeres mejoró de 14 ml/seg en el pre operatorio a 20.5 mll seg a los 6 meses. Se conservó la continencia en todos los pacientes. Se concluye que la cirugía endoscópica es una herramienta terapéutica válida-para el tratamiento de esta patología, ofreciendo un alivio definitivo sin complicaciones significativas. Especial interés le asignamos a este tratamiento en las mujeres con obstrucción funcional del cuello vesical, conservando la continencia

Esclerose do colo vesical pos-cirurgia prostatica / Bladder neck contracture following prostatic surgery

No periodo de julho de l985 a novembro de 1989 foram tratados em nosso Serviço, 11 casos de esclerose de colo vesical, sendo nove (82%) apos prostatectomia transvesical e dois (18%) apos ressecçao transuretral da prostata. O diagnostico foi firmado pela avaliaçao dos sintomas obstrutivos presentes apos uma cirurgia prostatica, pela uretroscopia e pela uretrocistografia retrograda. Foram utilizadas duas tecnicas para o tratamento da esclerose do colo vesical: ressecçao transuretral do colo vesical em sete casos (64%) e incisao do colo vesical com a Faca de Sachse em quatro casos (36%). Os resultados foram considerados bons em 86%, quando utilizada a ressecçao transuretral do colo vesical, e em 75% dos casos, quando utilizada a incisao do colo vesical com a Faca de Sachse

Incontinencia urinaria de esfuerzo: estudio comparativo del tratamiento quirurgico por las técnicas de Marshall-Marchetti-Krantz y suspensión endoscopica del cuello vesical / Stress urinary incontinenece: comparative study of the surgical treatment by Marshall-Marchetti-Krantz technics and endoscopie suspension of the bladder neck

Los autores comparan los resultados obtenidos con las técnicas de Marshall-Marchetti-Krantz y la suspensión endoscópica del cuello vasical en el tratamiento de la incontinencia urinaria de esfuerzo. En el Grupo I, 30 pacientes fueron operadas utilizándose cisto-uretropexia retropúbica con un índice de cura del 84%. En el Grupo II, 20 pacientes fueron sometidos a la suspensión endoscópica del cuello vesical con un porcentaje de cura de 95%. Los resultados obtenidos sugieren que la suspensión endoscópica del cuello vesical presenta mejores resultados que la cirugía de Marshall-Marchetti-Krantz en la corrección quirúrgica de la incontinencia urinaria de esfuerzo