Prediction of spontaneous ureteral calculous passage by an artificial neural network.

PURPOSE: Although a consensus exists that small stones presenting in the distal ureter have a good probability of spontaneous passage, it is difficult to predict in individuals whether a particular ureteral stone would pass or require intervention. If an accurate judgment were made at presentation on the likelihood of stone passage, patients would receive immediate intervention for the stone or be notified of a more appropriate time at which to expect passage. We used an artificial neural network to evaluate data in patients with ureteral calculi to predict whether a stone would pass spontaneously or require intervention. MATERIALS AND METHODS: Data were collected from the records of 181 patients presenting with colic due to a ureteral calculus. Patient input factors included age, sex, race, marital status, insurance, stone side, level and size, hydronephrosis and obstruction grades, duration of symptoms before presentation, serum creatinine, history of stone passage or intervention and nausea, vomiting or fever. Outcomes evaluated were stone passage or intervention. Data were entered into a neural network created using commercially available computer software. RESULTS: A set of 125 patients from the database was used for training the network. The network correctly predicted outcome in 38 of the remaining 55 patients (76%) used for testing. In the 25 cases in which stones passed spontaneously sensitivity was 100%. Duration of symptoms before presentation was the most influential factor in network ability to predict accurately stone passage, followed by hydronephrosis grade. CONCLUSIONS: An artificial neural network may be used to predict accurately the probability of spontaneous ureteral stone passage. Using such a model at presentation may help to determine whether a patient should receive early intervention for a stone or expect a lengthy interval before stone passage.

Scrotal dog bites.

PURPOSE: Dog bites to the scrotum are rare but they potentially result in morbidity if improperly managed. MATERIALS AND METHODS: Between 1991 and 1999 we treated 4 men and 3 boys with dog bites to the scrotum. All 7 patients presented to the emergency department shortly after the injury. Of the 4 adults 3 were ingesting alcohol and 2 were obviously intoxicated, and 1 had a T4 spinal cord injury and was bitten during sleep. Of the children 2 were apparently bitten without provocation, while a 5-year-old boy was bitten when the family dog was disturbed while eating. RESULTS: All wounds were explored, irrigated and débrided. There was no involvement of the testes or spermatic cord. Each wound was closed primarily and 5 healed without sequelae. The spinal cord injured man had partial dehiscence of the incision and in another man superficial hematoma required drainage. Each patient received antibiotics and tetanus prophylaxis but none required rabies inoculation. CONCLUSIONS: Although there are reports of devastating scrotal injuries from dog bites, most such wounds may be treated by careful inspection for intrascrotal injuries followed by débridement and closure. Antimicrobial prophylaxis should be administered, as for any bite wound.

Traumatic posterior urethral injury and early primary endoscopic realignment: evaluation of long-term follow-up.

OBJECTIVES: The management of complete or partial posterior urethral disruption is controversial and much debate continues regarding immediate versus delayed definitive therapy. We further analyze our experience and long-term results using early endoscopic realignment. METHODS: Between April 1991 and June 1995, 8 men with posterior urethral avulsion, either complete or partial and secondary to blunt trauma and pelvic fractures, presented to our institution. A variety of endourologic techniques were employed to achieve urethral continuity while attempting to minimize stricture formation, incontinence, and impotence. RESULTS: After a mean of 50.4 months (range 35 to 85) of follow-up, 7 men (87.5%) are continent, with 2 of those requiring intermittent self-dilation ranging from once every 7 days to once a month. One patient required conversion to an open perineal urethroplasty. Of the 8 patients, 5 (62.5%) are potent, and 2 others achieve adequate erections for intercourse using intracorporeal injections. Four of the 8 have required subsequent internal urethrotomies with eventual voiding stabilization over the course of 1 2 months. Average time to realignment was 9.5 days (range 0 to 19). CONCLUSIONS: Primary endoscopic realignment offers an effective method for treating traumatic urethral injuries. Our long-term follow-up provides further support for use of this technique by demonstrating that urethral continuity can be established without increased incidence of impotence, stricture formation, or incontinence. By achieving early and minimally invasive realignment, we seem to lessen the severity of stricture disease that almost uniformly afflicts those patients who undergo delayed repair. If a minimally invasive technique should fail, it does not seem to delay nor does it preclude further management using open techniques.

Surgical correction of stress incontinence in morbidly obese women.

PURPOSE: Obesity is a contributing factor to the development of stress urinary incontinence in women, in addition to surgical technical factors which may make some urologists reticent to offer operative therapy. We reviewed our series of morbidly obese women who underwent anti-incontinence surgery to determine if they were at higher risk for surgical failure. MATERIALS AND METHODS: The records of our operative series of female stress urinary incontinence were reviewed and 16 women were considered morbidly obese. Transvaginal bladder neck suspension was performed in 4 women and sling procedures in 12, depending on preoperative urodynamic findings. RESULTS: Bladder neck suspension procedures failed in 2 cases, and no sling procedures failed. There was no recurrent or new pelvic floor deficit. The operations were somewhat more difficult to perform due to the body habitus of these patients but there were no intraoperative complications and only 1 minor wound infection postoperatively. CONCLUSIONS: Morbidly obese women with stress urinary incontinence can undergo operations for this disorder with a good chance of success. We recommend complete evaluation including urodynamics to ensure proper classification of stress incontinence. Sling operations may be the procedure of choice for stress incontinence in morbidly obese women.

Leak point pressures in women with urinary stress incontinence: correlation with patient history.

PURPOSE: We examined the relationship between historical factors in women with urinary stress incontinence and the Valsalva leak point pressure. MATERIALS AND METHODS: Valsalva leak point pressure measurements in 57 women with urinary stress incontinence were compared to findings in the history. RESULTS: Valsalva leak point pressure was low in 83% of women with severe leakage and previous surgery. Interestingly, 47% of patients without predisposing factors had low Valsalva leak point pressures. CONCLUSIONS: Women with severe leakage and previous bladder neck surgery are likely to have urethral dysfunction as demonstrated by Valsalva leak point pressure testing. A significant incidence of low Valsalva leak point pressures in patients without predisposing factors could account for many failures of routine suspension procedures.

Transurethral collagen injections in the therapy of post-radical prostatectomy stress incontinence.

PURPOSE: We report on our initial results with glutaraldehyde cross-linked collagen used as an injectable bulking agent for the therapy of post-radical prostatectomy stress incontinence. MATERIALS AND METHODS: A total of 19 men underwent collagen injection for treatment of post-radical prostatectomy stress incontinence. RESULTS: Of the 19 patients treated 11 had either a good (4) or improved (7) result, for an overall satisfaction rate of 58% with a followup of 3 to 15 months (mean 10.4). Failure correlated with presence of bladder neck contracture or scarring and severity of incontinence. CONCLUSIONS: Injection of collagen for stress incontinence after radical prostatectomy has an acceptable short-term success rate, particularly in men with milder incontinence and lack of bladder neck scarring.

Laparoscopic surgery for bladder carcinoma.

Recent utilization of laparoscopy in urology has led to the performance of several pelvic procedures. The successful performance of laparoscopic diverticulectomies and cystectomies for benign pathology has led to speculation about, and utilization of, the laparoscopic approach in the treatment of bladder cancer. Herein, we relay our experience with the laparoscopic approach for bladder surgery and discuss the pros and cons of its current status in the treatment of bladder cancer.

Radical perineal prostatectomy without pelvic lymphadenectomy: selection criteria and early results.

PURPOSE: We evaluated the surgical efficacy of radical perineal prostatectomy and determined preoperative parameters to identify patients at low risk for nodal metastasis. MATERIALS AND METHODS: Of 155 men evaluated for radical perineal prostatectomy, 74 were assigned to a low risk category (prostate specific antigen less than 10 ng./ml., Gleason score less than 7). Of the patients 40 underwent laparoscopic lymph node dissection and 34 did not. This group was compared to 81 patients who underwent surgical staging and did not fit the low risk criteria. RESULTS: None of 74 patients in the low risk group had nodal metastasis, while metastasis was present in 5 of 81 (6.1%) who did not meet such parameters. Organ-confined disease was present in 71.6% of men with low risk criteria, which was a significantly different rate than the 51.9% found in the other 81 men. CONCLUSIONS: Radical perineal prostatectomy confers adequate cancer control and can be performed without pelvic node dissection in select patients.

Evaluation of fluid absorption during laser prostatectomy by breath ethanol techniques.

PURPOSE: Laser prostatectomy has evolved as a less invasive method of relieving bladder outlet obstruction due to prostatic enlargement. The elimination of adenomatous tissue by laser induced coagulation necrosis theoretically avoids the sequelae of fluid absorption noted during traditional transurethral resection of the prostate. However, to our knowledge no accurate determination of fluid absorption during laser prostatectomy has been performed to date. MATERIALS AND METHODS: A technique previously described to determine the amount of irrigant absorbed during transurethral resection of the prostate measures breath ethanol levels using a standard alcohol breath analyzer during the procedure after a predetermined amount of ethanol is added to the irrigant fluid. This method was used in 4 men undergoing laser prostatectomy. RESULTS: All 4 subjects had ethanol levels of 0 throughout the operation, indicating that little or no irrigant fluid was absorbed. CONCLUSIONS: We demonstrated in a quantitative manner that fluid absorption during laser prostatectomy is almost nil and patients are, indeed, at no risk for the transurethral resection syndrome.

Comparison between standard flank versus laparoscopic nephrectomy for benign renal disease.

To evaluate the role of laparoscopic nephrectomy in the management of benign renal diseases, 12 patients undergoing laparoscopic nephrectomy were compared to 13 undergoing a classical flank nephrectomy. Both groups were similar in regard to patient age and indications for surgery. The underlying pathological conditions included vesicoureteral reflux, tuberculosis, hydronephrosis, hypertension and failed pyeloplasty. Overall, operative time ranged from 105 to 360 minutes (mean 145) for the laparoscopic group and 60 to 240 minutes (mean 156.6) for the open surgery group. Hospital stay and interval to return to regular preoperative activities were 2 to 6 days (mean 3.5) and 10 to 21 days (mean 16) for patients undergoing laparoscopic nephrectomy, which was significantly shorter than for those undergoing a flank procedure, 3 to 16 days (mean 8) and 35 to 84 days (mean 32.3), respectively. Pain medication requirements were also markedly decreased after laparoscopic nephrectomy. Of the patients in the laparoscopic group 2 experienced complications with only 1 requiring conversion to open nephrectomy. The laparoscopic technique is an effective as the flank approach for benign renal conditions, while providing a more rapid recuperation and superior cosmetic result.

Laser prostatectomy: initial experience and urodynamic follow-up.

OBJECTIVES: An evolving technology for the treatment of bladder outlet obstruction due to benign prostatic hyperplasia (BPH) is the use of the side-firing neodymium: yttrium-aluminum-garnet (Nd:YAG) laser to achieve prostatic tissue ablation. The purpose of this study was to determine the short-term efficacy of this procedure in both an objective and subjective manner. METHODS: We examined this technique by carefully evaluating our first 25 men undergoing the procedure. Each patient was subjected to careful symptom score analysis using the American Urological Association symptom index and multichannel urodynamics, including pressure-flow studies both preoperatively and at 3 months postoperatively. RESULTS: At the 3-month follow-up, symptom scores improved from a preoperative mean of 11.4 to 7.2 and the mean maximum flow rate improved from 6.1 to 14.5 cc/s. These are both significant at P < 0.001. Statistically similar improvement was seen in detrusor pressure at opening and at maximum flow. Eighty percent of the men studied had at least a 50% reduction in symptom score and a 50% improvement in flow rate. CONCLUSIONS: We conclude that laser prostatectomy is a promising minimally invasive treatment for bladder outlet obstruction secondary to BPH and deserves further evaluation at longer terms of follow-up.

Seminal vesicle volume as a sonographic predictor of prostate cancer stage.

OBJECTIVES: Accurate clinical staging of prostate cancer continues to challenge the urologist, with understaging a common problem. Preoperative identification of men with capsular penetration or seminal vesicle invasion would allow deferment of radical surgery unlikely to cure the patient. We investigated the ability of seminal vesicle volume as determined by transrectal ultrasound (TRUS) to predict the stage of prostate carcinoma. METHODS: Forty-seven consecutive men undergoing radical prostatectomy had preoperative determination of the seminal vesicle volume by TRUS. The volume was determined for each individual seminal vesicle as well as the total seminal vesicle volume. Asymmetry was defined as one seminal vesicle having twice the volume of the other. RESULTS: Average total seminal vesicle volume was statistically greater for patients with Stage C disease as opposed to those with organ-confined tumors. Seminal vesicle asymmetry was also present statistically more often in Stage C patients than Stage B men. The combination of total seminal vesicle volume less than 15 cc and symmetrical seminal vesicles yielded a possibility of only 18% of extraprostatic extension of tumor. CONCLUSIONS: We believe that seminal vesicle volume as determined by TRUS can aid in the staging of adenocarcinoma of the prostate and should be considered along with other parameters, such as prostate-specific antigen, acid phosphatase, and Gleason score, when planning therapy for this disease.

Simple detubularization technique for construction of continent colonic urinary reservoirs.

OBJECTIVES: Despite the advantages offered by continent urinary diversion techniques, wide acceptance of the procedure has been hampered by the length of time required to detubularize and suture the reconfigured bowel. With the purpose of simplifying the procedure, a linear stapler loaded with absorbable staples was used to accomplish simultaneous detubularization and closure of the reservoirs. METHODS: Six patients, 4 men and 2 women received a stapled detubularized reservoir following radical cystectomy. The male patients all had construction of a neobladder, whereas in the females a catheterizable continent stoma was designed. RESULTS: Operative time was shortened by an average of 30 to 45 minutes without technical difficulties. No postoperative complications related to the staple line occurred and with a follow-up of 6 months good functional results have been achieved, with no patient experiencing diurnal incontinence. CONCLUSIONS: This simple mechanical detubularization technique offers results similar to the hand suture method while at the same time shortening and simplifying the procedure.

The value of laparoscopic lymphadenectomy in conjunction with radical perineal or retropubic prostatectomy.

A total of 76 men with clinically localized prostate cancer underwent surgical treatment at our institution during an 11-month period. Of the patients 26 underwent staging laparoscopic pelvic lymph node dissection followed by radical perineal prostatectomy (group 1), 24 underwent laparoscopic pelvic lymph node dissection and radical retropubic prostatectomy (group 2), and 26 underwent standard open lymphadenectomy and radical retropubic prostatectomy (group 3). Group 1 patients experienced statistically significantly less average blood loss (576 +/- 360 cc) than either group 2 (1,275 +/- 686.8) or 3 (1,100 +/- 459, p < 0.001). Hospital stay was also significantly less in group 1, with a mean of 4.6 +/- 1.9 days compared to 9.6 +/- 4.6 and 7.25 +/- 2.06 days for groups 2 and 3, respectively (p < 0.001). Our study supports the combination of laparoscopic pelvic lymph node dissection and radical perineal prostatectomy as a potentially less morbid approach to the surgical treatment of prostate cancer. However, no benefit was found for laparoscopic staging in patients before radical retropubic prostatectomy.

Complications of laparoscopic urological surgery: experience at St. Louis University.

A total of 221 patients underwent laparoscopic surgery at our institution. An outcome analysis with regard to type of procedure, success and complications was done. Overall, 216 of 221 procedures (97.7%) were performed as originally planned. One operation was converted to an open procedure. Complications producing morbidity occurred in 33 of 217 patients (15.2%). There was no associated mortality. Most complications occurred early in the participating surgeons experience. Of the complications 11 (5.0%) were considered major and included formation of symptomatic lymphoceles (4 patients), vascular injury (1), ureteral transection (1), bladder perforation (1), bowel obstruction (1), cecal perforation (1) and cerebrovascular accident (1). One patient had an idiopathic reaction to the inhalation anesthetic. Of the 11 major complications 9 occurred among 98 patients undergoing pelvic lymphadenectomy and 7 of these occurred among a subset of 15 patients undergoing an extended dissection. Adjuvant surgical intervention was necessary in 13 patients: celiotomy in 5, laparoscopic techniques in 4 and minor surgical procedures or percutaneous techniques in 4. Our experience suggests that urological laparoscopic surgery is safe and offers a shorter convalescence. However, the technique must be regarded as major surgery, associated with a steep learning curve.

Endocavitary bladder surgery.

The advent of laparoscopy has expanded the horizon for endocavitarily approaching urologic disorders, otherwise managed by open surgical procedures. In this article we will review our experience with this new modality as applied to the urinary bladder, and put into perspective future applications.

Endocavitary (laparoscopic) pelvic lymphadenectomy with specific indications in urologic surgery.

Recent reports have established the feasibility and minimal morbidity of laparoscopic pelvic lymph node dissection in the staging of prostate and bladder cancer. In addition, a prospective study recently published established the completeness and efficacy of this form of endocavitary surgical lymphadenectomy with respect to the standard modified open procedure. The method's utility prior to definitive radiation therapy or radical perineal prostatectomy is obvious. However, clear indications of its utility in identifying men with positive nodes prior to radical retropubic prostatectomy are less clear. A description of the surgical technique as well as a review of the existing literature, and our present indications for its use are presented. In addition, possible future applications of endocavitary node dissection will be put in context.