Bilateral ureteroarterial fistula: a case report and review of literature.

Ureteral arterial fistula (UAF) is an uncommon condition characterized by a direct fistulous communication between a ureter and an iliac artery resulting in bleeding into the ureter, which can be massive and life-threatening because of hemodynamic instability, as confirmed by the high mortality rate (7-23% overall).This condition is actually increasing in frequency because of its relation to predisposing factors such as vascular pathology, previous radiation therapy, previous surgery, and necessity of ureteral stenting. Diagnosis is often challenging, as in most patients, the only symptom is hematuria and the treatment may require a multidisciplinary approach, including the expertise of the urologist, vascular surgeon, and interventional radiologist. Endovascular approach offers advantages over open surgery decreasing morbidity (reduced risk of injury to adjacent structure) and shortening hospital staying. There is no consensus regarding the safety of intentional occlusion of the hypogastric artery: proximal occlusion of a hypogastric artery typically produces little or no clinical symptoms due to well-collateralized pelvic arterial networks. On the contrary, significant complications, such as colonic ischemia, spinal cord paralysis, buttock claudication, or erectile dysfunction, are well-recognized adverse events after hypogastric artery embolization, especially in bilateral cases. We describe our experience of a bilateral UAF treated with bilateral endvascular approach.

Urodynamic evaluation of sacral neuromodulation for urge urinary incontinence.

OBJECTIVE: To evaluate the urodynamic data before and 6 months after implantation of sacral neuromodulation (SNM, an established treatment for voiding dysfunction, including refractory urge urinary incontinence, UI) and to assess the correlation between the urodynamic data and clinical efficacy in patients with UI. PATIENTS AND METHODS: In all, 111 patients with a >50% reduction in UI symptoms during a percutaneous nerve evaluation test qualified for surgical implantation of SNM. Patients were categorized in two subgroups, i.e. those with UI with or without confirmed detrusor overactivity (DO) at baseline. At the 6-month follow-up all patients had a second urodynamic investigation, with the stimulator switched on. RESULTS: At baseline, there was urodynamically confirmed DO in 67 patients, while 44 showed no DO. A review of filling cystometry variables showed a statistically significant improvement in bladder volumes at first sensation of filling (FSF) and at maximum fill volume (MFV) before voiding for both UI subgroups, compared with baseline. In 51% of the patients with UI and DO at baseline, the DO resolved during the follow-up. However, those patients were no more clinically successful than those who still had DO (P = 0.73). At the 6-month follow-up, 55 of 84 implanted patients showed clinical benefit, having a >or=50% improvement in primary voiding diary variables. Patients with UI but no DO had a higher rate of clinical success (73%) than patients with UI and DO (61%), but the difference was not statistically significant. CONCLUSION: These urodynamic results show a statistically significant improvement in FSF and MFV in patients with UI with or with no DO after SNM. Although there was a urodynamic and clinical improvement in both groups, patients with UI but no DO are at least as successful as patients with UI and DO. Therefore in patients with UI, DO should not be a prerequisite selection criterion for using SNM.

Results of sacral neuromodulation therapy for urinary voiding dysfunction: outcomes of a prospective, worldwide clinical study.

PURPOSE: This 5-year, prospective, multicenter trial evaluated the long-term safety and efficacy of sacral neuromodulation in patients with refractory urge incontinence, urgency frequency and retention. MATERIALS AND METHODS: A total of 17 centers worldwide enrolled 163 patients (87% female). Following test stimulation 11 patients declined implantation and 152 underwent implantation using InterStim. Of those treated with implantation 96 (63.2%) had urge incontinence, 25 (16.4%) had urgency frequency and 31 (20.4%) had retention. Voiding diaries were collected annually for 5 years. Clinical success was defined as 50% or greater improvement from baseline in primary voiding diary variable(s). RESULTS: Data for all implanted cases were reported. For patients with urge incontinence mean leaking episodes per day decreased from 9.6 +/- 6.0 to 3.9 +/- 4.0 at 5 years. For patients with urgency frequency mean voids per day decreased from 19.3 +/- 7.0 to 14.8 +/- 7.6, and mean volume voided per void increased from 92.3 +/- 52.8 to 165.2 +/- 147.7 ml. For patients with retention the mean volume per catheterization decreased from 379.9 +/- 183.8 to 109.2 +/- 184.3 ml, and the mean number of catheterizations decreased from 5.3 +/- 2.8 to 1.9 +/- 2.8. All changes were statistically significant (p <0.001). No life threatening or irreversible adverse events occurred. In 102 patients 279 device or therapy related adverse events were observed. At 5 years after implantation 68% of patients with urge incontinence, 56% with urgency frequency and 71% with retention had successful outcomes. CONCLUSIONS: This long-term study demonstrates that InterStim therapy is safe and effective for restoring voiding in appropriately selected cases refractory to other forms of treatment.

Vaginal repair of vesico-vaginal fistulas: our experience.

Vesico-vaginal fistula repair is feasible both with abdominal and vaginal approach. We report our experience in vaginal repair of 34 vesico vaginal fistulas. Twenty-eight out of 34 fistulas have been treated by vaginal repair (82.3%) (in 2 cases after an attempt of endoscopic repair), 4/34 (11.8%) by abdominal repair and 4/34 (11.8%) by endoscopic repair with good outcome in 2 cases. In 96% of fistulas treated by vaginal repair (27/28) we obtained a complete recovery; in one patient we observed fistula recurrence after 2 months from the operation. Four patients were treated by abdominal approach: in two complex patients with vesico-uretero-vaginal fistula, the repair was associated with entero-cystoplasty and ureteral reimplantation; in one case of huge fistula following cesarean section (7 cm) a vesical flap was used; in one case we repaired a recurrent fistula in orthotopic ileal neobladder: A good outcome was achieved in all cases. Vaginal approach is less aggressive, well accepted by patients and can lead to lower legal issues. Abdominal surgery is mandatory in complex situations, when the fistula is big (> 4 cm) or when ureteral orifices are involved.

[The use of temporary stents in the treatment of urethral stenosis]. / Considerazioni sull'utilizzo degli stent temporanei nel trattamento delle stenosi uretrali.

The Authors report their past experience in the treatment of urethral strictures by means of temporary stent implants (Urocoil). The results at a long-term follow-up were poor in strictures of the bulbous and penile urethra (2/19 at 36 months) and very good in strictures of bladder neck and prostatic urethra (10/10 at 45 months). They conclude that this treatment has been at present abandoned due to high costs and poor results. It could however be effective in the treatment of postsurgical bladder neck strictures recurring after endoscopic treatment.