Sacral neuromodulation in functional urinary retention: an effective way to restore voiding.

OBJECTIVE: To determine the long-term efficacy and complications of sacral nerve stimulation as an alternative therapy for functional unobstructive urinary retention, often considered to be psychogenic and effectively treated by clean intermittent catheterization, but for which pelvic floor dysfunction has been recognized as a possible cause. PATIENTS AND METHODS: Twenty patients (17 women and three men, mean age 48 years) with idiopathic, unobstructive functional urinary retention and in whom other forms of therapy had failed, had a pulse generator implanted (Medtronic, Minneapolis, MN, USA) and a sacral nerve implant. Their mean duration of symptoms was 68 months; 13 patients had chronic pelvic and perineal pain associated with their obstructive voiding symptoms. All patients were managed with clean intermittent catheterization and pharmacological therapy (alpha-blockers) before the procedure. All patients had a percutaneous nerve evaluation before the permanent implant, which showed> 50% improvement in their symptoms. All patients were evaluated at 1, 6 12, 18 and 24 months, then yearly thereafter. The results were assessed both subjectively by patient's symptoms and objectively by checking the postvoid residual volume (PVR) and voided volume. RESULTS: Eighteen patients were able to void spontaneously with a mean increase in voided volume from 48 to 198 mL, and a significant decrease in PVR from 315 to 60 mL. Eighteen of the patients had a > or = 50% improvement in their symptoms and said they would recommend the therapy to a friend or relative. Complications occurred in six patients. CONCLUSION: Sacral nerve stimulation is an effective and durable new approach to functional urinary retention, with few associated complications. Test stimulation provides a valuable tool for selecting patients.

A complication of scleral expansion surgery for treatment of presbyopia.

PURPOSE: To report a patient who developed complications from an experimental technique using scleral expansion to treat presbyopia. METHODS: Case report of a 46-year-old woman who underwent scleral expansion surgery on her right eye. Postoperatively, the patient developed chronic pain and swelling that necessitated removal of the scleral expanders. RESULTS: After removal of the scleral expanders, the patient demonstrated a -1.4 diopter myopic shift in the right eye relative to her preoperative refraction. Axial length of the right eye was 1.15 mm longer than of the left, whereas preoperative axial lengths were equal. CONCLUSION: This patient developed scleral thinning with resultant axial lengthening and myopic shift, akin to the phenomenon observed with scleral buckles used to treat retinal detachments. We believe this was responsible for improved near vision in her right eye, rather than any increased accommodative potential purported to result from this operation.

Retrobulbar anesthesia for repair of ruptured globes.

PURPOSE: To describe two cases involving patients with ruptured globes in whom retrobulbar anesthesia was used successfully. METHOD: A modified retrobulbar anesthesia technique was used to repair two ruptured globes in two patients in whom general anesthesia was contraindicated. RESULT: Using a modified technique, retrobulbar anesthesia did not cause wound gape or prolapse of intraocular contents. CONCLUSIONS: Most open globes should be repaired after administration of general anesthesia. Modified retrobulbar anesthesia can provide a reasonable alternative in rare situations in which general anesthesia subjects the patient to an unacceptable risk.

A fixation aid for slit-lamp biomicroscopic examination of the optic nerve.

The traditional articulated fixation light used on slit lamps is somewhat inconvenient, requiring repositioning for each eye. A simple, inexpensive fixation aid is described, which allows examination of both optic nerves without repositioning.

Neodymium-YAG laser: new treatment for urethral stricture disease.

This is a preliminary report concerning the use of Neodymium-YAG laser for urethral strictures. A new technique, not previously described, is explained, and the early results and complications are analyzed. The results were documented with urethrograms and uroflowmetry. We believe the Nd:YAG laser is a safe and effective means of treating urethral strictures. Also it reduces the cost of treatment, and the patients return to work in four to five days.

The etiology of detrusor hyperreflexia in patients with infravesical obstruction.

Bladder function was studied in 44 patients with bladder outlet obstruction by gas cystometry, integrated sphincter electromyography and uroflowmetry. Of these 44 patients 18 demonstrated detrusor hyperreflexia on cystometry. To identify the prostate as a possible source for triggering sensory stimuli pharmacologic ablation with lidocaine was performed through a perineal approach in 11 patients with hyperreflexia. Prostatic block eliminated hyperreflexia in 10 of 11 patients and had no effect in 4 patients with a normal cystometrogram. We believe that this study lends support to the concept that sensory stimuli from an anatomically altered prostatic urethra induces detrusor hyperreflexia. This suggests that permanent ablation of sensory stimuli from the prostate in patients with outlet obstruction would be of benefit.