Effects of depletion of complement in the development of labyrinthitis ossificans.

HYPOTHESIS: Labyrinthitis ossificans results in part from the intense inflammatory response to Streptococcus pneumoniae cell wall components. Depletion of complement in Mongolian gerbils following induction of meningitis will reduce the degree of inflammation and subsequent cochlear fibrosis. STUDY DESIGN: Random prospective study. Histological evaluations were performed with the researcher blinded to the experimental group METHODS: S. pneumoniae meningitis was induced in 10 control and 18 experimental Mongolian gerbils with an intrathecal injection of the bacteria. Both groups of animals received treatment with penicillin. The experimental group was also treated with cobra venom factor to deplete complement in the animals. Three months after the induction of meningitis, the animals' temporal bones were harvested for histological evaluation. RESULTS: The decomplemented animals developed significantly less intracochlear fibrosis (P < .01). The mortality rate for the experimental group was 11% compared with 40% in the control group (P = .14). CONCLUSIONS: Reduction of the intense inflammatory response to the S. pneumoniae cell wall components in suppurative labyrinthitis secondary to bacterial meningitis reduced the degree of labyrinthitis ossificans.

Müllerian duct remnants: surgical management and fertility issues.

PURPOSE: We reviewed our experience with mullerian duct remnants, also known as prostatic utricular and mullerian duct cysts, to advance further the understanding of the surgical management of these challenging congenital anomalies. The indications, merits and disadvantages of each surgical approach are presented, and the effects of mullerian duct remnants and their treatment on future fertility are discussed. MATERIALS AND METHODS: We reviewed the records of 26 patients 1 month to 19 years old with mullerian duct remnants who were seen between January 1984 and October 1998. Clinical presentation included perineoscrotal hypospadias in 10 cases, urinary retention and/or difficult voiding in 7, urinary tract infection in 6, acute scrotum in 2, and recurrent hemospermia and dysuria in 1. RESULTS: Of the 26 patients 13 required surgical intervention for various symptoms and to correct large diverticula. The surgical approach was transvesical transtrigonal in 8 cases, extravesical in 2, perineal in 2 and posterior sagittal in 1. Transurethral fulguration was performed in 2 cases. The initial surgical approach was successful in 11 of the 13 patients. One patient required conversion to a transvesical transtrigonal approach due to inadequate exposure during attempted perineal excision. Two cases treated with transurethral fulguration failed to resolve completely, and in 1 excision was required using the transvesical transtrigonal technique. A total of 13 patients were treated nonoperatively, including 10 in whom the condition was discovered incidentally during screening for perineoscrotal hypospadias. In 5 of the 10 patients urinary tract infection subsequently developed and they were maintained on long-term chemoprophylaxis. CONCLUSIONS: By tailoring the surgical approach to the type of mullerian duct remnant and the relevant anatomical relationships a high degree of success may be achieved with minimal morbidity.

Outcome of vaportrode transurethral vaporization of the prostate using pressure-flow urodynamic criteria.

OBJECTIVES: To use pressure-flow urodynamic parameters to evaluate the outcome of patients with benign prostatic hyperplasia (BPH) who were treated with transurethral vaporization of the prostate (TUVP) using the Vaportrode. METHODS: Forty consecutive patients (mean age 71.7 years) undergoing TUVP for treatment of symptomatic obstructive BPH or urinary retention were evaluated preoperatively and postoperatively with American Urological Association (AUA) Symptom Score, uroflowmetry, and pressure-flow multichannel urodynamic studies. RESULTS: Twenty-nine patients were voiding preoperatively. Eleven patients presented with urinary retention and were analyzed separately. At 3-month mean follow-up, the AUA Symptom Score decreased from 20.7 to 7.2 (n = 26). Peak uroflow rate (Qmax) increased from 8.2 to 15.5 mL/s (n = 27), whereas detrusor pressure at maximal flow (Pdet) decreased from 95.0 to 44.7 cm H2O (n = 24), indicating relief of obstruction. Postvoid residual urine volume decreased from 181.8 to 37.3 mL (n = 27). At 1-year mean follow-up, the AUA Symptom Score was 5.6 (n = 15) and Qmax was 14.3 mL/s (n = 19). The overall complication rate was 17.5% and included meatal stenosis (n = 1), bulbar urethral stricture (n = 1), refractory detrusor hyperreflexia (n = 1), dystrophic bladder neck calcification (n = 1), prostatic synechial formation requiring revision (n = 2), and residual prostatic tissue requiring revision (n = 1). CONCLUSIONS: This study provides objective evidence that TUVP is effective in providing prompt relief of bladder outlet obstruction with durable improvement in symptoms and flow rate with no acute morbidity. Accordingly, TUVP should continue to be considered as a minimally invasive surgical alternative to transurethral resection of the prostate.

Pubovaginal sling using polypropylene mesh and Vesica bone anchors.

OBJECTIVES: To report preliminary results from a modified pubovaginal sling procedure using polypropylene mesh as the sling suspended by nonabsorbable sutures anchored to the pubic tubercle with Vesica bone anchors. METHODS: Thirty-five women with type III stress urinary incontinence (SUI) (with or without associated urethral hypermobility) or type II SUI with additional risk factors such as obesity, chronic obstructive pulmonary disease, or failed prior incontinence-correcting procedures underwent this modified pubovaginal sling procedure. Postoperative voiding status was evaluated during office follow-up visits and telephone surveys. RESULTS: With a mean follow-up of 8.4 months (range 2 to 18), 32 women (91.4%) were dry, 1 improved, and 2 remained incontinent. The pubovaginal sling procedure was the only operation performed in 46% of patients, with a mean operative time of 72 minutes, a mean estimated blood loss of 137 mL, and a mean hospital period of 2.3 days. Patients on whom concomitant gynecologic procedures were performed had a mean duration of surgery of 122 minutes, a mean estimated blood loss of 202 mL, and a mean hospitalization period of 2.9 days. Thirteen women had preoperative urgency that persisted in 31% of patients. De novo urgency developed in 3 patients. Seven women required prolonged suprapubic tube drainage but no patient remained in permanent retention. There has been no infection or erosion. CONCLUSIONS: Our experience with this modified pubovaginal sling procedure using polypropylene mesh and Vesica bone anchors showed excellent results with greater technical ease, minimal morbidity, and decreased hospitalization period when compared to a traditional pubovaginal sling performed in our hands. Additional follow-up will be needed to assess long-term efficacy.

Sphincteric incontinence: the primary cause of post-prostatectomy incontinence in patients with prostate cancer.

Post-prostatectomy incontinence in patients with cancer of the prostate is often the result of sphincteric injury. However, recent studies have emphasized the role of detrusor instability and decreased bladder compliance in the etiology of post-prostatectomy incontinence. To further clarify the primary cause of incontinence, we reviewed the urodynamic studies of 39 patients referred for evaluation of incontinence after prostatectomy (35 radical, 4 TURP and radiation) for prostate cancer. Multichannel videourodynamic studies were performed to characterize bladder function, and sphincteric incontinence was assessed by Valsalva leak point pressure (VLPP). Flexible cystourethroscopy was used to evaluate the vesicourethral anastomosis. A pad scoring system was used to measure symptom severity. Sphincteric damage was found to be the sole cause of urinary incontinence in 23 patients (59%) and a major contributor in 14 others (36%). Twenty-seven patients (69%) had VLPP less than 103 cmH2O (mean = 55) with a urethral urodynamic catheter in place. An additional 10 (26%) had VLPP less than 150 cmH2O (mean = 63) upon removal of the catheter. VLPP is an indication of the severity of sphincteric damage. The importance of removing the urodynamic catheter during measurement of the VLPP is emphasized. Urethral fibrosis was confirmed by cystourethroscopy in 26 (67%) patients. Bladder dysfunction characterized by detrusor instability and/or decreased bladder compliance was seen in 15 patients (39%). In contrast to previous studies, our results indicate that sphincteric damage, and not bladder dysfunction, accounts for the vast majority of post-prostatectomy incontinence in patients with prostate cancer. However, it is essential to identify and treat bladder dysfunction in order to optimize the outcome of treatment for sphincteric incontinence.

Otolaryngological manifestations of factitious disorders--a case and literature review.

Otolaryngological manifestations of factitious disorders are rare. The case of a health care worker who injected her face and orbits with air in order to masquerade as facial cellulitis is presented. The literature and treatment strategies are reviewed.

Evaluation of transurethral vaporization of prostate with pressure-flow analysis and other clinical measures.

Transurethral vaporization of the prostate (TUVP) is a promising new alternative modality for resection of obstructing adenomatous prostatic tissue. We evaluated the efficacy of TUVP for treatment of symptomatic benign hyperplasia (BPH) or urinary retention using pressure-flow analysis and other clinical measures. Twenty-seven men (mean age 72) with symptomatic BPH (N = 21) or urinary retention (N = 6) underwent TUVP using the VaporTrode loop. Patients were evaluated both preoperatively and postoperatively by subjective and objective criteria including AUA symptom score, uroflowmetry, postvoiding residual volume (PVR), and detrusor pressure (Pdet) at maximum flow. Complete follow-up data were available in 19 patients with an average follow-up of 9 weeks (range 4-32). The average symptom score was reduced from 19.9 to 5.58 (p < 0.0001). The average peak uroflow rate (Qmax) improved from 7.0 ml/sec to 18.1 mL/sec (p < 0.001). The average PVR was reduced from 163 mL to 14 mL (p < 0.003), and there was a similar reduction in Pdet at maximum flow from 96 cm H2O to 44 cm H2O (p < 0.001). The overall complication rate was 11%. These included meatal stenosis (N = 1), temporary urinary retention (N = 1), and residual prostate tissue causing obstruction (N = 1). In conclusion, TUVP with the VaporTrode yields a significant improvement in AUA symptom score, peak uroflow rate, PVR, and detrusor pressure at maximum flow, denoting relief of bladder outlet obstruction. This review of our experience with TUVP provides additional evidence for the use of the VaporTrode as a safe and effective alternative surgical modality for the treatment of symptomatic BPH.

Effect of radiation fraction size on local control rates for early glottic carcinoma. A model analysis for in vivo tumor growth and radio-response parameters.

BACKGROUND: Two recent studies have suggested that the probability of local control for early glottic carcinoma (stages T1 and T2) following radiation therapy is lower when daily fractions of 1.8 Gy are given instead of 2.0 Gy when the total dose is kept constant at approximately 66 Gy. METHODS: We reviewed our experience with a total of 42 patients with T1, N0, M0 squamous cell carcinoma of the glottic larynx who were treated with radiation alone during the period 1979 to 1989. All patients received conventional fractionation radiation therapy (one treatment per day, 5 days per week). Eight patients received 2.0 Gy per fraction for an average total dose of 64.8 Gy, and 34 patients received 1.8 Gy per fraction for an average total dose of 66.7 Gy. We also calculated overall survival statistics. Combining the clinical data from our series and those of patients from other series (171 total patients), we analyzed the tumor response curve and doubling time for early glottic carcinoma by using a time-dependent, linear quadratic equation model. The analysis is valid for the typical range of radioresponsiveness for most tumors in healthy tissue. RESULTS: Using statistical z analysis, we noted a significant difference in the local control rates at 5 years, with better local control in the group that received 2.0 Gy per fraction (100% vs 70%). Our results for the calculated doubling time and tumor response curves correspond with experimental values for in vitro squamous cell carcinoma systems. CONCLUSION: It appears from the literature and from our data that the control rates for T1, N0, M0 glottic carcinoma may be significantly improved by using 2.0 Gy per fraction dose vs 1.8 Gy per fraction dose. Our analysis has provided a model of in vivo tumor response of early glottic carcinomas based on reported local control rates using these two different treatment regimens.

Neuroregulation of a chemosensitive afferent system in the canine distal esophagus.

Systemic and local responses mediated by chemonociceptive receptors located in the mucosa of the canine distal esophagus were examined following stimulation with capsaicin (8-methyl-N-vanillyl-6-nonenamide). The neural pathways and neurotransmitters mediating these sensory responses were also investigated. Topical application of capsaicin solution to the distal esophageal mucosa produced significant increases in lower esophageal sphincter pressure (LESP), mean arterial pressure (MAP), pulse rate (PR), and respiratory rate (RR) (P < 0.01). Pretreatment with tetrodotoxin completely abolished this reflex activity. Following truncal vagotomy and pyloroplasty, topical capsaicin application produced an increase in LESP, but the increases in MAP, PR, and RR were blocked. The initial increase in LESP was blocked by hexamethonium, atropine, and 4-diphenylacetoxy-N-methylpiperidine, but was not inhibited by phentolamine. Excitatory cardiovascular responses were inhibited by hexamethonium. Administration of a Substance P antagonist attenuated both local and systemic responses. These studies suggest that the vagus nerves serve as the primary afferent pathways through which chemonociceptive esophageal stimuli can induce cardiovascular and respiratory reflex excitation. The increase in lower esophageal sphincter pressure in response to mucosal capsaicin stimulation is mediated via an intrinsic neural pathway that functions independently of vagal innervation, but is dependent on both cholinergic ganglionic neurotransmission and muscarinic type 2 smooth muscle receptor excitation. Substance P appears to play a role in primary sensory afferents as a chemonociceptive neurotransmitter in the canine distal esophagus.