The role of pelvic floor exercises on post-prostatectomy incontinence.

PURPOSE: Post-radical prostatectomy incontinence occurs in 0.5% to 87% of patients. This condition may be attributable to intrinsic sphincteric deficiency, and/or detrusor abnormalities. Previous studies of pelvic floor exercise (PFE) for improving post-prostatectomy incontinence have shown mixed results. We determined whether preoperative and early postoperative biofeedback enhanced PFE with a dedicated physical therapist would improve the early return of urinary incontinence. MATERIALS AND METHODS: A total of 38 consecutive patients undergoing radical prostatectomy from November 1998 to June 1999 were randomly assigned to a control or a treatment group. The treatment group of 19 patients was referred to physical therapy and underwent PFE sessions before and after surgery. Patients were also given instructions to continue PFE at home twice daily after surgery. The control group of 19 men underwent surgery without formal PFE instructions. All patients completed postoperative urinary incontinence questionnaires at 6, 12, 16, 20, 28 and 52 weeks. Incontinence was measured by the number of pads used with 0 or 1 daily defined as continence. RESULTS: Overall 66% of the patients were continent at 16 weeks. A greater fraction of the treatment group regained urinary continence earlier compared with the control group at 12 weeks (p <0.05). Three control and 2 treatment group patients had severe incontinence (greater than 3 pads daily) at 16 and 52 weeks. Of all patients 82% regained continence by 52 weeks. CONCLUSIONS: PFE therapy instituted prior to radical prostatectomy aids in the earlier achievement of urinary incontinence. However, PFE has limited benefit in patients with severe urinary incontinence 16 weeks after surgery. There is a minimal long-term benefit of PFE training since continence rates at 1 year were similar in the 2 groups.

Prospective randomized study of various techniques of percutaneous nephrolithotomy.

OBJECTIVES: To compare the modifications of the technique of percutaneous nephrolithotomy (PCN), including "mini-PCN" and tubeless PCN, to establish which technique is associated with the least morbidity and complications. METHODS: We performed a prospective randomized trial to assess the efficacy and morbidity of each method of percutaneous renal access. Standard PCN involved tract dilation to 30F for passage of a 34F working sheath, and our "mini-PCN" involved tract dilation to 22F for passage of a 26F sheath. Tubeless PCN involved the use of a double-J stent for internal drainage without the use of a nephrostomy tube for external drainage at termination of the procedure. Thirty patients (10 patients in each group) were enrolled, and 27 patients completed the study. All three groups were compared with regard to postoperative pain using a validated pain questionnaire comprised of a visual analogue scale and a verbal rating scale. The operative time, estimated blood loss, stone burden, procedure success rate, stone-free rate, length of hospitalization, total procedural cost, and complications were also compared for each technique. RESULTS: The tubeless PCN population required less morphine use, had a decreased length of hospitalization, and had a smaller total procedural cost compared with the other two groups. One complication was noted in both the standard and mini-PCN groups, consisting of renal bleeding requiring a 2 and 3-U blood transfusion in the standard and mini-PCN groups, respectively. CONCLUSIONS: The tubeless technique is associated with the least amount of morbidity and the greatest cost efficiency compared with the other techniques. No overall advantage was found for the mini-PCN versus the standard technique, but the mini-PCN is at a slight disadvantage because of poorer visualization and optics and difficulty with use of the nephroscopic graspers.

Effect of sildenafil citrate on post-radical prostatectomy erectile dysfunction.

PURPOSE: We assess the effect of sildenafil in a subgroup of patients after prostatectomy with erectile dysfunction and determine whether nerve preservation improves sildenafil response in this subgroup. MATERIALS AND METHODS: Between April 1998 and January 1999, 53 patients who had undergone radical retropubic prostatectomy and were prescribed oral sildenafil were surveyed using a confidential mail questionnaire. Of the patients 21 underwent bilateral and 15 unilateral neurovascular bundle sparing procedures, while in 17 a nonnerve sparing procedure was performed. All patients received 25 to 100 mg. sildenafil in a flexible dose escalation manner. Response, satisfaction and side effects were assessed using a modified, self-administered International Index of Erectile Function questionnaire. Response was defined as erection sufficient for intercourse. Preoperative and postoperative/pretreatment erectile functions were assessed for baseline comparison in each patient, and partner overall satisfaction with sildenafil was measured. Statistical data analysis was performed using analysis of variance and Newman-Keuls multiple comparison tests. RESULTS: Of the 21 patients who underwent a bilateral nerve sparing procedure 15 had a positive response. Of the 15 patients who had undergone a unilateral nerve sparing procedure 12 had a positive response, and only 1 of the 17 patients who had undergone a nonnerve sparing procedure responded to sildenafil. The most commonly reported adverse events of all causes were headaches (21%), flushing (8.3%), visual disturbance (6.3%) and nasal congestion (6.3%). CONCLUSIONS: Sildenafil is an equally effective treatment for erectile dysfunction after bilateral and unilateral nerve sparing procedures, and patient response to sildenafil is confirmed by the partners. However, patients who undergo nonnerve sparing procedures do not respond satisfactorily to sildenafil.

Management of ureteral obstruction secondary to pelvic malignancies.

PURPOSE: To assess the efficacy of urinary diversion (internal v external) in the management of ureteral obstruction secondary to pelvic malignancies and the patients' quality of life after diversion. PATIENTS AND METHODS: Thirty-seven patients presented with malignant ureteral obstruction secondary to primary neoplasms of the pelvis or metastatic disease of the pelvis and retroperitoneum and underwent urinary diversion. Patients were categorized into two groups according to the success (Group I) or failure (Group II) of internal stent drainage. Successful drainage was defined according to either radiologic study or the serum creatinine concentration in the case of a solitary kidney. "Useful life" was defined as satisfying four criteria: (1) little or no pain; (2) no complications; (3) ability to return home for at least 2 months; and (4) full mental capacity. RESULTS: Of the total patient population, 58% ultimately failed internal diversion. Nearly all (92%) of the cervical cancer patients required external drainage. Complications were seen in 10% of the stented patients and 13% of the patients with a percutaneous nephrostomy tube, but no procedure-related deaths occurred. Useful life was achieved by 84% of all patients. CONCLUSION: Antegrade drainage should be considered initially in patients who are likely to fail internal drainage (i.e., those with cervical cancer). The majority of these patients have a reasonably good quality of life, and intervention is most often warranted.