[A new approach to the transvaginal needle suspension technique after Raz. Technique and long-term results]. / Eine neue Annäherungsweise im transvaginalen Nadelsuspensionsverfahren nach Raz. Technik und langfristige Ergebnisse.

AIM: Our aim is to describe the surgical technique and to present a long-term evaluation of the results. MATERIALS AND METHODS: A total of 53 patients with stress incontinence underwent a Raz transvaginal needle suspension operation with the introduction of a polypropylene mesh strip (15x1.5-2 cm) pulled under the suspension threads. The suspension threads occur on the endopelvic fascia in order to support the bladder neck and to permit the function of the polypropylene mesh strip, which, however, does not take part in supporting the bladder neck. The same urologist carried out 53 consecutive operations with clinical evaluation at 6 months, 1 and 5 years after surgery. RESULTS: After 6 months, 51 of the patients (96.2%) reported remaining dry after increasing intra-abdominal pressure. Two (3.7%) still had stress incontinence symptoms. After 1 and 5 years, 47 (88.6%) were dry and urinated normally, with spontaneous disappearance of nightly enuresis in two and surgery for subvesicular obstruction in one. CONCLUSIONS: The introduction of a polypropylene mesh strip in the suspension threads in cases using the trasvaginal suspension technique has good, long-term results for the treatment of patients with stress incontinence.

Surgical treatment of Peyronie's disease based on penile length and degree of curvature.

The aim of the study was to present the selection criteria for surgical techniques for the treatment of patients with Peyronie's disease. A total of 55 men with Peyronie's disease were surgically treated. We created specific criteria for selection of the appropriate surgical technique. All patients had a stable disease for 6 months and impossible vaginal intromission. All patients had subjective (as reported by the patient) and/or objective normal penile rigidity (as observed after intracavernous administration of alprostadil). Also, they all underwent drug therapy, which was unsuccessful. Among them, 40 patients with penile curvature of <60 degrees and erect penile length of >13 cm underwent Nesbit's operation, whereas plaque excision and grafting with polytetrafluoroethylene patch was performed in 15 patients with penile curvature of > or =60 degrees and/or erect penile length of < or =13 cm. At a mean (+/-s.d.) follow-up of 81.1+/-33.8 and 78.7+/-32.8 months, respectively, straightening of the penis was achieved in 35 out of 40 (87.5%) and 12 out of 15 (80%) patients, respectively, whereas erectile dysfunction developed in two out of 40 (5%) and one out of 15 (6%), respectively. Shortening of the penis occurred in all 40 patients undergoing Nesbit's operation, and in none of the patients undergoing plaque excision. Six out of 40 (15%) patients undergoing Nesbit's operation reported subjective perception of penis shortening, whereas none of the patients undergoing plaque excision complained of this discomfort. In conclusion, we recommend the selection of surgical technique based on penile length and degree of curvature. Nesbit's operation is an appropriate surgical technique for the treatment of patients with erect penile length of >13 and deviation of <60 degrees , whereas the plaque excision and grafting with polytetraflouroethylene patch is a technique of choice in the treatment of patients with erect penile length of < or =13 and/or deviation of > or =60 degrees.

Symptomatic physiologic hydronephrosis in pregnancy: incidence, complications and treatment.

OBJECTIVE: We present the incidence and results of treatment of symptomatic physiologic hydronephrosis in 3,400 pregnant women. METHODS: We analyzed 103 consecutive women who presented with clinical signs and symptoms related to the upper urinary system. Renal sonography, urinalysis, serum creatinine levels, white blood cell (WBC) count, and urine culture were done in all patients at first visit and repeated at least once a month until 1 month after delivery. In patients who manifested acute pyelonephritis, urinalysis, WBC count, erythrocyte sedimentation rate and C-reactive protein levels were repeated every 3 days until normalization, and urine culture as well as renal sonography were performed once a week until 1 month after delivery. Conservative measures (positioning, analgesia, antibiotics) were performed in all patients with symptomatic physiologic hydronephrosis. If the patient's condition was refractory to medical management, drainage of the ureter with a double pigtail stent was performed. RESULTS: Conservative measures were successful in 97 (94%) of 103 patients but 6 (6%) patients had ongoing signs and symptoms of acute pyelonephritis progressing to urosepsis. In all of them, antibiotics were continued and a double pigtail stent was placed resulting in fast regression of symptoms, curing of renal infection and progress of the pregnancies to the term with vaginal delivery. CONCLUSIONS: Symptomatic hydronephrosis in pregnancy can be treated conservatively. If the patient's condition is refractory to medical management, an internal drainage with double pigtail stent may be necessary.

Tansvaginal needle suspension operation: the way we do it. Clinical and urodynamic study: long-term results.

OBJECTIVES: To evaluate the long-term results of the transvaginal needle suspension operation for urinary stress incontinence. MATERIALS AND METHODS: A total of 88 women with proved genuine stress incontinence were treated with transvaginal needle suspension with fixation of suspension sutures to the rectus fascia using the technique of crossing suspension sutures. By using this method the proximal end of suspension suture from one side is tied with the distal end of suspension suture from the other side. The suspension sutures fixed in this way ensure 3-4 cm of rectus fascia which is used as a carrier of the suspension sutures. The same urologist peformed 88 consecutive operations. Clinical and urodynamic evaluations were performed at 6 months, 1 year and 5 years after surgery with the same technique and the same equipment. RESULTS: Analysis of the questionnaire showed that 81 patients (92.0%) were continent after 6 months while 78 (88.6%) patients were still continent after 1 year. After 5 years (n = 71) there were only continent 54 (76.0%) and incontinent patients (n = 17, 23.9%). Urodynamic analysis showed that 49 (69.0%) patients were continent after 5 years (n= 71). The increase in the number of incontinent patients is achieved at the cost of the previously continent patients. Of the 22 incontinent patients (after 5 years), 16 were still stress incontinent, while 6 (8.3%) patients had urge incontinence due to de novo detrusor instability. Three patients (n = 88, 3.4%) had undergone unilateral suture removal due to infection without influence on their continence status. In 2 patients (n = 88, 2.2%) the clinical pictures were highly suggestive of ilioinguinal nerve entrapment. CONCLUSIONS: Our results suggest that the transvaginal needle suspension operation is satisfactory for the management of genuine stress incontinence in women. However, we believe that the success of any suspension operation lies in adequate mobilization of the bladder neck and urethra (anterior vaginal wall) as well as in a surgeon's familiarity with the procedure.

Comparative analysis of bladder neck suspension using Raz, Burch and transvaginal Burch procedures. A 3-year randomized prospective study.

PURPOSE: Ever since Pereyra described needle suspension of the bladder neck for the treatment of stress urinary incontinence in women, numerous modifications have been presented. There were variations in the success reported by different authors. We report 3-year follow-up results in 146 women operated on for stress urinary incontinence using Raz, Burch and our own new procedures. MATERIALS AND METHODS: During a 5-year period, 146 women were operated on for genuine stress urinary incontinence. Using the method of Raz, and transvaginal Burch as well as the Burch retropubic urethropexy, a modified bladder neck suspension was performed in 46 (32%), 44 (30%) and 56 (38%) patients, respectively. In all patients a prior gynecological or urological operation for urinary incontinence and a clear neuropathic condition had been excluded before surgery. The routine diagnostic procedure consisted of multichannel cystometry, voiding cystourethrography, infusion urography and cystoscopy. A pressure-flow electromyography study was done in patients with a residual volume greater than 50 ml following voiding. The operations were performed by the same surgeon (I.G.). Initial follow-up was done after 12 months and then every year. RESULTS: Urodynamic testing did not reveal significant differences between Burch and Raz (p = 0.2652), Raz and transvaginal Burch (p = 0.5745) as well as between Burch and transvaginal Burch procedures (p = 0.7602; Fisher's exact test). Three years after surgery, 50 of 56 (89.3%; Burch procedure), 37 of 46 (80.4%; Raz modification) and 38 of 44 patients (86.4%; transvaginal Burch) were continent. CONCLUSIONS: There is no reason (except patient condition) to prefer any of the numerous modifications of bladder neck suspension. We believe that the success of the operation lies in adequate mobilization of the bladder neck and urethra as well as in a surgeon's familiarity with the procedure.

Bladder function in patients with lumbar intervertebral disk protrusion.

PURPOSE: We prospectively studied the effect of lumbar intervertebral disk protrusion on bladder function. Cystometry findings were particularly examined according to spinal level of disk protrusion and urological symptoms. MATERIALS AND METHODS: We evaluated 77 men and 37 women 25 to 63 years old with lumbar intervertebral disk protrusion. Urodynamic investigation included uroflowmetry and simultaneous recording of intravesical, abdominal and detrusor pressure during bladder filling and voiding. RESULTS: Detrusor areflexia was noted in 31 of the 114 patients (27.2%), while detrusor activity was normal in the remaining 83. According to the spinal level of disk protrusion, detrusor areflexia was evident in 3 of the 8 cases of L3, 10 of the 54 L4 and 18 of the 52 L5 disk protrusion. All 31 patients with detrusor areflexia reported difficult voiding with straining. CONCLUSIONS: Detrusor areflexia develops in approximately a quarter of the patients with lumbar intervertebral disk protrusion. We did not find that the spinal level of lumbar disk protrusion had an effect on detrusor activity. All patients with detrusor areflexia had voiding disorders that manifested as voiding with straining.

[Urinary bladder incontinence after prostatectomy. Urodynamic evaluation and results of therapy]. / Inkontinencija mokrace nakon prostatektomije. Urodinamska evaluacija i rezultati lijecenja.

Forty-seven males referred due to postprostatectomy urinary incontinence (34 after transurethral resection of prostatic adenoma and 13 after open suprapubic adenomectomy) were retrospectively studied. Urodynamic evaluation identified 19 (40.4%) men with incontinence due solely to sphincter incompetence, and 19 (40.4%) men, in addition to sphincter incompetence, had urinary bladder dysfunction (unstable detrusor and/or reduced bladder compliance). Seven (14.8%) men had pure bladder dysfunction as the only cause of urinary incontinence. Two patients had normal urodynamic findings (N = 2; 4.2%). Men with urinary incontinence due only to sphincter incompetence were treated by insertion of artificial sphincter devices or condom catheter drainage (lack of artificial sphincters), while others were treated pharmacologically (imipramine, propantheline, oxybutynin or their combinations ... N = 25), or by augmentation cystoplasty using ileum after unsuccessful pharmacological treatment (N = 3). Out of 25 patients with pharmacological treatment, 21 were available for the final assessment of the treatment efficacy. Eleven (52.3%) patients were "socially continent" after the treatment. It is concluded that in the assessment of the cause of postprostatectomy urinary incontinence urodynamic evaluation is mandatory, and that the treatment should be based on the results of such studies. The role of bladder dysfunction as a cause of postsurgical urinary incontinence is again strongly emphasized.

Vaginal vs. transabdominal ultrasonography in the evaluation of female urinary tract anatomy, stress urinary incontinence and pelvic organs static disturbances.

In this multicentric prospective and randomized study we compared the results obtained by application of a vaginal ultrasound probe in the vaginal introitus to those obtained by the transabdominal one. 66 examined patients were separated in five groups according to the history and gynaecological investigation. Stress urinary incontinence was urodynamically proved. After analysing the results obtained by those methods we conclude that the transabdominal method gives more useful data for stress urinary incontinence and pelvic organs static disturbances (SUI and POSD) diagnosing, but the introital application of the vaginal probe is also very useful for analysing the urethrovesical junction (UVJ) position comparing of its mobility in rest and maximal strain positions. We have found that a posterior vesicourethral angle less than 75 degrees measured by the endovaginal probe was a reliable proof of the cystocele. The results were comparable to clinical status and transabdominal sonography of the moderately full bladder. Transabdominal and endovaginal methods give rather complementary than competition data which are very useful in diagnosing of the POSD, SUI and UVJ position and degree of its mobility. For that reason both techniques may precisely discover and document the presence of anatomic stress urinary incontinence causative defects aiding in the selection of patients suitable for operative therapy of stress urinary incontinence and for their postoperative follow-up.

The sigmoidorectal pouch (Mainz pouch II).

A sigmoidorectal pouch was constructed in 20 patients (18 with invasive bladder cancer, 2 with complete urethral destruction with multiple vesicovaginal fistulas). The rectal-dynamic studies showed that by detubularization and reconfiguration of the sigmoid colon and rectum, we obtained a low-pressure reservoir, with the high-pressure contractions eliminated. Preoperatively, the basal rectum pressure was 21.4 cm H2O; rectum contractions reached a mean of 27.6 cm H2O (maximum 48 cm H2). Postoperatively (9-36 months) the mean basal pressure of the pouch was 19.3 cm H2O (p > 0.05; t test comparison with the preoperative value), with a mean contraction value of 19.1 cm H2O (p < 0.05). All the patients experienced continence day and night with a pouch emptying frequency of four times during the day and once at night, after 9 months. By fixing the pouch to the promontory or psoas muscle, without compromising the blood supply to the pouch, the risk of ureteral kinking and upper urinary tract dilatation were considerably decreased. The price to be paid for almost perfect continence was hyperchloremic acidosis in most patients.

A modified Raz bladder neck suspension operation (transvaginal Burch)

A total of 36 female patients with genuine stress urinary incontinence underwent Raz needle suspension with fixation of suspension sutures to the iliopectineal ligament (transvaginal Burch procedure). By fixing suspension sutures to the iliopectineal ligament we expected to achieve a static suspension independent of everyday patient activities. Considering the small number of patients and limited followup, our results revealed continence in 80 to 85% of the patients after 3 years. We believe that fixation of suspension sutures to the iliopectineal ligament can favorably influence long-term results of needle suspension in the treatment of female stress urinary incontinence.

Urodynamic and clinical characteristics of small intestine reservoir directly connected to urethral sphincter.

Eight patients in whom a small intestine reservoir with direct anastomosis to the urethral sphincter had to be performed after radical cystectomy for invasive carcinoma of the urinary bladder, were included in the study. The function of small intestine reservoir was clinically and urodynamically monitored during 24 months postoperatively. All patients urinated per urethram, with abdominal strain or with urethral sphincter relaxation without abdominal strain. After 21 months, diurnal continence was maintained in 87.5%, and circadian continence in 75% of the patients. Urodynamic tests showed it to be a low-pressure reservoir, where the basal reservoir pressure never exceeded 30 cm H2O during filling. The values of maximal cystometric capacity showed that a certain time of reservoir maturation had to elapse after the reservoir construction. After 3-6 months, the mean maximal cystometric capacity was 250 ml, and after 9 months it was 520 ml. The proportion of continent patients was observed to rise with the increase in the small intestine reservoir capacity. We believe that three substantial issues are ensured by the described surgical technique, i.e. the antireflux mechanism, appropriate capacity and acceptable continence.

Retrograde ejaculation and loss of emission: possibilities of conservative treatment.

Twenty-five patients with retrograde ejaculation/loss of emission were treated with ephedrine sulfate or imipramine hydrochloride. Seventeen of them suffering from both diabetes and retrograde ejaculation were treated with ephedrine or, in case that ephedrine failed to convert retrograde ejaculation into anterograde ejaculation, with imipramine. Positive results were obtained in 5/17 (29.3%) patients, i.e. in 3 (17.6%) and 2 (11.7%) patients on ephedrine and imipramine, respectively. The daily dose of ephedrine was 50 mg and that of imipramine 75 mg, during a 4-week period. In the group with retroperitoneal lymphadenectomy, after treatment with ephedrine, only 1 (12.5%) had retrograde ejaculation while the remaining patients (n = 7) continued to lack semen emission. These 7 patients were treated with imipramine, and 3 of them (42.8%) achieved anterograde ejaculation. In one third of patients with retroperitoneal lymphadenectomy and diabetes, with retrograde ejaculation or loss of semen emission, conservative treatment can offer improvement or conversion to anterograde ejaculation.

[Neurologic and urodynamic characteristics of patients with Guillain-Barré syndrome]. / Neuroloske i urodinamske osobine u bolesnika s Guillain-Barréovim sindromom.

Neurologic and urodynamic aspects of five patients with Guillain-Barré syndrome are presented. Four patients were urodynamically investigated in the acute stage of neurological disease. All of them had complete urinary retention. Following moments causing urinary retention were determined: detrusor areflexia with the signs of urethral sphincter denervation in one patient, detrusor hyperreflexia with dyssinergia of the sphyncter in two patients and detrusor hyperreflexia with synergia of the sphincter in one patient. One patient was examined in the chronic stage of Guillain-Barré syndrome showing urodinamically detrusor hyperreflexia with synergia of sphincter.

Conservative treatment of female stress incontinence with imipramine.

The results of a clinical study of conservative treatment of women with stress incontinence are presented. A daily dose of 75 mg. imipramine hydrochloride was given for 4 weeks. Special attention was paid to the effects of imipramine on the functional urethral length and maximum urethral closure pressure. A total of 21 women (71 per cent) stated that they were continent after treatment with imipramine, while 9 (29 per cent) did not improve and treatment was stopped. According to our results, imipramine extended the functional urethral length and made it independent of stress factors in women who were continent after treatment with imipramine. In patients with persistent incontinence the functional urethral length was extended significantly but was shortened with stress despite imipramine therapy. We believe that imipramine could be an alternative treatment in selected cases with stress incontinence.