A novel radiographic technique to asses grafts in the female -pelvis: a comparison of the Inside-Out and the Outside-In trans-obturator mid urethral sling positioning.

UNLABELLED: The three-dimensional configuration of mid-urethral sling tapes is difficult to demonstrate in traditional anatomical dissections or imaging studies. The aim of this study was to test the utility of a novel technique using mesh tapes to assess spatial differences between the in-out and out-in transobturator mid-urethral slings. Two independent surgeons performed their usual transobturator mid-urethral sling placement on 10 fresh thawed cadavers, alternating sides in the consecutive cadavers. Tantalum wires threaded through the polypropylene-tapes rendered them radio-opaque. Following placement, CT scans were obtained to generate 3-D and MIPS images for analysis. Results showed that the mean angle formed by the in-out sling measured 122º (95%CI: 107º-136º); versus 144º (95%CI: 131º-151º) for the out-in sling (p = 0.02). The paired differences between the tapes' inner angles were significantly different; with a mean difference of 20º (median 19.0º), (p = 0.008). There was no significant correlation between either approach and BMI or angle of the pubic arch. The images revealed that the tapes lie as a band posterior/dorsal to the urethra rather than inferior. IN CONCLUSION: marking mesh with -Tantalum wire, in combination with 3-D and MIPS CT-scan reconstruction images, provided a unique method to visualize the entire sling trajectory. The clinical implications of the more horizontal positioning after the out-in approach remain to be determined.

Urinary retention after tension-free vaginal tape procedure: incidence and treatment.

OBJECTIVES: To review our experience with persistent urinary retention after the tension-free vaginal tape (TVT) procedure and report our treatment results. Ulmsten recently introduced the TVT procedure for female stress urinary incontinence. Although the morbidity is minimal, no surgical procedure is without risks, and experience will better define the morbidity of the TVT procedure. METHODS: Since November 1998, we have collectively performed 600 TVT procedures. Of these, 17 patients (2.8%) developed urinary retention or symptoms consistent with obstruction (including hesitancy, straining to void, or feeling of incomplete emptying) lasting more than 1 week from the date of the procedure. We reviewed the operative record, noting the operative time, estimated blood loss, presence of bladder penetration, and any reported complications. All 17 patients subsequently underwent transvaginal release on an outpatient basis. RESULTS: Seventeen patients (mean age 56 years, range 38 to 81) underwent sling release a mean of 64 days (range 6 to 228) after the TVT procedure. All patients voided to completion within 24 hours of release and reported no further subjective complaints of outlet obstruction. None of the subjects reported de novo urge incontinence or urgency. In each patient, the estimated blood loss was minimal; the operative time averaged 15 minutes. One urethral injury occurred and was managed intraoperatively without sequelae. Sixteen patients who underwent sling release have remained dry; the remaining patient, in whom a urethral injury was repaired, redeveloped stress incontinence and underwent an uncomplicated successful transvaginal sling procedure. CONCLUSIONS: Outlet obstruction is a risk of the TVT procedure and occurred with an incidence of 2.8% in our experience. The TVT mesh can be released by a simple vaginal incision under local anesthesia with rapid return to normal voiding. Although the number of patients studied was small, stress incontinence did not recur after uncomplicated release in our series.

Treatments used in women with interstitial cystitis: the interstitial cystitis data base (ICDB) study experience. The Interstitial Cystitis Data Base Study Group.

OBJECTIVES: To evaluate the frequency and types of treatments reported at baseline in women who entered the Interstitial Cystitis Data Base (ICDB) cohort study. METHODS: From 1993 to 1997, 581 women were enrolled and followed in the ICDB. All treatments reported at study entry, including those prescribed for interstitial cystitis (IC) and concomitant medications, were reviewed. The number and types of treatments were evaluated with respect to baseline factors such as prior diagnosis of IC and symptom severity. RESULTS: One hundred five (18%) women were receiving no therapy at baseline. Single-mode therapy was reported by 195 (34%) women, and a combination of two treatments was reported by 119 (21%) women. Three or more treatments were reported in 162 (28%) women. A total of 183 different types of therapies were recorded. The five most commonly used therapies for IC symptoms were cystoscopy and hydrodistention, amitriptyline, phenazopyridine, special diet, and intravesical heparin. Because most patients entered the ICDB before the approval of oral pentosan polysulfate sodium (PPS), only 6% of women reported oral PPS use at baseline. There were statistically significant associations between the number and types of treatments and clinical center, a prior diagnosis of IC, and symptom severity. CONCLUSIONS: The diversity of IC therapies underscores the lack of understanding about the treatment of this syndrome. Further research in IC is essential to develop and to evaluate rational therapies and treatment algorithms. These algorithms should be "evidence based" and should be revised as the underlying etiology and pathophysiology of IC is delineated.

Associations among urodynamic findings and symptoms in women enrolled in the Interstitial Cystitis Data Base (ICDB) Study.

OBJECTIVES: The goal of this study was to correlate the cystometric findings with the presenting symptoms of the 388 women enrolled in the NIH/NIDDK-funded interstitial Cystitis Data Base (ICDB) Study as of December 31, 1995. METHODS: All patients underwent a complete history and physical and completed standardized questionnaires to assess voiding symptoms and quality of life (QOL). A 3-day voiding log was also obtained, followed by a baseline urodynamic exam. All results are expressed as mean values +/- 1 standard deviation, and all reported correlations were significant. RESULTS: A correlation was seen between reported daytime, nighttime, and 24-hour frequency, and both volume at first sensation to void (VFSV) and maximal cystometric capacity (VMCC). Patients with constant severe urgency had smaller VFSV, 63 +/- 59 mL versus 108 +/- 90 mL, and lower VMCC, 163 +/- 102 mL versus 288 +/- 135 mL, than patients without the complaint. A negative trend was seen for both VFSV and VMCC versus the global severity. An inverse trend was seen between minimal and maximal pain scores over the 4 weeks before the exam and VMCC. (No correlation existed between current pain noted during baseline screening visits and VFSV or VMCC). No urodynamics correlates were seen with global measures of body pain and global health. Uninhibited detrusor contractions (UDCs) were seen in 56 of 384 patients (14.6%). A positive correlation was seen between urgency symptoms and the presence of UDCs. Correlations between the VFSV and VMCC were made with both the average voided volume (AVV) and the average maximal voided volume (AMVV) as determined by a 3-day voiding log. Significant positive correlations were seen with each pair-wise comparison (P = 0.001). CONCLUSION: These findings confirm that subjective measurements of symptoms associated with interstitial cystitis can be confirmed objectively with urodynamic studies.

Bilateral bone anchor vaginal vault suspension: an initial report of a new technique.

Vaginal vault prolapse is usually treated by sacrospinous fixation. Although this procedure is very effective, it is associated with various complications that include injury to the pudendal neurovascular structures, the sciatic nerve, and/or chronic gluteal pain. A safer and simpler modification of sacrospinous vaginal vault suspension using the Vesica bone anchor kit is reported. Vaginal vault prolapse was corrected in six patients by suspending the apex of the vaginal vault to the ischial spine with Vesica bone anchors. Bladder neck suspension and correction of other vault pathology was performed at the same time. All patients had complete relief of their prolapse and have demonstrated no recurrence during the brief mean follow-up period of 7 months.

Questionnaire-based outcomes study of nononcological post-vasectomy complications.

PURPOSE: We conducted an outcomes analysis to determine the incidence of post-vasectomy complications. MATERIALS AND METHODS: A questionnaire (154 questions) addressing post-vasectomy complications, incidence of post-vasectomy scrotal pain and quality of life issues was sent to 470 patients. Followup telephone surveys were made. RESULTS: A total of 182 patients (42.3%) responded. Mean follow-up was 4.8 years. The most common complication was post-vasectomy scrotal pain in 34 men (18.7%), which adversely affected the quality of life in 4 (2.2%). In retrospect, 71.4% of the men were satisfied with the decision for vasectomy, 19.3% had equivocal feelings and 9.3% were dissatisfied. CONCLUSIONS: Chronic scrotal pain is the most common post-vasectomy complication that may adversely affect quality of life in men undergoing vasectomy.

PIP: 500,000 to 1 million vasectomies are performed annually with only a 2-3% complication rate. However, despite the low complication and failure rates of the procedure, vasectomy is a leading cause of urological litigation. The authors conducted an outcomes analysis to determine the incidence of post-vasectomy complications, particularly the incidence of chronic scrotal pain related to vasectomy and its impact upon quality of life. A questionnaire of 154 questions addressing post-vasectomy complications, incidence of post-vasectomy scrotal pain, and quality of life issues was sent to 470 patients selected from the Henry Ford Hospital database who underwent vasectomy between January 1988 and November 1992. Follow-up telephone surveys were conducted. 182 patients responded to the questionnaires. The participants were followed for a mean period of 4.8 years. The most common complication was post-vasectomy scrotal pain in 34 men, which adversely affected the quality of life in four. 71.4% of the men were, however, satisfied with having decided to undergo vasectomy, 19.3% had equivocal feelings, and 9.3% were dissatisfied.

Lack of correlation of the American Urological Association Symptom 7 Index with urodynamic bladder outlet obstruction.

The objective of this study is to assess whether subjective information from the American Urological Association (AUA) Symptom 7 Index correlates with or predicts objective urodynamic parameters of bladder outlet obstruction. Seventy-five men, mean age 67 years (range 42-85 years), were referred for evaluation of "prostatism." Evaluation consisted of the AUA Symptom 7 Index, noninvasive uroflow, post-void residual (PVR) urine measurement, and pressure-flow analysis. Men were categorized as "obstructed," "equivocal," or "unobstructed" according to pressure-flow nomogram of Abrams and Griffiths. The total AUA 7 score, and all individual components, were compared with all invasive urodynamic parameters, and to the pressure-flow categories of obstructed, equivocal, or unobstructed. The AUA index severity categories (mild 0-7, moderate 8-19, and severe > or = 20) were compared to the urodynamic pressure flow categories. Thirty-three men had severe symptoms, and 42 had moderate or mild symptoms. Forty men were urodynamically obstructed, and 35 men were equivocal or unobstructed. There was no correlation of any AUA index parameter (total symptom score, obstructive or irritative score component, or any individual question) with any noninvasive urodynamic parameter. The sensitivity and specificity of the AUA index for urodynamic obstruction was 42.5% and 54.3% respectively. Multivariable logistic regression analysis was used to determine whether clinical data easily obtained in the office setting (age, PVR, noninvasive maximum and average flow rates) could predict urodynamic obstruction when combined with any component of the AUA index. Only age was found to be a significant predictor of obstruction status (P = 0.026). Subjective information from the AUA Symptom 7 Index does not correlate with objective data assessing bladder outlet obstruction. Though the AUA index is a valid clinical tool, it should not be used to gauge the presence or severity of bladder outlet obstruction.

The effect of study methodology on reported success rates of the modified Pereyra bladder neck suspension.

PURPOSE: We compared surgical results in a cohort of women after modified Pereyra bladder neck suspension using questionnaire based outcomes analysis versus a retrospective chart review. MATERIALS AND METHODS: Of 151 patients who underwent modified Pereyra bladder neck suspension 102 had complete questionnaire and chart data for review. Mean patient age was 56 years and followup was 25 months. RESULTS: According to outcomes analysis 48 patients (47.1%) were cured and in 65 (64%) stress urinary incontinence improved compared to 74 (72%) cured and 89 (89%) improved by retrospective review. Of the 102 chart review patients 10 (9%) reported daily pad use compared to 55 of the 102 (53%) in the questionnaire study. CONCLUSIONS: This study controls for patient selection, definition of cure and length of followup, and demonstrates that study methodology profoundly affects reported outcomes for the modified Pereyra bladder neck suspension.

Intravesical thiotepa-induced eosinophilic cystitis.

Eosinophilic cystitis is a rare form of an allergic cystitis. Factors such as food allergens, parasites, and drugs have been implicated in the genesis of eosinophilic cystitis. Associated risk factors include bronchial asthma, atopic diseases, and environmental allergens. Intravesical mitomycin is a reported causative agent. We report the first case of eosinophilic cystitis that developed after intravesical instillation of thiotepa for treatment of superficial bladder cancer.

Success rate of modified Pereyra bladder neck suspension determined by outcomes analysis.

The reported success rates of the modified Pereyra bladder neck suspension vary from 51 to 90%. Retrospective chart review studies have reported cure rates of 77 to 90%. In contrast, a questionnaire based outcomes analysis, using a strict definition of cure, reported 51% of the patients to be cured of stress urinary incontinence after modified Pereyra bladder neck suspension. We conducted a questionnaire based outcomes analysis of the modified Pereyra bladder neck suspension at our institution. The objectives of the study were to determine the success rates of this procedure using strict criteria in an outcomes analysis format, assess the overall satisfaction of patients postoperatively and identify historical factors that may be predictive of outcome. Between September 1988 and December 1991, 151 patients underwent a modified Pereyra bladder neck suspension for urodynamically documented genuine stress urinary incontinence. Mean patient age was 56 years (range 19 to 82 years) and mean followup was 25 months (range 9 to 45). All patients had type 2 incontinence (anatomical) based on history (severity of symptoms), physical examination, and fluoroscopic assessment of the bladder neck and urethra. Preoperative pad use, and irritative and obstructive symptoms were retrospectively assessed, and a preoperative Stamey incontinence score was assigned. A standardized questionnaire was used to compare preoperative and postoperative voiding symptoms, perception of urinary control and satisfaction with the decision to undergo an operation. Followup telephone calls were made by a trained registered nurse not associated with the original procedure. Postoperative pad use also was quantified and a postoperative Stamey score was assigned. A total of 106 patients (70%) returned the questionnaires. Cure was strictly defined as no urine leakage under any circumstance. While 78% of the patients required no to minimal protection postoperatively, 50 (47%) reported cure of the stress urinary incontinence, 68 (64%) reported subjective improvement, 27 (26%) were the same and 11 (10%) were subjectively worse after modified Pereyra bladder neck suspension. Of the patients 77% were satisfied with the decision to undergo the operation. Patients subjectively worse were significantly older than those subjectively improved (66 versus 54 years, p = 0.05). Postoperative failures had significantly higher obstructive and irritative symptom scores. Questionnaire based outcomes analysis has consistently demonstrated success rates less than those reported in retrospective chart review studies. Outcomes analysis, based on patient assessment of satisfaction, may more accurately reflect the expected surgical outcome after a modified Pereyra bladder neck suspension. We emphasize the need for standardized questionnaires and outcomes analysis to evaluate patient satisfaction with surgery designed to improve quality of life.

Radical surgery in the treatment of localized carcinoma of the prostate.

New methods of early detection combined with recent advances in surgical techniques have resulted in more patients undergoing radical surgery for treatment of localized carcinoma of the prostate. Over 350 radical prostatectomies have been performed by our group since January 1987. We review the role of radical prostatectomy in the treatment of prostate cancer and our experience with 100 patients undergoing radical retropubic prostatectomy since the advent of nerve-sparing techniques to preserve potency.

Familial testicular cancer and urogenital developmental anomalies.

In a case-control study of testicular cancer, 6 of 269 cases (2.2%) reported a first-degree relative with testicular cancer, compared to 1 of 259 controls (0.4%). Fathers and brothers of testicular cancer cases had a six-fold elevated risk of developing a testicular malignancy compared to men in the general population. Cryptorchidism was reported in a first-degree relative in 1 (17%) of the familial cases versus 7 of 259 (2.7%) controls and 14 of 263 (5.3%) cases with a negative family history for testicular cancer. One half of the 6 familial cases reported a first-degree relative with a groin hernia (all surgically repaired before age 12), compared to 12.7% of 259 controls and 10.3% of 263 nonfamilial cases. Three familial clusters identified through the case-control study were selected for clinical evaluation. One of the 6 surviving males with testicular cancer in these 3 families had undergone orchiopexy and inguinal herniorrhaphy at age 6 years, and one had a hydrocele associated with his testicular tumor. Of the 12 living fathers and brothers of these 6 men, 3 reported childhood inguinal hernias, two with coexisting hydroceles. One additional hernia and two additional hydroceles were detected during urologic evaluation of these healthy relatives. The high prevalence of cryptorchidism, inguinal hernias, and hydroceles among men in these families suggests that an underlying alteration in urogenital embryogenesis may be associated with the familial predisposition to testicular neoplasia.

Venous access: a prospective, randomized study of the Hickman catheter.

This prospective, randomized study evaluated the risks associated with the Hickman catheter (HC) by a comparison of rates of placement and use complication, infection, treatment failure, and thrombogenicity with a group of patients with polyvinylchloride central venous catheters (CVC). Complications were studied prospectively. The patient populations of the two groups were similar and most patients were entered in the study because of prior venoablation. No significant difference in complication rates was noted for catheter placement complications, infection, or treatment failures. No catheter-related deaths occurred. Seven CVCs were exchanged for malfunction and one HC fractured and required repair. Venography was performed in seven patients in each group when the catheter was removed. The incidence of fibrin sheath formation was significantly increased in the HC group (P less than 0.05). One venous thrombosis was identified in a patient with a CVC. A separate group of patients with HCs who were not placed in the randomized study was followed. This group had a significantly higher incidence of septic complications than did the study group (P less than 0.005). We conclude that the HC is as safe as is the CVC when the conditions of placement and maintenance are rigorously controlled.

Tumor and host carcass changes during total parenteral nutrition in an anorectic rat-tumor system.

The independent effects of total parenteral nutrition (TPN) on tumor growth and host carcass are important in designing effective nutritional support. In this study, a TPN regimen was used to keep substrate intake at normal levels during a 10-day period of tumor-induced anorexia and cachexia in rats transplanted with a sarcoma. Tumor mass was increased in TPN-supported animals compared to orally-fed controls. Tumor composition (water, fat, nitrogen) was similar in all tumors. Host carcass mass in tumor-bearing (TB) animals was increased by TPN as compared to orally-fed TB controls, but not to the same extent as in orally-fed or TPN-supported nontumor-bearing controls. Host carcass composition determinations demonstrated significantly increased fat content but no significant change in protein or water content in TB-TPN animals compared to orally-fed TB animals. This study demonstrates increased tumor growth and increased host carcass fat stores secondary to TPN.

Serum vitamin level maintenance in cancer patients on total parenteral nutrition.

The quantity of water and fat soluble vitamins required to maintain serum levels in cancer patients on total parenteral nutrition (TPN) has yet to be determined. A prospective evaluation of our current intravenous vitamin regimen during TPN was performed in order to define these requirements. Seventy-five patients receiving 97 TPN courses for seven to 60 days were studied. Serum levels of vitamins A (74 courses), B12 (85), folate (62), C (97), and 25-OH-cholecalciferol (25-OH-D) (9) were available for analysis. Daily vitamin intakes were recorded and serum levels were determined weekly. Restoration and maintenance of normal mean serum vitamin levels were achieved for all but 25-OH-D. However, analysis of individual courses in previously depleted patients revealed that serum levels were not restored in three patients (4%) for vitamin A and six patients (66%) for 25-OH-D. A TPN regimen designed to provide the following weekly vitamin quantities: A: 21,000 IU, D: 2100 IU, C: 3500 mg, B12: 126 micrograms, and folate: 7 mg will maintain mean serum vitamin levels for all but 25-OH-D. This regimen has the ability to uniformly restore and maintain vitamins B12, C, and folate in all patients but not in those patients previously deficient in vitamins A and D.

Percutaneous subclavian vein placement of the Hickman catheter.

Vascular access by means of a permanently implanted cuffed silicone rubber catheter has become increasingly popular in the management of cancer patients. A method is described for the percutaneous placement of this catheter using a modified Seldinger technique. The catheter was successfully placed in 14 of 15 consecutive cancer patients using this method. The morbidity rates were low, and no deaths occurred because of the procedure. This technique allows rapid, accurate placement of the Hickman catheter in patients whose peripheral venous access sites have been exhausted.