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.

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.