Rupture of the Left Renal Fornix after Vaginal Repair of Postpartum Vesicovaginal Fistula.

Surgical repair of vesicovaginal fistulas carries a risk of postoperative obstruction of the upper urinary tract. In the case described here, a postoperative intramural edema led to urinary retention and subsequent rupture of the renal pelvis. This is a rare but typical urological emergency. If patients complain postoperatively of flank pain, ultrasound should be carried out promptly. If the findings are unclear (no urinary retention despite clinical symptoms), additional computed tomography should be performed to determine whether rupture of the fornix has occurred.

Results of a BoNT/A antibody study in children and adolescents after onabotulinumtoxin A (Botox®) detrusor injection.

BACKGROUND: Onabotulinumtoxin A (OnaBoNT/A, Botox®) is effective in the treatment of neurogenic detrusor overactivity, however this therapy can fail. In a prospective study, we analyzed patient serum for BoNT/A antibodies (BoNT/A-AB) as a possible cause of therapy failure. METHODS: 17 patients (average age 14.5 years) who had neurogenic detrusor overactivity were admitted for repeated OnaBoNT/A injection into the detrusor muscle. We analyzed their serum for BoNT/A-AB. The clinical findings were correlated with the incidence of BoNT/A-AB. RESULTS: Positive BoNT/A-AB were clearly or marginally determined in 6 patients. Therapy had failed in all 6. In 4 of the 6, therapy might have failed because of a low-compliance bladder (3 patients) or tethered-cord syndrome (1), but BoNT/A-AB were found as the only possible cause in 2 patients. Thus, the incidence of BoNT/A-AB in the 17 patients was 35%, and the antibodies were clinically significant in 12%. All patients with BoNT/A-AB had a history of recurrent urinary tract infections. CONCLUSIONS: Patients who show a failure of therapy after OnaBoNT/A injections for which no other causes can be determined should have their serum checked for BoNT/A-AB. Recurrent urinary tract infection might be a predisposing factor for BoNT/A-AB.

[A look beyond urology: vaginal cancer]. / Ein Blick diesseits des Tellerrandes: Das Vaginalkarzinom.

Primary carcinomas of the vagina are very rare. Nevertheless, they need to be included in differential diagnoses when carrying out a urological examination of the pelvic floor and the vagina in patients with micturition problems, also in younger patients: we report a case of a 35-year-old woman with a primary carcinoma of the vagina and present a review of the literature.

Efficacy of botulinum-A toxin bladder injections for the treatment of neurogenic detrusor overactivity in multiple sclerosis patients: an objective and subjective analysis.

AIMS: We studied the use of botulinum-a toxin (BTX-A) injections into the bladder as an alternative approach in patients with neurogenic detrusor overactivity due to multiple sclerosis (MS) with drug-refractory overactive bladder (OAB) symptoms. METHODS: Sixteen MS patients--11 women, 5 men; mean age 48.6 years--with refractory OAB symptoms were included in a one-center prospective study. For outcome analysis, we used a bladder diary, a complete urodynamic study, and validated questionnaires for subjective assessment. We injected 300 U of BTX-A (Botox) into the bladder and into the external sphincter muscle to reduce the probability of posttreatment urine retention. RESULTS: There was an increase in residual volume from 81.3 +/- 23.8 to 126.3 +/- 32.9 ml after 4 weeks. In one woman, transient self-catheterization was unavoidable. Four weeks and 3 and 6 months after BTX-A injection, the significant results were as follows: daytime frequency was reduced by 29%, 44%, and 30%, respectively. Nocturia diminished by 33%, 72%, and 40%. Use of pads was be reduced by 38% after 4 weeks and by 64% after 3 months. Urodynamically, reflex volume and maximal cystometric bladder capacity increased by 73%, 77%, and 58% (at 6 months, the increase was not significant) and by 36%, 27%, and 36% (not significant). Maximal detrusor pressure decreased by 35%, 22%, and 57%. Subjective outcome indicated significant improvement of symptoms at 4 weeks and 3 months, but not at 6 months. Patient satisfaction with the therapy was very high. CONCLUSIONS: BTX-A detrusor injections are very effective in the treatment of drug-resistant OAB symptoms in MS patients as reflected in urodynamic measurements and in patient satisfaction. Build up of residual urine remains a problem of which patients must be informed.

A new option for the management of urethral trauma: primary reconstruction of posterior urethral disruption with a buccal mucosa transplant.

Up to now, the management of traumatic posterior urethral disruption ranges from primary realignment to delayed urethroplasty. However, we reconstructed the membranous part of the urethra with an onlay graft of buccal mucosa after traumatic complete disruption as a first line therapy. After 7 months followup, the clinical outcome is very good. Because primary reconstruction of the urethra with a buccal mucosa graft after traumatic disruption has not yet been reported, the question arises whether this technique should be routinely included as an option for primary urethral reconstruction after trauma of the posterior urethra.

[Subjective patient satisfaction after injection of botulinum-a toxin in detrusor overactivity]. / Subjektive Patientenzufriedenheit nach Botulinumtoxin-A-Injektionen bei Detrusorhyperaktivität.

PURPOSE: The established treatment for overactive detrusor function consists of anticholinergic drugs. But this treatment can fail or produce intolerable side effects. We therefore investigated the effect of botulinum-A toxin in treating overactive detrusor function in patients with neurogenic and nonneurogenic bladder dysfunction. We were particularly interested in patient satisfaction with this therapy. MATERIAL AND METHODS: The subjects were 38 patients who had overactive detrusor function of different origins and in whom therapy with anticholinergic drugs had failed. To measure results, we used urodynamic studies and a questionnaire that consisted of 27 validated questions ("Urogenital Distress Inventory UDI-6", "Symptom Severity Index" and "Symptom Impact Index") as well as a satisfaction questionnaire. We injected 200 - 300 U of botulinum-A toxin (Botox) cystoscopically. RESULTS: At least 4 weeks after injection, 90 % of the patients reported clear improvement of their voiding situation and 93 % stated that they would undergo this procedure again. The frequency of micturition decreased by 29 % in average, and the increased postvoid residual volume was clinically irrelevant. Patients reported side effects or complications in 6.7 % of cases. The satisfaction scale (0 - 10) averaged 6.9. Urodynamically, reflex volume increased by 85 %, maximal bladder capacity increased by 47 %, and bladder pressure decreased by 33 %. CONCLUSIONS: Botulinum-A toxin injection into the overactive detrusor muscle seems to be very effective. The effect is not only reflected in urodynamic studies but also in the subjective patient satisfaction.

Pubovaginal bone anchor fixation with polyethylene versus fascia lata slings in the treatment of female stress incontinence: sling material and processing are predominant factors in success.

OBJECTIVE: The opponents of the In-Taca bone anchor system note the risk of a high rate of wound infection and osteitis pubis. We evaluated whether there is a difference in the outcome of the use of two different sling materials--polyethylene and fascia lata--with regard to wound infection, and analyzed the incidence of osteitis pubis further in a larger series. MATERIAL AND METHODS: A total of 61 women (mean age = 65.4 years) were treated for stress urinary incontinence (SUI) type II and III using the In-Taca bone anchor system. In 15 of 61 patients, we used a synthetic sling of polyethylene, and in 46, a fascia lata sling. The subjective success rate was determined with validated questionnaires (Urinary Distress Inventory-6, Symptom Severity Index and Symptom Impact Index). The objective assessment included a pad test according to the ICS- standard and a urogynecologic evaluation. Mean follow-up was 10.2 months. RESULTS: Wound inflammation of only very mild degree occurred in 15% in the fascia lata group, whereas 33% in the polyethylene group developed serious sling infection; in three patients explantation of the sling was necessary. Accordingly, satisfaction with the procedure was low in the polyethylene group. In both groups, there were no hints of osteitis pubis. The sling material used did not affect continence rate. CONCLUSION: Using the bone anchor system, the infection rate depends primarily on the sling material used and its processing: polyethylene is well tolerated in other reconstructive procedures (such as TVT, where a netlike mesh is used), so the processing of synthetic sling material plays an extremely important role in infection rate: platelike, dense synthetic material tends to cause wound infection.

[Botulinum toxin in urology. An inventory]. / Botulinumtoxin in der Urologie. Eine Bestandsaufnahme.

Botulinum toxin (BTX) is highly potent in neurogenic and non-neurogenic voiding disorders. Experience with it in neurourology began 15 years ago in the treatment of neurogenic detrusor-sphincter dyssynergia. Indications were expanded not only to neurogenic detrusor hyperactivity but also to non-neurogenic detrusor hyperactivity, other forms of dysfunctional voiding, and some types of pelvic pain syndrome. Sphincter injections can be recommended for patients with symptomatic post-voiding residual urine due to insufficient detrusor contractility, and detrusor injections can be recommended for patients with neurogenic detrusor hyperactivity in which anticholinergic drugs are not sufficient. Because of the lack of evidence-based studies, botulinum toxin is not approved for urologic use, although there is a desperate need for it.

Laparoscopic management of hydronephrosis in a woman with rare genitourinary anomalies: unicornous uterus, contralateral agenesis of the kidney, and contralateral ectopic ovary in the groin.

A 40-year-old woman had infected right-sided hydronephrosis and rare genitourinary anomalies-a dextroposed unicornous uterus-as the cause of the hydronephrosis, which had to be mobilized laparoscopically by dissecting the scar tissue. Furthermore, the patient had left-sided agenesis of the kidney and a left-sided ectopic ovary with a rudimentary tube in the inner inguinal canal.

Botulinum-a toxin detrusor injection as a novel approach in the treatment of bladder spasticity in children with neurogenic bladder.

OBJECTIVES: Children with neurogenic hyper-reflexive bladder in whom classical therapy with anticholinergic drugs and intermittent catheterization fails are threatened by high intravesical pressure, vesicoureteral reflux, and impairment of kidney function. Surgery, such as bladder augmentation, is often necessary in such cases. To obviate surgery in these high-risk children, we investigated the use of detrusor injection of botulinum-A toxin (Botox). METHODS: Our subjects were 20 children with hyper-reflexive detrusor muscle and high bladder pressure, over 40 cmH(2)O despite anticholinergic therapy. After baseline urodynamic measurements, we injected botulinum-A toxin into the detrusor muscle at 30-50 sites at 12 U/kg of body weight up to a maximum of 300 U. Follow-up cystometric measurements were taken two to four weeks and three and six months after injection. RESULTS: From basic measurements to follow-up cystometry, mean reflex volume changed from 97.1 ml before injection to 178.6 ml after four weeks (p<0.01) and to 162.8 ml after three months (p<0.01). After six months mean reflex volume returned to 119.3 ml (n.s.). Maximal bladder capacity changed from 163.1 ml to 219.9 ml (p<0.01), to 200.6 ml (p<0.01) and to 222.4 ml (p<0.01), respectively, and maximal detrusor pressure changed from 59.6 cmH(2)O to 34.9 cmH(2)O (p<0.01), to 46.7 cmH(2)O (n.s.) and to 61.8 cmH(2)O (n.s.), respectively. CONCLUSION: Botulinum-A toxin (Botox) is effective when injected into the hyper-reflexive detrusor muscle. It is a valuable treatment option in the management of neurogenic bladder. The effect lasts about six months, and then reinjection is necessary.

Alfuzosin in the treatment of high leak-point pressure in children with neurogenic bladder.

OBJECTIVE: To decrease the detrusor leak-point pressure (LPP) of > 40 cmH2O in children with a neurogenic bladder, using the alpha1-adrenergic blocking agent alfuzosin. PATIENTS AND METHODS: Videocystometry was used to measure the detrusor LPP and several other variables before and 3 weeks after the oral administration of alfuzosin (2.5-7.5 mg/day) in 17 children (mean age 6.3 years) with an upper motor neurone lesion. RESULTS: The mean (sd) detrusor LPP decreased from 68 (37) to 46 (31) cmH2O (P < 0.01), reflex volume (defined as the volume at the first uninhibited bladder contraction of > 15 cmH2O) increased from 78 (69) to 112 (118) mL (+ 44%), bladder compliance increased from 9.3 (6.1) to 19.6 (14.6) mL/cmH2O (+ 111%), maximal vesical pressure decreased from 84 (40) to 70 (47) cmH2O (- 17%), and the mean number of uninhibited bladder contractions decreased from 6.3 to 3.5 (- 44%). The therapy was well tolerated; side-effects were rare and not severe. Intermittent catheterization could be avoided in six children. CONCLUSION: Alfuzosin decreases the detrusor LPP in children with a neurogenic bladder caused by an upper motor neurone lesion, significantly and therapeutically, and should be considered as an alternative or addition to intermittent catheterization and anticholinergic drugs in selected patients.

Efficacy of botulinum-a toxin in children with detrusor hyperreflexia due to myelomeningocele: preliminary results.

OBJECTIVES: The established treatment of children with neurogenic bladder consists of the use of anticholinergic drugs, such as oxybutynin and tolterodine, and clean intermittent catheterization four or five times a day. If anticholinergic drugs and clean intermittent catheterization fail, surgery is often necessary. With the intent of avoiding surgery, we investigated the effect of botulinum-A toxin for treating detrusor hyperreflexia in this group of patients. METHODS: The subjects were 17 children (average age 10.8 years) who had detrusor hyperreflexia and were using clean intermittent catheterization four or five times a day. Urodynamic studies were followed by injection of 85 to 300 U of botulinum-A toxin into 30 to 40 sites in the detrusor muscle. Urodynamic follow-up was done 2 to 4 weeks after injection. RESULTS: The mean reflex volume increased by 112.1%, from 95.00 plus minus 34.54 mL (range 47 to 147) to 201.45 plus minus 68.57 mL (range 77 to 310) (P <0.005). The maximal bladder capacity increased by 56.5%, from 137.53 plus minus 59.96 mL (range 59 to 242) to 215.25 plus minus 96.36 mL (range 60 to 380) (P <0.005). The maximal detrusor pressure decreased by 32.6%, from 58.94 plus minus 32.32 cm H(2)O (range 19 to 149) to 39.75 plus minus 26.12 cm H(2)O (range 7 to 100) (P <0.005). Detrusor compliance increased by 121.6%, from 20.39 plus minus 26.5 mL/cm H(2)O (range 4.5 to 40) to 45.18 plus minus 45.4 mL/cm H(2)O (range 5.3 to 100) (P <0.01). CONCLUSIONS: Botulinum-A toxin injection into the hyperreflexive detrusor muscle seems to be very effective and might be a therapeutic alternative to anticholinergic drugs.

Urodynamic effects of oral oxybutynin chloride in children with myelomeningocele and detrusor hyperreflexia.

OBJECTIVES: To investigate the effects of oral oxybutynin chloride (OC) on standard urodynamic measures in children with myelomeningocele (MMC) and detrusor hyperreflexia. METHODS: Forty-one MMC children with detrusor hyperreflexia (19 boys and 22 girls, aged 2 months to 15 years; mean 4.9 years) were evaluated urodynamically before and within 3 months after initiation of oral OC therapy (0.2 to 0.3 mg/kg/day). Therapy with oral OC was always combined with clean intermittent catheterization (CIC). RESULTS: Oral OC treatment caused an increase in bladder capacity from 141 +/- 96 to 197 +/- 99 mL (+ 40%; P < 0.01), a decrease in detrusor pressure at maximal capacity from 45 +/- 32 to 28 +/- 23 cm H2O (-38%; P < 0.01), and an increase in detrusor compliance from 6.5 +/- 5.6 to 16.8 +/- 13.7 mL/cm H2O (+ 158%; P < 0.01). Improvement in urodynamic measures and continence were correlated. After a follow-up of at least 2 years, effective protection of renal function was achieved in 38 of the 41 children (93%) with conservative therapy alone. Adverse effects resulted in discontinuation of oral OC treatment in only 2 cases. CONCLUSIONS: Treatment with oral OC and CIC is effective and safe in children with MMC and detrusor hyperreflexia and should be initiated early when indicated by urodynamic findings.

Pneumatic lithotripsy applied through deflected working channel of miniureteroscope: results in 143 patients.

Although extracorporeal shockwave lithotripsy (SWL) is a successful treatment for ureteral calculi, introduction of miniureteroscopes has advanced endoscopic management. We combined the use of a semirigid ureteroscope with a pneumatic lithotripter (Swiss Lithoclast) for the treatment of ureteral calculi. From January 1992 to August 1994, 143 patients (87 male, 56 female; mean age 48.7 years; age range 22-74 years) with urolithiasis underwent endoscopic lithotripsy with the Swiss Lithoclast under general anesthesia. The 0.8 = mm probe was inserted through the deflected working channel (3.4F) of the Micro-6L ureteroscope (tip diameter 6.9F). The calculi were in the distal (N = 96; 67.1%), mid (N = 34; 23.8%), and proximal part (N = 13; 9.1%) of the ureter. The mean stone size was 6.8 mm (range 5-26 mm). Of the 137 patients whose stones we could access adequately, 70 (51.1%) were stone free immediately after the procedure, and another 31 (22.6%) had residual fragments <3 mm that passed spontaneously. The remaining 36 patients underwent another 50 procedures; 30 SWL sessions in 26 patients (19%), 17 further endoscopic lithotripsies in 14 (10.2%), and open surgery in 3. Application of the Swiss Lithoclast through semirigid miniureteroscopes is highly effective for endoscopic lithotripsy, regardless of stone composition. Deflection of the probe up to 30 degrees did not impair the disintegration rate. Because of the high migration rate of mid and proximal ureteral stones, the Swiss Lithoclast is not recommended in these cases as a primary procedure. Low capital cost and simple and safe handling are the device's major advantages over laser lithotripsy.

Is routine excretory urography necessary at first diagnosis of bladder cancer?

PURPOSE: We determined whether routine excretory urography (IVP) at initial diagnosis of bladder cancer is useful in screening the upper urinary tract for clinically inapparent urothelial tumors. MATERIALS AND METHODS: IVPs and ultrasound findings of 314 patients with bladder cancer were reviewed retrospectively. RESULTS: Only 1 silent upper urinary tract tumor was detected with IVP (0.3%), resulting in nephroureterectomy. IVP had no further therapeutic consequences except for destruction of an asymptomatic prevesical stone. IVP was followed by ureterorenoscopy in 5 patients with negative results. Upper urinary tract obstruction could be documented equally well by sonography in all cases. CONCLUSIONS: Routine IVP at first diagnosis of bladder cancer is unnecessary.

Local interferon-alpha 2b is not an effective treatment in early-stage Peyronie's disease.

OBJECTIVE: Peyronie's disease is characterized by an acquired penile deviation that may lead to severe penile deformity. It is refractory to most conservative therapy, and surgical correction is therefore the treatment of choice once the disease process has come to a halt. Basic science, as well as our first clinical results on the use of interferons (IFNs), have been promising, suggesting a beneficial effect in the early noncalcified disease stage. MATERIAL AND METHODS: From July 1994 to October 1995, 30 patients suffering from early Peyronie's disease were treated with three local injections of 3 million units of IFN-alpha 2b each into the plaque(s). The interval between the injections was 1 week. Patients were assessed clinically and ultrasonographically 6 months after the last injection. RESULTS: Peyronie's disease clinically improved in only 1 case, remained stable in 26 patients and worsened in 3. In 7 patients, a total of 10 plaques at different sites were detected. By ultrasonography the treated plaques now showed calcifications in 3 cases, remained unchanged in 26 and could not be detected in 1 case. Of the 10 new plaques, 2 showed calcifications. Side effects (myalgia, fever) were considerable; in 74 of 90 injections, fever > 38 degrees C occurred, and a total of 8 working days were lost. CONCLUSION: IFN-alpha 2b, given according to our regimen, is not useful for the treatment of Peyronie's disease in the early stage since the disease progress continues at different sites in about 25% of the patients, and the side effects are untolerable. Our results also demonstrate that local therapy is not indicated in Peyronie's disease.