Stress incontinence surgery: which operation when?

PURPOSE OF REVIEW: Many operations have been developed to treat stress urinary incontinence and yet, at present, there is no consensus about whether there is a single best surgery for all patients with this condition. Can a consensus be reached to determine the best surgical procedure? Can one surgery be successful for patients with varied characteristics, or should a specific procedure be applied to each individual patient? RECENT FINDINGS: There are many factors to consider when choosing an operation for stress urinary incontinence in an individual patient. Body habitus, prior pelvic surgery, including prior antiincontinence surgery, urethral function or obstruction or both, and the presence or absence of vaginal wall prolapse can all significantly impact on the potential surgical intervention. These characteristics may affect the choice of procedure with respect to optimizing a favorable outcome or minimizing the risk of a poor outcome or associated complications. SUMMARY: At present, there is no evidence to support the notion that there exists a single best operative intervention for all patients with stress urinary incontinence. There is a small but slowly developing literature base by which to guide the choice of surgical procedure for contemporary treatment of stress urinary incontinence in individual patients.

Evaluation and management of gunshot wounds of the penis: 20-year experience at an urban trauma center.

BACKGROUND: Although gunshot injuries to the penis occur relatively infrequently in patients with penetrating trauma, they often present dilemmas of subsequent evaluation and management. We review our extensive experience with gunshot wounds to the penis at a high volume urban trauma center. METHODS: The urologic trauma database was retrospectively reviewed to extract and compile information from the records of 63 patients treated for gunshot wounds to the penis. Data were accumulated for a 20-year period from 1985 to 2004 with regard to findings on physical examination, diagnostic evaluation, associated injuries, management, and outcome. We detail our technique of penile exploration and artificial erection in the management of these injuries. RESULTS: Penile gunshot wounds were associated with additional injuries in 53 of 63 (84%) patients. A total of 48 (76%) patients were taken to the operating room and 44 (70%) penile explorations were performed. Evaluation included retrograde urethrogram in 50 of 63 (79%) patients and was diagnostic for urethral injury in 11 of 12 (92%) cases. Primary urethral repair was performed in 8 of 12 (67%) patients with urethral injury versus 4 of 12 (33%) who underwent urinary diversion by means of suprapubic cystotomy. CONCLUSIONS: Evaluation and management of gunshot wounds to the penis may potentially be complex. Retrograde urethrogram should be performed in all cases except the most insignificant and superficial wounds. We describe our technique of penile exploration and artificial erection, noting excellent results in patients for whom follow-up is available. Additional studies are needed to prospectively evaluate techniques for management of gunshot urethral injuries.