Two-stage management of severe postprostatectomy bladder neck contracture associated with stress incontinence.

OBJECTIVES: To report our experience using a two-stage, rather than a synchronous, approach in the management of bladder neck contracture (BNC). Anastomotic BNC associated with urinary incontinence is a major complication after radical prostatectomy. Patients may present with a decreased force of stream, urinary retention, or stress, urge, or overflow urinary incontinence. METHODS: The pertinent data of 15 patients (age range 52 to 78 years, mean 62) with postradical prostatectomy BNC associated with stress urinary incontinence (mean pad use 3 per day) were retrospectively reviewed. Video-urodynamic evaluation in 10 of 15 patients revealed a Valsalva leak point pressure of less than 80 cm H2O in all 10 patients. Bladder outlet obstruction was noted in 4 of 10 patients. Of the 15 patients, 2 declined an artificial urinary sphincter (AUS), the other 13 proceeded with our two-stage management. Step one consisted of deep transurethral incision of the BNC (TUIBNC) with Collin's knife electrocautery. Step two consisted of implantation of an AUS (AMS-800) 6 to 8 weeks after TUIBNC once bladder neck patency had been demonstrated cystoscopically. RESULTS: During a mean follow-up of 15 months, 3 patients developed early recurrence of BNC: 2 at the 5-week cystoscopy, 1 at 8 weeks discovered at the scheduled AUS placement. All 3 patients underwent repeat TUIBNC and remained clinically patent at a mean follow-up of 9 months. The remaining 10 patients were clinically patent after a single TUIBNC, with good subjective flow and postvoid residual volume of less than 30 mL at a mean follow-up of 11 months. Of the 13 patients who underwent AUS placement, 12 were socially continent (wearing 0 to 1 thin pad daily). The thirteenth patient remained incontinent after AUS placement. One of the 12 continent patients developed an infection at the device 8 months postoperatively and required explantation. CONCLUSIONS: We recommend a two-stage approach (TUIBNC followed by AUS insertion) rather than synchronous management for postprostatectomy BNC associated with stress urinary incontinence. Such an approach allows identification of BNC recurrence and its safe management before AUS implantation.

Grade 4 cystocele repair using four-defect repair and porcine xenograft acellular matrix (Pelvicol): outcome measures using SEAPI.

OBJECTIVES: To determine the efficacy of grade 4 cystocele repair using the four-defect repair (FDR) or modified FDR with porcine xenograft matrix (FDR+Pelvicol). METHODS: During a 4-year period, 45 women underwent grade 4 cystocele repair. Of the 45 patients, 43 (95.5%) were available for follow-up. The mean age was 65 years. Patients presented with the following problems: grade 4 cystocele in 43 (100.0%), stress urinary incontinence in 24 (55.8%), urge urinary incontinence in 26 (60.4%), and obstructive voiding symptoms in 26 (60.4%). Patients were evaluated using the stress, emptying, anatomic, protection, and instability (SEAPI) test. We performed FDR in the first consecutive 24 (55.8%) and FDR+Pelvicol in the remaining 19 (44.2%) patients. Cystocele repair was accompanied by other transvaginal repair in 38 (88.3%) of the 43 patients. RESULTS: The mean follow-up time was 15 months. A comparison of the preoperative and postoperative SEAPI scores of 0, representing the absence of complaints, revealed a statistically significant improvement in all the SEAPI domains using McNemar's test. Cystocele recurred in 3 patients (6.9%), all in the Pelvicol subgroup. Two patients (4.7%) had postoperative urinary retention. De novo urge incontinence occurred in 2 patients (11.7%). No infection, erosion, fistula, or vaginal stenosis have been reported. CONCLUSIONS: Grade 4 cystocele repair using FDR or FDR+Pelvicol are two effective methods of cystocele repair. Although cystocele failures occurred exclusively in the Pelvicol+FDR subgroup, their small number and asymptomatic presentation did not result in statistical or clinical significance at this point. Both techniques are simple, efficacious, and well tolerated by patients. Follow-up is ongoing to evaluate the durability of the techniques.

Small bowel obstruction associated with tension-free vaginal tape.

A 73-year-old woman with stress urinary incontinence and uterine prolapse underwent vaginal hysterectomy followed by tension-free vaginal tape (TVT) placement. Postoperatively, she presented with low-grade fever and abdominal distension. Abdominal computed tomography revealed bowel distension and abrupt cutoff of the distended small bowel and normal bowel caliber. Transperitoneal laparotomy demonstrated perforation of the mesentery by the TVT without other injury. The tape was cut in its intraperitoneal portion. The patient resumed normal bowel function and, at last follow-up, remained continent. We advocate that when performing TVT placement in conjunction with vaginal hysterectomy, TVT placement should be performed at the beginning of the procedure.

Value of express T2-weighted pelvic MRI in the preoperative evaluation of severe pelvic floor prolapse: a prospective study.

OBJECTIVES: To report our prospective experience with extended-phase conjugate-symmetry rapid spin-echo sequence (EXPRESS) magnetic resonance imaging (MRI) of the female pelvis in the preoperative staging of severe pelvic floor prolapse (PFP). Severe PFP represents a significant diagnostic and reconstructive challenge for clinicians. Although the clinical utility of dynamic MRI has already been demonstrated, EXPRESS MRI has not been prospectively studied in the evaluation of PFP. METHODS: Between January 1999 and December 2001, 31 consecutive female patients with severe PFP were referred to our institution. Twenty of them underwent EXPRESS dynamic pelvic MRI. The physical examination, MRI, and intraoperative findings were statistically correlated. RESULTS: The mean age of the 20 patients undergoing preoperative EXPRESS MRI was 67 years. The mean duration of prolapse was 6.1 years. All 20 patients underwent surgery for symptomatic PFP with or without associated voiding dysfunction. No postoperative complications or recurrent PFP had occurred at a median follow-up of 19 months. Significant correlations were found between the preoperative pelvic examination findings and operative findings of cystourethrocele and vaginal cuff prolapse, and significant correlations were found between MRI findings and operative findings of enterocele, cystourethrocele, vaginal cuff prolapse, and uterine prolapse. CONCLUSIONS: EXPRESS MRI can accurately stage PFP. The technique is rapid, precise, and noninvasive. Practitioners should consider obtaining dynamic, rapid-sequence sagittal pelvic MRI scans in cases of severe PFP when the diagnosis is not clear before surgery. More accurate preoperative information may ultimately result in improved long-term surgical outcomes and guide the refinement of surgical techniques.

Current practice patterns in the urologic surveillance and management of patients with spinal cord injury.

OBJECTIVES: To determine current trends in management and surveillance of the spinal cord injury (SCI) population among specialized urologists who routinely work and provide care to patients with SCI. There is a lack of consensus on the optimal urologic surveillance and management protocol of the urinary tract in SCI patients. METHODS: A mailed questionnaire was sent to the 269 American members of the Society for Urodynamics and Female Urology (SUFU). The type of investigation used in the assessment and follow-up of upper and lower urinary tract function in SCI patients and their optimal frequency and management modalities were the topics of inquiry. RESULTS: One hundred sixty of the 269 urologists responded for a response rate of 60%. Most physicians (85%) favor a yearly renal ultrasound for routine surveillance of the upper tracts, whereas more than half (65%) routinely use videourodynamic studies for evaluation of the lower urinary tract. The combination of clean intermittent catheterization (CIC) plus anticholinergic agents is the favored modality for management of hyperreflexic bladder, whereas CIC alone is preferred for the areflexic bladder. CONCLUSIONS: This study confirms that most urologists working with SCI patients follow principles reported in published data regarding the need for evaluation, surveillance, and management of the urinary tract. However, there is a lack of consensus in the specific methods used for surveillance of the urinary system. The present results emphasize the need for clear guidelines in this area.