Use of aggregate fitness indicators to predict transition into the National Hockey League.

Athletes (n = 345) invited to the annual combine conducted by the National Hockey League (NHL) prior to the entry draft were administered tests to measure upper body strength, lower body power, aerobic and anaerobic energy systems, and body composition. Their common variance was extracted using factor analysis from which an overall composite index was derived. A score on this index in the 90th percentile is associated with 72% and 60% probability of playing in the NHL within 4 years after the draft for defensemen and forwards, respectively. These findings demonstrate that by taking into account the shared variance on standard tests of fitness, it is possible to use the athlete's results to gauge his potential for playing in the NHL.

Urethral diverticulum: a new complication associated with tension-free vaginal tape.

A case of a urethral diverticulum following the insertion of a tension-free vaginal tape (TVT) is presented. The patient was a woman with stress urinary incontinence who underwent surgery to correct intrinsic sphincter deficiency. Three cases of urethral diverticula have been published thus far as complications of TVT insertions, but this is the first complication associated with intrinsic sphincter deficiency. The high pressures in the proximal urethra that result from positioning the TVT in the middle urethra, especially when obstruction co-exists with an open bladder neck, can be a predisposing factor for this complication. The possibility of a urethral diverticulum when postvoid incontinence occurs after the insertion of a TVT should be carefully evaluated.

Relationship of physical fitness test results and hockey playing potential in elite-level ice hockey players.

The primary purpose of this study was to determine the fitness variables with the highest capability for predicting hockey playing potential at the elite level as determined by entry draft selection order. We also examined the differences associated with the predictive abilities of the test components among playing positions. The secondary purpose of this study was to update the physiological profile of contemporary hockey players including positional differences. Fitness test results conducted by our laboratory at the National Hockey League Entry Draft combine were compared with draft selection order on a total of 853 players. Regression models revealed peak anaerobic power output to be important for higher draft round selection in all positions; however, the degree of importance of this measurement varied with playing position. The body index, which is a composite score of height, lean mass, and muscular development, was similarly important in all models, with differing influence by position. Removal of the goalies' data increased predictive capacity, suggesting that talent identification using physical fitness testing of this sort may be more appropriate for skating players. Standing long jump was identified as a significant predictor variable for forwards and defense and could be a useful surrogate for assessing overall hockey potential. Significant differences exist between the physiological profiles of current players based on playing position. There are also positional differences in the relative importance of anthropometric and fitness measures of off-ice hockey tests in relation to draft order. Physical fitness measures and anthropometric data are valuable in helping predict hockey playing potential. Emphasis on anthropometry should be used when comparing elite-level forwards, whereas peak anaerobic power and fatigue rate are more useful for differentiating between defense.

Rodent carcinogenicity with the thiazolidinedione antidiabetic agent troglitazone.

Carcinogenic potential of the thiazolidinedione antidiabetic troglitazone was assessed in 104-week studies in mice and rats. Mice were given 50, 400, or 800 mg/kg, male rats 100, 400, or 800 mg/kg, and female rats 25, 50, or 200 mg/kg. Vehicle and placebo controls were included. Survival was significantly decreased in both sexes of both species at high doses, but was adequate for valid evaluation of carcinogenicity. Hypertrophy and hyperplasia of brown adipose tissue was observed in both species at all doses, and fatty change and hypocellularity of bone marrow was noted in mice at all doses and in female rats at 50 and 200 mg/kg. Hepatocellular vacuolation was observed in mice at 400 and 800 mg/kg, and centrilobular hepatocellular hypertrophy occurred in rats at > or = 200 mg/kg. Ventricular dilatation, myocardial fibrosis, and atrial myocyte karyomegaly in male rats at 400 and 800 mg/kg and female rats at all doses were morphologically similar to spontaneous lesions, but incidence and severity were increased compared with controls. In mice, the incidence of hemangiosarcoma was increased in females at 400 mg/kg and in both sexes at 800 mg/kg. The incidence of hepatocellular carcinoma was increased in female mice at 800 mg/kg. Troglitazone exposure [AUC((0-24))] at the lowest dose associated with increased tumor incidence in mice was 16 times human therapeutic exposure at 400 mg daily. No tumors of any type were increased in rats at exposures up to 47 times therapeutic exposure.

Revision rate after artificial urinary sphincter implantation for incontinence after radical prostatectomy: actuarial analysis.

PURPOSE: We determined the actuarial revision rate for artificial urinary sphincters implanted in patients who were incontinent after radical prostatectomy. MATERIALS AND METHODS: We reviewed the records of 70 consecutive patients who were incontinent after radical prostatectomy and who underwent primary artificial urinary sphincter implantation at the University of Michigan between 1984 and 1999. Questionnaires were mailed to all patients with an indwelling device, and telephone calls were placed to those who did not respond to the mailing. Information about surgical revision and current continence status was obtained from chart review and questionnaire response. The Kaplan-Meier curves for actuarial freedom from operative revision were constructed. RESULTS: Of the 66 patients with available postoperative data 24 (36%) required reoperation at a mean followup of 41 months. The 5-year actuarial rate for freedom from any operative revision was 50%, and the corresponding rate for cuff revision was 60%. A single operative revision did not predispose the patient to further revision. Questionnaire data indicated a continence rate of 80% (range 0 to 2 pads). CONCLUSIONS: Approximately half of the patients who were incontinent after radical prostatectomy may expect to undergo operative revision within 5 years after artificial urinary sphincter implantation. Despite this high reoperation rate, an excellent level of continence is maintained.

Studies on coronary arteriopathy in dogs following administration of CI-1020, an endothelin A receptor antagonist.

A selective nonpeptide endothelin A (ETA) receptor antagonist, CI-1020, was administered to beagle dogs intravenously (i.v.) for 4 hours to 4 weeks. One animal/sex received CI-1020 at 1 mg/kg/hr intravenously for 4, 8, or 24 hours to investigate onset of arteriopathy. Control animals (1/sex) received the vehicle only. To determine reversibility of arteriopathy, 8 dogs/sex were given CI-1020 at 1 mg/kg/hr for 4 days. Two dogs/sex were sacrificed 1, 3, 8, and 29 days following cessation of infusion. Lesion development with prolonged exposure was investigated in 1 male dog. It was given CI-1020 by i.v. bolus at 120 mg/kg/day for 4 weeks and Monastral blue dye was administered i.v. to facilitate localization of vascular lesions. Coronary blood flow was determined in 4 dogs infused with CI-1020 at 0.3, 3, and 30 mg/kg for one hour at each dose. Macroscopically, hemorrhage or blue discoloration of Monastral blue was noted in the extramural coronary arteries along the coronary groove and atrium. Histologically, the earliest coronary changes were noted in animals sacrificed after 24 hours of treatment and characterized by medial hemorrhage and necrosis with a few infiltrating neutrophils. In the reversibility study, incidence and severity of arteriopathy was dependent on time of sacrifice following cessation of infusion. Acute necrotizing inflammation of arteries was present in all animals (n = 4) on day 1 postinfusion, whereas on day 8 postinfusion, lesions characterized by medial small pockets of trapped red cells, cell debris, and adventitial thickening were seen in 1 dog/sex. By day 29 postinfusion, coronary arteries were similar to controls. In the dog given daily i.v. bolus injections of CI-1020 for 4 weeks, arterial inflammatory lesions varied from acute to chronic, although most lesions were considered chronic active. Monastral blue pigments were noted in the wall of most arteries with chronic or chronic active lesions. Acute lesions were similar to those noted in day 1 postinfusion of the reversibility study. Medial smooth muscle necrosis and/or fibrosis with mixed inflammatory cell infiltrates characterized chronic or chronic active lesions. Smooth muscle proliferation and migration into the intima were also noted. There were no significant changes in coronary blood flow, coronary vascular resistance, or mean arterial blood pressure following CI-1020 infusion for 3 hours. In the 24-hour infusion study, plasma endothelin 1 (ET-1) levels were mildly elevated (1.5-4 fold) during CI-1020 infusion when compared to either pretest or control values. These results indicate that administration of endothelin antagonist (CI-1020) to dogs was associated with development of coronary arteriopathy, which was completely resolved within 29 days following cessation of treatment. With prolonged (4-week) CI-1020 treatment, arterial lesions at varying stages of development (acute, chronic active, chronic) were seen, suggesting that tolerance to treatment (up to 4 weeks) does not occur.

Surgical procedures for the treatment of urge incontinence.

PURPOSE: Cure of urge incontinence refractory to conservative management may require the application of several surgical techniques. The Ingelman-Sundberg bladder denervation procedure, detrusor myectomy, and augmentation cystoplasty are among the surgical possibilities aimed at dealing with severe urgency and uninhibited detrusor contractions. METHODS AND MATERIALS: A review of the literature was performed to evaluate surgical treatments for refractory urgency and urge incontinence with a focus on the Ingelman-Sundberg bladder denervation procedure, detrusor myectomy, and augmentation cystoplasty. RESULTS: The Ingelman-Sundberg bladder denervation has a complete response rate of 54% at a mean of 44.1 months. Among a heterogeneous group of patients, the detrusor myectomy resulted in improvement of compliance and/or resolution of uninhibited detrusor contraction in 63%. The augmentation cystoplasty has the highest overall rate of success but with a much higher likelihood of early and late postoperative complications. CONCLUSIONS: Surgical procedures for urge incontinence have a reasonable success rate with respect to cure of symptoms and urodynamic improvement when present. The possibility of cure or improvement appears to vary directly with the invasiveness of the procedure. However, a logical progression from least to most invasive should be undertaken unless very poor compliance and upper tract abnormalities dictate a more aggressive initial course of action.

Advantages of rectus fascial slings for urinary incontinence in children with neuropathic bladders.

PURPOSE: Many surgical procedures to improve outlet resistance in children with neuropathic bladders are obstructive and increase the detrusor leak point pressure. In contrast, fascial slings are designed to achieve continence by increasing the Valsalva or stress leak point pressure without altering the detrusor leak point pressure. We evaluate the effectiveness of fascial slings in achieving continence in pediatric patients with neuropathic bladder. MATERIALS AND METHODS: From October 1994 until February 1999, 10 females and 8 males with neuropathic bladder secondary to myelodysplasia or traumatic spinal cord injury underwent fascial sling procedures. Mean patient age was 14 years (range 8 to 18) and all were incontinent despite aggressive medical management. Urodynamic evaluation was performed preoperatively and postoperatively. Specific urodynamic measurements included detrusor leak point pressure, stress leak point pressure and detrusor compliance. Compliance was only compared in the 12 nonaugmented cases. RESULTS: With a mean followup of 21.2 months (range 6 to 57), preoperative and postoperative urodynamics revealed little change in mean detrusor leak point pressure (23.2 versus 23.22 cm. H2O) but a substantial increase in mean stress leak point pressure (41.6 versus 64.5 cm. H2O). Mean compliance was unchanged in the nonaugmented group (22.00 versus 26.78 ml/cm. H2O). Four patients (22.22%) remained wet after surgery, of whom 2 were successfully treated with a repeat sling procedure and 1 with collagen injection for an overall continence rate of 94.44%. CONCLUSIONS: Fascial slings can be effectively used in pediatric patients for neuropathic incontinence. Furthermore, stress urinary incontinence is corrected by increasing the Valsalva or stress leak point pressure with preservation of the detrusor leak point pressure. Preservation of detrusor leak point pressure is particularly advantageous because other forms of bladder outlet procedures achieve continence at the expense of increasing detrusor pressures, thus placing the upper tracts at risk for damage.

External urethral sphincter dilation for the management of high risk myelomeningocele: 15-year experience.

PURPOSE: We investigate the long-term outcome using external urethral sphincter dilation for high risk myelomeningocele. MATERIALS AND METHODS: Since 1984 external urethral sphincter dilation was performed in 25 patients with myelomeningocele who demonstrated passive leak point pressure greater than 40 cm. H2O and/or poor bladder compliance. Mean followup from the first dilation was 8.4 years. Overall 2.4 dilations were performed per patient (range 1 to 8). Cystometrography, imaging study and continence status were evaluated retrospectively. RESULTS: Overall external urethral sphincter dilation produced durable improvements in mean leak point pressure (60.9 versus 34.4 cm. H2O), capacity (119.8 versus 233.3 ml.), initial compliance (11.5 versus 28.4 ml./cm. H2O) and terminal compliance (1.1 versus 7.7 ml./cm. H2O). Categorical analysis revealed 3 groups in terms of outcome. Group 1 consisted of 11 patients (44%) who demonstrated durable improvements in urodynamic parameters as well as preservation of the upper tracts. These patients demonstrated a 2-step compliance pattern on pre-dilation cystometrography, in which elevated leak point pressure was associated with excellent initial compliance. Group 2 consisted of 5 patients (20%) who failed to maintain safe leak point pressure and whose upper tracts deteriorated, including 4 who eventually underwent augmentation cystoplasty. This group demonstrated a 1-step hypertonicity in which elevated leak point pressure was associated with a steep pressure increase during early filling. Group 3 consisted of 9 patients (36%) who responded minimally in terms of leak point pressure reduction but whose upper tracts remained well preserved. They demonstrated a high pressure instability pattern associated with excellent baseline compliance. CONCLUSIONS: External urethral sphincter dilation provides an effective long-term solution for select high risk myelomeningocele cases. Those who demonstrate elevated leak point pressure and poor bladder compliance at the time of external urethral sphincter dilation are less likely to respond, suggesting that the bladder may have already undergone irreversible changes due to high outlet resistance. Patients who demonstrate instability patterns are less likely to respond to external urethral sphincter dilation in terms of leak point pressure reduction but the upper tracts appear to be well preserved.

A brief history of testosterone.

PURPOSE: We explore the history of testosterone in the context of medical and scientific developments. MATERIALS AND METHODS: A review of the scientific and historical literature was conducted. RESULTS: The origins and effects of testosterone have been recognized throughout the history of humankind. Hunter performed testicular transplantation experiments in 1767 while studying tissue transplantation techniques, and almost a century later Berthold linked the physiological and behavioral changes of castration to a substance secreted by the testes. Brown-Séquard gave birth to the field of organotherapy in 1889 when he announced that his auto-injection of testicular extracts resulted in rejuvenated physical and mental abilities. Steinach and Niehans expanded upon Brown-Séquard's work with rejuvenation treatments involving vasoligation, tissue grafts and cellular injections. In 1935 David et al isolated the critical ingredient in organotherapeutic treatments, testosterone. CONCLUSIONS: The effects of the powerful hormone testosterone continue to inspire research and controversy 65 years later.

Urinary tract erosions after synthetic pubovaginal slings: diagnosis and management strategy.

OBJECTIVES: To review our experience with the diagnosis and management of genitourinary tract erosions after pubovaginal sling placement. METHODS: Clinic and operative records from the urology and gynecology services at two university hospitals were reviewed, and 14 patients were identified who underwent surgical treatment for a urogenital tract erosion after pubovaginal sling placement. The presenting symptoms, physical findings, diagnostic procedures, surgical treatments, and outcomes were reviewed. RESULTS: Six vaginal erosions, six urethral and vaginal erosions, and two bladder erosions occurred. All were associated with synthetic sling or suture materials. Common symptoms included vaginal and urethral pain, irritative voiding symptoms, vaginal discharge and/or bleeding, and recurrent urinary tract infections. All vaginal and urethral erosions were detected by physical examination and cystoscopy. Symptoms resolved after removal of the eroded sling component. Of the 12 patients with vaginal or urethral erosions, 7 developed recurrent postoperative stress incontinence. CONCLUSIONS: Persistent painful or irritative symptoms after pubovaginal sling placement may be due to urogenital tract erosion, especially if synthetic materials were used. Appropriate evaluation and treatment will result in dramatic symptomatic improvement, although recurrent stress incontinence may occur.

Is intrinsic sphincter deficiency a complication of simple hysterectomy?

PURPOSE: Intrinsic sphincter deficiency may cause disabling stress urinary incontinence. While some pelvic operations are implicated as a cause of this condition, simple hysterectomy for benign disease is not recognized as one of them. We evaluated the association of simple hysterectomy with intrinsic sphincter deficiency. MATERIALS AND METHODS: We performed a case control study to assess the association of simple hysterectomy with intrinsic sphincter deficiency in a consecutive group of 387 incontinent women. From 1995 to 1997 we identified 67 patients with and 67 controls without a history of hysterectomy. Further comparison was done after forming a subgroup at low risk for intrinsic sphincter deficiency. All patients were evaluated by a fluoroscopic urodynamic technique and abdominal leak point pressure was determined. RESULTS: Intrinsic sphincter deficiency was present in 48% of the 67 patients and 24% of the 67 controls. In the lower risk subgroup we noted this condition in 29 patients (52%) and 53 controls (21%). CONCLUSIONS: In this population of incontinent women intrinsic sphincter deficiency, as diagnosed by low abdominal leak point pressure, appears to be a complication of simple hysterectomy.

Salvage prostatectomy with continent catheterizable urinary reconstruction: a novel approach to recurrent prostate cancer after radiation therapy.

PURPOSE: Salvage prostatectomy after full dose radiation therapy is associated with a high risk of urinary incontinence. We evaluated the complications of salvage prostatectomy with continent catheterizable reconstruction and its impact on urinary incontinence. MATERIALS AND METHODS: Between August 1995 and February 1999, 13 patients with biopsy proved, locally recurrent prostate cancer after radiation therapy underwent salvage prostatectomy with complete bladder neck closure and reconstruction with an appendicovesicostomy to the native bladder in 9 and ileovesicostomy in 4. RESULTS: There were no intraoperative complications. Four patients had serious complications necessitating reoperation, including a vesicourethral fistula requiring delayed cystectomy, wound dehiscence with disruption of the appendicovesical anastomosis, leakage from the small bowel anastomosis that resulted in sepsis and death, and stomal stenosis requiring delayed stomal revision in 1 each. Of 12 patients 2 (17%) used pads for incontinence, while 10 were dry during the day and night with a catheterization interval of 2 to 6 hours. CONCLUSIONS: Salvage prostatectomy with continent catheterizable reconstruction is a technically challenging operation with the potential for serious complications. The postoperative continence rate is excellent and appears superior to those in the literature for salvage prostatectomy and vesicourethral anastomosis.

Bladder endometriosis: conservative management.

PURPOSE: We evaluate the characteristics of women with bladder endometriosis successfully treated with hormonal therapy. MATERIALS AND METHODS: The records of 14 patients with a mean age of 48.7 years (range 26 to 71) diagnosed with bladder endometriosis on cystoscopic evaluation were reviewed for presenting complaints, findings and response to therapy. RESULTS: The most frequent presenting complaints were urgency (78%), frequency (71%), suprapubic pain (43%), urge incontinence (21%) and dyspareunia (21%). Of the patients 86% did not have a history of recurrent urinary tract infections, 6 (42%) had a history of endometriosis, including 3 who were previously treated with hysterectomy/oophorectomy and 8 (57%) were on some form of therapy for estrogen deficiency. In all patients endometrial implants were identified on cystoscopic examination. In 2 patients the endometrioma correlated to lesions on the serosal surface of the bladder during laparoscopic evaluation. Of the patients 13 were treated either with low dose oral contraceptives, decrease or elimination of the estrogen component of the present regimen or addition of progesterone to therapy, and 12 (92%) reported sustained improvement of symptoms at a mean of 18.6 months (range 8 to 24). CONCLUSIONS: In more than 70% of cases the presenting symptoms of bladder endometriosis are identical to those of interstitial cystitis. Therefore, endometriosis should always be considered in the patient referred for frequency, urgency and pain with no documented infection. Hormonal therapy is reasonable and effective management for bladder endometriosis. This option preserves fertility, making it especially attractive to younger women.

Pubovaginal sling: 4-YEAR outcome analysis and quality of life assessment.

PURPOSE: Stress urinary incontinence is a common disease with a devastating impact on patient quality of life. Needle suspension procedures, which produce disappointing long-term results for type II stress incontinence, are being replaced by pubovaginal slings which previously were reserved solely for the treatment of type III stress incontinence. We report the long-term outcomes of pubovaginal slings for the treatment of types II and III stress urinary incontinence, and assess its quality of life impact. MATERIALS AND METHODS: From January 1993 until December 1996, 247 females 10 to 84 years old (mean age 54.5) with type II (54%) or III (46%) stress urinary incontinence diagnosed by fluoroscopic urodynamics received a pubovaginal sling. Concomitant urge incontinence was present in 109 patients (44%). Quality of life was assessed with the Urogenital Distress Inventory short form. RESULTS: At a mean followup of 51 months (range 22 to 68) the continence rates were 88% overall, 91% for type II and 84% for type III. Preoperative urge incontinence resolved in 81 of 109 patients (74%), while de novo urge incontinence developed in 10 (7%). Intermittent urethral catheterization duration averaged 8.4 days, with 5 women undergoing urethrolysis for a hypersuspended urethra. Secondary procedures were required in 9 patients with type II and 5 with type III incontinence, and included transurethral collagen injections in 6 and repeat pubovaginal slings in 8. There was a 4% complication rate due to pelvic hematoma in 2 cases, incisional hernia in 2, deep venous thrombosis in 1 and pulmonary embolus in 1. Of the 247 patients 235 (95%) completed the quality of life questionnaire with 92% reporting a high degree of satisfaction with low (less than 20 of 100 points) symptom distress scores. CONCLUSIONS: Pubovaginal slings are effective and durable, and significantly improve quality of life in patients with types II and III stress urinary incontinence.

Mixed symptomatology.

Mixed symptomatology, i.e. both stress and urge incontinence, is reported by patients, either of their own accord or in response to a questionnaire. Our understanding of motor urge incontinence, detrusor instability, stress incontinence and sensory urge incontinence is changing. Detrusor instability is now known to be a urodynamic observation of uncertain clinical significance. Symptoms reported by patients are not equivalent to a urodynamic diagnosis but the problem seems to be more in the urodynamics than in the symptoms. Evidence shows that sensory urge incontinence and motor urge incontinence are probably gradations of the same condition. The relationship between stress incontinence and an overactive bladder is complex. For example, neither detrusor instability nor urge incontinence appear to adversely influence the outcome of surgical treatment for stress incontinence; however, this treatment does not have a good success rate. At present, it is not clear whether this poor outcome reflects a lack of efficacy of the operations used, or their application to inappropriate patients.

Balloon dilation of posterior urethral stricture secondary to radiation and cryotherapy in a patient with a functional artificial urethral sphincter.

Severe urethral stricture disease as an isolated entity can be a management dilemma. In the patient described here, this problem was associated with prior external-beam radiation and cryosurgical ablation of the prostate, and a functional artificial urethral sphincter (AUS) had been placed. An attempt to relieve partial urinary obstruction while preserving AUS function led to successful balloon dilation proximal to the sphincter cuff.