Hydronephrosis caused by cystocele. Treatment by colpopexy to sacral promontory.

A case of marked bilateral hydroureteronephrosis due to extreme prolapse of the bladder is reported. This latter condition led also to obstructive urinary tract symptoms and residual urine. After repair of the cystocele in an unusual way by fixation of the vaginal vault to the sacral promontory, the caliber of the upper urinary tracts became almost normal and postvoiding residual urine disappeared.

Bladder neck incision in the female: a hazardous procedure?

Anterior bladder neck incision was carried out in 32 female patients suffering from difficult, mostly incomplete, bladder emptying. All patients underwent a full urodynamic investigation with voiding cystourethrography and endoscopy. Detrusor failure was observed in 20 patients; in the remainder, a mechanical iatrogenic bladder neck obstruction was held responsible for inefficient voiding. Twenty-eight patients (56%) benefited in some degree from the procedure. Six were submitted to a repeat incision and two of them developed severe stress incontinence later on. As the results are far from promising, intermittent self-catheterisation may be proposed in some cases as an alternative to bladder neck incision for fear of incontinence. The urodynamic findings and the results of bladder neck incision, which are very different in the two sexes, are analysed. The poorer results in the female are presumably due to the decompensated state of the bladder, mostly responsible for incomplete bladder evacuation.

Extended bladder neck incision for outflow obstruction in male patients.

Thirty-two male patients with mechanical or functional bladder outlet obstruction were treated by bilateral endoscopic bladder neck incision. In three cases a repeat incision was necessary. Subjective cure or improvement was obtained in 81%. Objective evaluation, including uroflowmetry and residual urine measurements, showed a similar improvement. Bladder neck incision takes only a few minutes, is simple and less traumatic than transurethral resection. The aetiology of impaired micturition and the value of urodynamic assessment are discussed and some attention devoted to the problem of post-operative retrograde ejaculation.

The value of intravesical prostaglandin E2 and F2 alpha in women with abnormalities of bladder emptying.

A clinical study of intravesical prostaglandin E2 (PGE2) and F2 alpha (PGF2 alpha) in the treatment of 13 female patients with difficulties in emptying their bladder is reported. Urodynamic investigations were performed before and after instillation of the drug. Although 3 patients had some reduction in residual urine volume, the remainder showed no obvious change and no patient experienced subjective improvement. In 6 patients, biopsies of the vesical mucosa were taken before and after instillation in order to measure the uptake of prostaglandin by the mucosa, but no conclusions could be drawn from these measurements. Although prostaglandins are known to have contractile effects on the detrusor muscle, the results of this study suggest that intravesical PGE2 and PGF2 alpha have no therapeutic value in the treatment of voiding dysfunction and residual urine.

The use of indomethacin in the treatment of idiopathic bladder instability.

55 patients suffering from voiding disorders associated with primary detrusor instability, have been treated with indomethacin. All patients have remained resistant to conventional medical treatment. 7 patients did not complete the clinical trial. After a 6-week trial period, the patients' symptom changes and side-effects were assessed. Only 17% of the patients who completed the trial, benefited from the treatment. Side-effects were encountered in 42% of the cases.

Fibroepithelial polyp of ureter.

Fibroepithelial polyp of the ureter, a mesodermal benign tumor, is extremely rare. Four cases of our own prompted us to review the world literature on this subject (108 documented cases since 1950). The mode of presentation, etiology, clinical features, and treatment modalities of this lesion are discussed.

Prolonged bladder distension in the management of the unstable bladder.

We treated 63 patients with urinary symptoms associated with uninhibited detrusor contractions on cystometry by prolonged bladder distension. All patients had received drug therapy previously without success. Fourteen patients whose symptoms relapsed after a previous distension or who failed to obtain any improvement have had repeat distension. Postoperative cystometry was done in 36 cases. Only in 7 patients (19 per cent) did the unstable pattern convert to stable bladder function. The results of symptomatic assessment were dependent upon the moment of followup, since many patients had relapses. After a 3-month followup 17 per cent of the patients were cured and 19 per cent noticed some symptomatic improvement. A subjective evaluation after 1 year revealed 11 per cent cured and 21 per cent improved. The results after a second distension were even less than after prior distension. Complications included a ruptured bladder in 6 female subjects (8 per cent), 2 patients were temporarily unable to void spontaneously, while 1 patient still had atony of the bladder after 6 months of followup. Bladder distension appears to be of limited or doubtful value in the treatment of the patient with an unstable bladder. Moreover, when the high incidence of complications is considered we do not recommend this therapy to be pursued further.

Cold knife optical urethrotomy.

Cold knife optical urethrotomy with the Sachse urethrotome was used in 44 patients with urethral strictures. Appraisal if the results, after a mean follow-up of fourteen months, showed 77.3 per cent success rate regarding urine flow rates and 81.8 per cent regarding subjective response of the patient.

Transection of the bladder as a method of treatment in adult enuresis nocturna.

Ten adults with enuresis were treated by bladder transection. Urodynamic assessment was carried out before and after the operation. No significant urodynamic changes were recorded following transection. However, good results were obtained in 5 cases and improvement in 2.

[The place of surgery in the treatment of testicular tumors other than seminoma (author's transl)]. / Het aandeel van de chirurgie bij de behandeling van niet-seminomateuze testistumoren.

Surgery plays an important part in the treatment of non seminomatous testicular tumors. An oncologically correct technique of orchidectomy is the first essential if the better prognosis of these tumors, noted in the past decade, is to be further improved. The testis should be removed through an inguinal approach. Radical retroperitoneal lymphadenectomy is gaining more favour at the present time. This operation, routinely performed in the US. is being performed more frequently in Europe. The justification for this major operation with a definite morbidity is to be found in the better survival rate achieved in patients undergoing surgery as compared to that achieved using other treatment modalities. A description of the operative technique delineates the magnitude of the surgery but also shows that, working methodically the operation is feasible.

Anterior vaginal repair, cause of troublesome voiding disorders?

Clinical experience and urodynamic observations in 85 female patients with voiding disorders after anterior vaginal repair are presented. Iatrogenic or persistent urinary stress incontinence (72%), irritable trigone syndrome (48%), bladder outlet obstruction (40%), unstable bladder (25%) and recurrent cystitis (23.5%) were the most frequent findings. Also, 5 cases of urogenital fistula and 2 cases of loss of a great part of the urethra were noted. Attempts to cure these complications with different pharmacologic agents and/or surgical methods were often disappointing.

Uretero-neo-cystostomy in renal transplantation. Is an antireflux mechanism mandatory?

We report a retrospective analysis of 120 kidney transplantations in which a simple end-to-end ureteric implantation in the bladder without antireflux mechanism was made. From this study no greater incidence of vesico-ureteric reflux could be demonstrated and, even when present, reflux neither interfered with graft function nor caused an increased incidence of recurrent urinary tract infections. The incidence of other urological complications (leakage, obstruction) being equal, this very simple technique yielded in our hands the best results and we recommend its use in kidney transplantation.

Has bromocriptine a place in the treatment of the unstable bladder?

A clinical study of bromocriptine in the treatment of 18 patients with an unstable bladder is reported. All patients had previously received drug therapy and/or vesical distension, without success. Ten of the 18 patients had side-effects, and 2 of these did not complete the study. Only 2 patients noted moderate improvement in their urinary symptoms. Bromocriptine appears to be of little value in the treatment of the unstable bladder.

Epidermoid cyst of the testis.

Surgical exploration of a mass in the right testis revealed an epidermoid cyst. In the literature some controversy exists on surgical treatment of this lesion. Orchiectomy seems to be recommended although several patients treated by simple enucleation had an uneventful follow-up from 6 to 15 years.

Intrarenal arteriovenous fistula following renal allograft biopsy.

Arteriovenous fistulae in renal allograft are rarely mentioned in papers dealing with vascular complications after renal transplantations. 2 cases of such central fistulae are reported. In our patients the fistulae remained asymptomatic and were incidentally detected, so that neither surgical nor medical measures had to be taken. Reviewing the rather scarce literature on this subject the etiology, symptomatology, prevention and therapy of these fistulae are discussed.