Devastating complications after brachytherapy in the treatment of prostate adenocarcinoma.

OBJECTIVE: To report a retrospective chart review of patients who developed recto-urethral fistula (RUF) or several bladder neck contracture (BNC) recurrences after brachytherapy for treating localized prostate cancer. PATIENTS AND METHODS: In the past 3 years 18 patients with devastating complications after prostate brachytherapy were referred to our centre (RUF in 11, BNC in seven; mean age 63 years, range 60-81). All patients with RUF initially underwent diverting colostomy (six cystoprostatectomy with closure of the fistula, omental interposition and urinary diversion; one prostatectomy, bladder neck closure, fistula closure with omentum flap and continent vesicostomy). Three patients had the fistula closed with gracilis muscle flap using the York-Mason approach (one had a bladder neck closure and suprapubic tube; one elected to have no treatment). All patients with BNC had received three or more procedures to resect or incise their contracture. Four had diversion with a catheterizable segment, two used an indwelling Foley catheter and one uses intermittent catheterization. RESULTS: All six patients who had cystoprostatectomy with urinary diversion have had no recurrence of their RUF. All three treated with the York-Mason procedure healed well. One developed recurrent prostate adenocarcinoma and two a secondary neoplasia in the prostate or rectum (leiomyosarcoma and neuroendocrine, respectively). The enterocystoplasty patient developed sepsis after colostomy reversal and subsequently died. In those patients with BNC, the four who underwent urinary diversion fared well; two tolerate the indwelling catheter poorly, and the seventh uses intermittent catheterization with occasional difficulty. CONCLUSIONS: Brachytherapy with or without external irradiation can be associated with severe complications. RUF managed with aggressive anterior pelvic exenteration and urinary diversion can be associated with excellent results. The York-Mason procedure in patients with an adequate urinary continence mechanism and bladder dynamics may provide good functional results. The presence of a secondary malignancy in patients deserves further investigation. Many recurrences of a BNC tend be refractory to transurethral resection/incision; indwelling catheters are then poorly tolerated and patients may require a major reconstructive procedure.

Evaluation and management of mechanical dysfunction in continent colonic urinary reservoirs.

PURPOSE: We analyze a group of patients who presented with mechanical dysfunction of the reservoir and/or efferent limb of a continent colonic urinary diversion, and establish an evaluation and management algorithm. MATERIALS AND METHODS: A total of 16 patients with a mean age of 58 years and 1 or more symptoms related to continent colonic urinary diversion were evaluated. Presenting symptomatology included difficult catheterization in 8 cases (50%), disabling incontinence in 8 (50%) and recurrent urinary tract infections in 6 (37.5%). All patients had normal, nonobstructed, nonrefluxing upper tracts and none presented with stone disease. Urological evaluation consisted of catheterization, fluoroscopy and urography of the pouch, retrograde urography of the external limb and urodynamics (enterocystometrogram and outlet pressure profilometry). RESULTS: Of the 8 patients with difficulty with catheterization 4 had stomal stenosis, 2 had an elongated and redundant external limb, and 2 had a false passage. Diagnosis was established by the inability to catheterize, fluoroscopy of the pouch and retrograde urography. Disabling incontinence occurred in 8 patients, including 7 who presented with an incompetent outlet and 2 with high pressure intestinal contractions of the reservoir. The aforementioned abnormalities were diagnosed by a combination of retrograde urography, urography of the pouch and urodynamics. Recurrent symptomatic urinary infections were observed in 5 patients of the previous groups and in another with an hourglass reservoir, which was primarily diagnosed by urography of the pouch. Surgical correction in 15 patients included outlet reinforcement, reservoir revision, stomal or external limb revision and conversion to a urinary conduit. Surgical treatment was successful in 14 of 15 patients (93%). CONCLUSIONS: Catheterization difficulty requires retrograde urography to define possible anatomical abnormalities (false passage, conduit elongation) if catheterization and fluoroscopy of the pouch do not demonstrate stomal stenosis. Urinary incontinence benefits from enterocystometry and outlet pressure measurement to determine reservoir and external limb function. Recurrent urinary tract infections not related to ureteral obstruction or reflux requires fluoroscopy of the pouch and external limb to determine abnormalities in patients with detubularization and localization of areas of urine pooling.

Evaluation of flap valve as an alternative continence mechanism in the Florida pouch.

OBJECTIVES: To evaluate urodynamic findings in a successful flap valve (FV) continence mechanism in association with a continent colonic urinary reservoir (Florida pouch) and to compare the urodynamic findings of the FV mechanism with the doubly plicated (PI) standard anti-incontinence segment in the same reservoir. METHODS: Thirteen patients who successfully received the Florida pouch between 1988 and 1996 agreed to undergo urodynamic evaluation as part of a pilot study. Eight patients had a PI continence mechanism and a mean time from surgery of 51 months; 5 had a FV continence mechanism and a mean time from surgery of 14 months. Enterocystometry was performed with a trans-stomal Bard triple channel 7F catheter. Volume and pressure at first desire to empty (VFDE, PFDE), as well as maximal enterocystometric capacity and pressure (VMEC, PMEC), were recorded. Maximal outlet pressure (MOP) was recorded using the catheter withdrawal technique. RESULTS: PI and FV groups demonstrated the following mean values respectively: VFDE, 692.7 and 403 mL; PFDE, 19.5 and 19.2 cm H2O; VMEC, 876.5 and 515 mL; PMEC, 25.9 and 24.6 cm H2O; MOP, 57.5 and 51.2 cm H2O (reservoir empty) and 50.5 and 52.6 cm H2O (reservoir full); and functional length of outlet, 24.3 and 24.6 cm. MOP measurement demonstrated greater variability in the PI than in the FV group. CONCLUSIONS: Urodynamic comparison of these mechanisms reveals that MOP measurement was closer to the mean among FV than PI patients. In addition, the mean VFDE (692.7 mL for PI versus 403 mL for FV, P < 0.05) and the mean VMEC (876.5 mL for PI versus 515 mL for FV, P < 0.05) were significantly less in the FV group. Lower VMEC and less variability in MOP indicate that continence may be more dependent on MOP in the FV mechanism. A longer follow-up time and a larger number of patients will be of assistance in clarifying these findings.

Penile prosthesis insertion with corporeal reconstruction with synthetic vascular graft material.

Difficulty with penile prosthesis insertion may be encountered in patients with severe cavernous scarring or tunica albuginea deficiencies. Eleven patients who underwent penile prosthesis implantation required simultaneous corporeal reconstruction due to prior prosthesis infection and/or erosion in 6, priapism in 2 and Peyronie's disease in 1. One patient underwent prior neophallus construction with a tubularized abdominal wall flap for gender reassignment and 1 had congenitally deficient corporeal bodies. In 4 patients previous additional attempts at prosthesis replacement were unsuccessful. The reconstruction techniques included exposure of the corpora usually through a ventral midline incision and repair with synthetic vascular graft material. Accessory sub-coronal incisions were used when the disease was localized to the distal corpora. Six patients required reconstruction of more than half of the corporeal lengths bilaterally and in 5 smaller portions were repaired. Two patients received a semirigid and 9 an inflatable implant. Mean followup was 46 months (range 5 to 81). One patient required early reexploration for separation of the graft from the tunica and 2 required late surgical revision for distal tip divergence. Healing has been excellent and prosthesis function satisfactory in all patients. Infection, erosion and mechanical failure have not occurred. Penile prosthesis insertion with corporeal reconstruction using synthetic graft material is possible in these cases with acceptable morbidity rates and satisfactory erectile function.

Surgical repair of stress urinary incontinence.

Genuine SUI is defined as that associated with hypermobility of the urethra and bladder neck. Accurate history-taking and physical examination allows for proper diagnoses and subsequent therapy in the majority of cases. Patients in whom bladder instability or intrinsic sphincteric deficiency are suspected may benefit from urodynamic testing. Regardless of method, all surgical procedures used to treat genuine SUI aim at supporting the bladder within the pelvic cavity. This allows for adequate compression of the urethra by those intra-abdominal forces that would otherwise only act to expel urine through a compromised outlet. The operation of choice should be determined by its ability to provide this proper positioning over the long-term with the least morbid approach. Comparison of the various procedures is hampered by the lack of objective long-term data. For a vaginal approach, we prefer either the modified Pereyra as developed by Raz, or the placement of a sling beneath the bladder neck to provide firm, long-term support. For those patients who have not had prior abdominal surgery, the laparoscopic approach is an exciting method to obtain accurate dissection and fixation of the bladder neck and urethra. With careful evaluation and performance of these multiple techniques, therapy can be individualized for patients with excellent results.

Diuretic Doppler sonography following successful repair of renal obstruction in children.

The measurement of resistive index (RI = [peak systolic velocity--end diastolic velocity]/peak systolic velocity) by Doppler sonography has demonstrated variable reliability as an indicator of pediatric urinary obstruction. By modifying Doppler studies with the addition of furosemide (diuretic Doppler sonography), we previously found significant differences between 10 nonobstructed and 10 obstructed kidneys in children (median age 7 months). The obstructed kidneys have since undergone surgical repair, and postoperative reevaluation has been performed by diuretic Doppler sonography and diuretic renography. Diuretic Doppler sonography was performed on well hydrated catheterized patients, with resistive index measurement of the renal interlobar and arcuate arteries obtained before and 10 minutes after 1 mg./kg. furosemide infusion. Following surgical repair of obstruction all 10 kidneys had stable glomerular filtration rate with improved pelvic emptying times as demonstrated by half-time. Of 6 kidneys evaluated by diuretic Doppler sonography before 3 months 2 had resistive index levels greater than 75. Of the 9 kidneys measured at 3 months or more postoperatively all had resistive index values of less than 75, even after furosemide infusion (5 kidneys underwent repeat evaluation). In our study the previously demonstrated post-diuretic elevation of resistive index in pediatric urinary obstruction was eventually reversed following surgical repair. Diuretic Doppler sonography appears to be a promising noninvasive method for evaluating pediatric hydronephrosis, providing an alternative physiological parameter with which to measure renal obstruction.

Diuretic Doppler sonography in postnatal hydronephrosis.

Renal resistive indexes were measured by Doppler sonography in 12 children undergoing other standard diagnostic studies to evaluate hydronephrosis. Measurement of renal resistive indexes was modified by prior placement of a bladder catheter, oral hydration and administration of 1 mg./kg. furosemide after baseline measurement. Renal resistive indexes were again measured at 10 and 30 minutes after diuretic. While diuretic administration had no measurable influence on 10 nonobstructed kidneys, the elevated 10-minute post-diuretic renal resistive indexes recorded in 10 obstructed kidneys differed significantly from the indexes recorded in the nonobstructed group (p less than 0.001). The highest elevations in renal resistive indexes were recorded in nonpaired kidneys, which included 7 of the 10 kidneys in the obstructed group. In the 3 unilaterally obstructed kidneys the 10-minute post-diuretic renal resistive indexes did not differ significantly. However, renal resistive indexes in these kidneys increased at least 15% over baseline readings after diuretic administration. Diuretic Doppler sonography appears to be another useful method for differentiating functionally significant hydronephrosis from nonobstructive hydronephrosis in children.