The application of laser techniques to vasectomy reversal surgery.

OBJECTIVE: A review of the application of laser technology to vasectomy reversal surgery. SUMMARY BACKGROUND: Modern methods of vasectomy reversal that employ microsurgical techniques have resulted in a high reported success rate. However, the procedure is tedious and time consuming. Laser technology offers the possibility of simplifying the procedure and reducing operative time, with possibly even better results. CONCLUSIONS: Application of lasers in vasovasostomy for vasectomy reversal is still in its early development. Several animal and human studies have been conducted with mixed results. Contained clinical trials will be necessary to prove the benefit of the laser in this surgical setting.

Results of laser tissue soldering in vasovasostomy and epididymovasostomy: experience in the rat animal model.

UNLABELLED: The use of microsurgical techniques (vasovasostomy and epididymovasostomy) for vasectomy reversal has now enabled surgeons to perform both procedures with certainly acceptable success rates. However, these operations are technically demanding and require special training in microsurgery. PURPOSE: A new method of performing these procedures using laser tissue soldering is described and results are evaluated. Laser tissue soldering is different from laser welding in that it involves the laser activation of a protein solder with a dye specific for the specific wavelength of laser light; therefore, surrounding tissue is not affected by the laser. MATERIALS AND METHODS: Ten rats underwent bilateral vasovasostomy and eleven underwent bilateral epididymovasostomy. In each rat, a sutured anastomosis was performed on one side while laser tissue soldering was performed on the other. Animals were sacrificed after one month and anastomoses were evaluated for patency and presence of sperm granulomas. Histologic analysis was also performed. RESULTS: Patency rates were 8/10 (80%) for sutured vasovasostomy versus 9/10 (90%) for the laser technique. Epididymovasostomy patency rates were 8/11 (73%) for sutured versus 9/11 (82%) for the laser technique. Mean operative times were significantly shorter for lasered anastomoses when compared to controls. The frequency of granuloma formation did not significantly differ between laser and control groups. CONCLUSIONS: Laser tissue soldering resulted in similar patency when compared to a conventional 2 layered sutured anastomosis while decreasing operative time. In addition, since fewer sutures are placed, the laser method is less technically demanding.

Accuracy of semen counting chambers as determined by the use of latex beads.

OBJECTIVE: To assess the accuracy of the Hemacytometer (Hausser Scientific, Horsham, PA), Makler (Sefi-Medical Instrument, Haifa, Israel), Cell-VU (Millennium Sciences Inc., New York, NY), and Micro-Cell chambers (Conception Technologies, San Diego, CA) counting chambers. DESIGN: A solution containing a known concentration of latex beads was used as the standard to perform counts on the four different counting chambers. MAIN OUTCOME MEASURES: Bead counts for the four different chambers were compared with the bead counts of the standard solution. Variability within chambers also was determined. RESULTS: Mean bead concentrations for both the Cell-VU and Micro-Cell chambers were consistently similar to the bead concentration of the standard solution. Both the hemacytometer and the Makler chambers overestimated the actual bead concentration of the standard solution by as much as 50% and revealed significant interchamber variability. CONCLUSIONS: Our data revealed marked differences in the accuracy and reliability of the different counting chambers tested and emphasized the need for standardization and quality control of laboratory procedures.

The ileal ureter neobladder is associated with a high success and a low complication rate.

PURPOSE: Several different methods to construct a bladder substitute after cystectomy have been described. We evaluated our experience with the Studer ileal ureter neobladder during the last 5 years. MATERIALS AND METHODS: We reviewed retrospectively the results in 32 patients who underwent construction of a slightly modified ileal neobladder from that originally described. Mean followup was 25 months (range 6 to 68). RESULTS: Patients experienced few complications and only 1 required reoperation. Daytime and nighttime continence rates were 94 and 74%, respectively. One patient sustained a ureteral stricture resulting in hydronephrosis (1 of 64 renal units). CONCLUSIONS: The results reveal the ileal neobladder to be an easily constructed pouch with a low complication rate, and a high success rate in regard to continence and the establishment of adequate capacity at low pressure. Within the study period upper tract preservation was excellent. However, a 10 to 15-year followup is indicated to confirm our initial results.

Improved continence with tubularized bladder neck reconstruction following radical retropubic prostatectomy.

OBJECTIVES: Incontinence after radical retropubic prostatectomy remains a common problem. This study determines the efficacy of a tubularized bladder neck reconstruction for improving the time to continence and also the total rate of continence following radical retropubic prostatectomy. METHODS: Tubularized bladder neck reconstruction was performed in 29 patients by creating a trapezoidal-shaped anterior bladder flap and performing tubularization over a 30 F red rubber catheter prior to urethrovesical anastomosis. This flap measured approximately 5 cm at its base and 3 cm at its apex. Continence rates of these patients were compared to results of 30 randomly selected patients in whom a bladder flap was not used. RESULTS: Seven of 29 (24%) patients with tubularized bladder neck reconstruction were fully continent within 24 hours of catheter removal and 27 of 29 (93%) were fully continent by 3 months follow-up. An additional patient was continent at 6 months for a total continence rate of 28 of 29 (97%). These continence rates were significantly higher at all follow-up times than for patients in whom an anterior bladder flap was not used. One patient developed a bladder neck contracture and was successfully managed with visual urethrotomy. He is fully continent. CONCLUSIONS: Tubularized bladder neck reconstruction following radical prostatectomy may both increase the successful achievement of postoperative continence and decrease the time needed to achieve full continence without increasing morbidity.

Transperineal prostate needle biopsy guided by transurethral ultrasound in patients without a rectum.

OBJECTIVES: Patients with elevated prostate-specific antigen (PSA) and no access to the rectum present a diagnostic challenge to the urologist. This study was undertaken to determine the efficacy of transperineal prostate biopsy using transurethral ultrasound guidance for the detection of prostate cancer. METHODS: Five men status post either total colectomy or abdominoperineal resection (age range: 58 to 73 years, mean age 65.8 years) were referred to us for the evaluation of an elevated PSA (range: 5.6 to 21.4 ng/dL, mean 16.1 ng/dL). Seven procedures were performed utilizing transurethral ultrasound to guide transperineal prostate biopsies in these men. RESULTS: Biopsy results revealed benign prostatic hyperplasia in 4 procedures and prostate cancer in 3 procedures. CONCLUSIONS: Transurethral ultrasound enables the practitioner to perform accurate sonographic assessment and precise biopsy of the prostate in such patients.

High incidence of asymptomatic brain lesions in metastatic renal cell carcinoma.

The metastatic pattern of renal cell carcinoma has been well established. Studies have revealed a relatively high incidence of spread to lung, liver, bone and brain. A retrospective review of the records of ninety patients with metastatic renal cell carcinoma showed seven to have evidence of brain metastases. Six of the seven were asymptomatic at time of diagnosis. This study shows a significant incidence of asymptomatic brain metastases in patients with metastatic renal cell carcinoma. Subsequent to our chart review, an additional two patients have presented to our institution with asymptomatic brain lesions from metastatic renal cell carcinoma.

Vaginal reconstruction in children and adults.

There are many different approaches to vaginal reconstruction. Methods include simple dilation, skin graft techniques, amnion graft and use of intestinal segments for vaginal replacement. When dealing with vaginal aplasia, sigmoid vaginoplasty seems to have a clear advantage with an excellent surgical success rate and a low rate of complications.

Persistence or recurrence of symptoms after transurethral resection of the prostate: a urodynamic assessment.

Approximately 15 to 20% of patients who undergo transurethral resection of the prostate for benign prostatic hyperplasia have persistent or recurrent voiding symptoms requiring further therapy. To elucidate the etiology of these voiding abnormalities, the urodynamic findings of 129 consecutive men (mean age 72 years) with post-transurethral resection voiding symptoms were retrospectively analyzed with respect to symptoms, uroflowmetry and synchronous video pressure-flow cystometry. Our findings revealed obstruction in 38% of the patients, impaired contractility in 25% and intrinsic sphincter deficiency in 8%. Among 80 patients without neurological disorders involuntary bladder contractions were detected in 50%. However, in 49 patients with neurological disorders involuntary bladder contractions were detected in 76%. This difference was statistically significant. There were 15 patients who failed 2 or more transurethral resections of the prostate, and involuntary bladder contractions were detected in 80%, obstruction in 27%, impaired contractility in 27% and sphincteric incontinence in 20%. Our study reveals residual or recurrent obstruction to be a contributing factor in less than half of all patients who fail transurethral resection of the prostate. Furthermore, patients with a concomitant neurological disorder and those who have undergone more than 1 transurethral resection of the prostate have a significantly higher incidence of involuntary bladder contractions. These results underscore the importance of obtaining complete urodynamic assessment in patients with persistent or recurrent voiding symptoms following transurethral resection of the prostate to guide appropriate therapy.

Predictive value of prostate-specific antigen density for the presence of micrometastatic carcinoma of the prostate.

OBJECTIVE: To examine the efficacy of prostate-specific antigen (PSA) density (PSAD; serum PSA/prostate volume) as a predictor of clinical outcome of patients undergoing radical retropubic prostatectomy for clinically confined prostate cancer, and its ability to determine the presence of micrometastatic disease. METHODS: A retrospective analysis of patient outcome as reflected by surgical stage and postoperative PSA was performed with respect to PSAD as determined by preoperative PSA and pathologic prostate gland volume. The findings for 107 consecutive patients who underwent radical prostatectomy are reported. RESULTS: PSAD at low values was found to be 90 percent accurate in predicting operative success or absence of micrometastatic disease. PSAD at high values was shown to be 70 percent accurate in predicting failure. CONCLUSIONS: PSAD appears to be useful in selecting patients for radical prostatectomy and may be capable of identifying patients with micrometastatic disease.

Percutaneous approach to treatment of Indiana pouch stones.

Continent urinary diversions have gained popularity during recent years in the treatment of patients who require cystectomy. The formation of urinary stones remains a possible late complication of urinary diversion. We report the successful use of a percutaneous approach to remove stones from an Indiana pouch after other methods failed.

Treatment options for upper tract transitional-cell carcinoma.

Nephroureterectomy with a bladder cuff remains the gold standard of treatment of transitional-cell carcinoma of the upper urinary tract. The natural history of the disease, specifically its multifocal nature and its propensity for local recurrence, argues for an aggressive treatment approach. Good clinical results using renal-sparing treatment of low-grade ureteral tumors reveal the feasibility of renal-sparing approaches in limited circumstances. It is likely that, with increasing use of renal-sparing therapy by endoscopic means, topical chemotherapeutic agents will take on an analogous role in the treatment of superficial disease and their role on the treatment of bladder cancer.