Artificial urinary sphincter erosion: the role of corticosteroids in an unusual presentation.

Glucocorticosteroid use has proven beneficial for the management of many medical conditions. Unfortunately its anti-inflammatory properties also profoundly affect many aspects of wound healing. We present a case of an unusual presentation of an artificial urinary sphincter erosion in a patient treated with chronic high-dose steroids.

Incontinent ileovesicostomy: Long-term outcomes and complications.

AIMS: Incontinent ileovesicostomy was popularized in the mid-1990s as a surgical option for patients with neurogenic voiding dysfunction who lack the dexterity to perform clean catheterization. There are several case series in the literature, but few studies look at the long-term outcomes and complications associated with this procedure. METHODS: We review the outcomes of 12 patients who underwent incontinent ileovesicostomy for management of neurogenic voiding dysfunction since its introduction at our institution in 1998. We discuss, specifically, the preoperative and postoperative problems encountered as well as complications pertaining to ileovesicostomy itself. RESULTS: At an average of 5 1/2 years follow-up, all 12 patients who underwent incontinent ileovesicostomy have experienced some form of urinary tract problem either associated with the ileovesicostomy or with their underlying neurogenic voiding dysfunction. After ileovesicostomy, seven of 12 patients (58%) have been able to reduce antibiotic usage and/or hospital admission related to chronic upper tract infection. Two patients (17%) have subsequently been converted to ileal conduit. CONCLUSIONS: Incontinent ileovesicostomy is a useful option for patients with lower urinary tract dysfunction who are unable to perform clean intermittent catheterization. It should be reserved for those patients who have exhausted less invasive therapy and in whom quality of life benefits cannot be achieved without diversion. Experience shows that there are no absolute indications for this procedure. The clinician and the patient must be aware of the importance of continued surveillance after this procedure for problems related to neurogenic voiding dysfunction and/or the ileovesicostomy itself.

Female urethral stricture disease.

Female urethral stricture disease is a rare entity. The most common etiologies are traumatic injury, iatrogenic injury, and inflammatory disease resulting in periurethral fibrosis. Hallmark symptoms are frequency and urgency, and may also be dysuria, hesitancy, slow stream, incontinence, and recurrent urinary tract infections. Female bladder outlet obstruction is a difficult entity to define, and the subset representing stricture disease may also be elusive. The diagnosis of female urethral stricture disease is usually based on symptoms, meatal appearance, and difficult instrumentation of the patient. Other testing, such as urodynamics, voiding urography, or cystoscopy, may be helpful. Treatment options are conservative management with dilatation, endoscopic treatment, or open repair with various tissue flaps or grafts. Considerable controversy surrounds the efficacy of urethral dilatation in women with voiding dysfunction.

Self-reported urinary continence outcomes for repeat midurethral synthetic sling placement.

OBJECTIVE: To evaluate our experience with tension-free transvaginal tape (TVT) placement for the management of stress urinary incontinence (SUI) in women who had previously undergone a failed midurethral synthetic sling (MUS) procedure. MATERIALS AND METHODS: Ten women underwent retropubic TVT insertion for continued or recurrent SUI following a prior MUS procedure. No attempt was made to remove the previously placed sling at the time of surgery. A retrospective chart review was performed to obtain perioperative and follow-up patient information. Post-operatively, each patient completed a mailed incontinence questionnaire to assess self-reported urinary continence outcomes. RESULTS: All 10 women were available for follow-up at a mean period of 16 months (range 6 to 33). Four of the 10 patients achieved complete continence, and another three patients reported significantly improved continence and quality of life. Three women stated that their continence did not improve. CONCLUSIONS: TVT placement may be a viable option for the management of women with persistent or recurrent SUI following an initial MUS procedure.

Self-reported urinary continence outcomes for repeat midurethral synthetic sling placement

OBJECTIVE: To evaluate our experience with tension-free transvaginal tape (TVT) placement for the management of stress urinary incontinence (SUI) in women who had previously undergone a failed midurethral synthetic sling (MUS) procedure. MATERIALS AND METHODS: Ten women underwent retropubic TVT insertion for continued or recurrent SUI following a prior MUS procedure. No attempt was made to remove the previously placed sling at the time of surgery. A retrospective chart review was performed to obtain perioperative and follow-up patient information. Post-operatively, each patient completed a mailed incontinence questionnaire to assess self-reported urinary continence outcomes. RESULTS: All 10 women were available for follow-up at a mean period of 16 months (range 6 to 33). Four of the 10 patients achieved complete continence, and another three patients reported significantly improved continence and quality of life. Three women stated that their continence did not improve. CONCLUSIONS: TVT placement may be a viable option for the management of women with persistent or recurrent SUI following an initial MUS procedure.

Limited anterior cystotomy: a useful alternative to the vaginal approach for vesicovaginal fistula repair.

In developed nations, vesicovaginal fistulas are most commonly encountered as a complication after gynecologic surgery. Most fistulas are corrected using a transvaginal approach; however, complicated cases often require intraabdominal repair. A novel abdominal approach is described, using a small anterior cystotomy and omental pedicle interposition.

Renal cortical deterioration in children with spinal dysraphism: analysis of risk factors.

BACKGROUND/OBJECTIVE: Because hydronephrosis and reflux are reversible, we believe cortical loss represents true renal deterioration in children with spinal dysraphism. Our goal was to better define risk factors for cortical loss. METHODS: After institutional review board approval, we reviewed the medical records of 272 children with spinal dysraphism. The following factors were evaluated: age, sex, renal and bladder imaging, urodynamic parameters, medications, catheterization program, continence, infections, and surgical history. Renal cortical loss was defined by scarring or a differential function greater than 15% using a nuclear scan. Univariate and multivariate logistic regression models were fitted to test the associations of specific variables with cortical loss. RESULTS: Renal cortical loss was found in 41% of children with high-grade reflux vs. 2% of children without reflux. Univariate analysis showed only high-grade reflux and female sex to be independent risk factors. Controlling for age and sex, reflux and initiation of catheterization after 1 year of age are significant risk factors. High bladder pressure and hydronephrosis in the absence of reflux were not associated with cortical loss. Multivariate analysis showed that girls with reflux have a 55-fold increased risk of cortical loss. CONCLUSION: By limiting the definition of renal deterioration to cortical loss, we identified relevant risk factors: reflux, female sex, and delayed initiation of clean intermittent catheterization. We have also discounted other suspected risk factors: hydronephrosis and elevated bladder pressure. Rather than continuing our focus on hydronephrosis and urodynamics, we believe more research and management debate should be afforded to females with reflux.

Umbilical stomal stenosis: a simple surgical revision technique.

Stenosis of stomas sited at the umbilicus presents a surgical challenge. A paucity of literature exists on the surgical management of this problem, despite its relatively frequent occurrence. A simple technique is described, using scar incision and advancement of an umbilical skin flap, to accomplish stomal revision.

Artificial urinary sphincter placement in elderly men.

OBJECTIVES: To evaluate the outcomes of primary artificial urinary sphincter (AUS) placement for the treatment of postprostatectomy stress urinary incontinence in patients aged 75 years or older at surgery. METHODS: From September 1987 through June 2005, 33 men aged 75 years or older underwent AUS insertion for postprostatectomy stress urinary incontinence. Through retrospective chart review and personal/family interview, the patients' outcomes with regard to continence, complications, and the need to deactivate the AUS for medical or social reasons were determined. RESULTS: Four patients were lost to follow-up and were excluded from the analysis. The mean patient age was 77.6 years (range 75 to 83). The average follow-up was 5.0 years (range 1 to 11). After AUS insertion, the mean pad use improved from 6.7 (range 3 to 10) to 0.8 (range 0 to 2) per day. Overall, 16 (55%) of 29 men reported no complications. AUS revision was necessary in 4 men (14%), and sphincter removal in 4 (14%). Six men (21%) required deactivation of the implant because of poor overall health an average of 47 months after placement. The "success" rate improved to 72% (21 of 29 men) when cuff deactivation without revision or removal was not considered a complication. CONCLUSIONS: In our study, elderly men did well after AUS placement for postprostatectomy stress urinary incontinence. The procedure should not be withheld solely on the basis of the age of the patient.

Early outcomes of mid-urethral slings for female stress urinary incontinence stratified by valsalva leak point pressure.

AIMS: To assess the early results of mid-urethral slings placed via the transobturator approach (TVT-O) for stress urinary incontinence (SUI) in women with high (>60 cm H(2)O) and low (60 cm H(2)O) or low (60. CONCLUSIONS: With limited follow up, TVT-O appears to be a safe and effective surgical treatment for female SUI producing excellent results in patients with VLPP >60 cm/H(2)0. Patients with low VLPP may consider conventional, retropubic mid-urethral slings or other procedures as treatment for SUI.

Transverse myelitis in children: long-term urological outcomes.

PURPOSE: Urological complications are well documented in patients with traumatic spinal cord injury. We examined the long-term urological outcomes in a large population of children affected by transverse myelitis. MATERIALS AND METHODS: We retrospectively reviewed the medical history, imaging studies and urodynamic findings in 22 children with transverse myelitis. Age at disease onset ranged from 3 months to 18 years (average 8.8 years). RESULTS: At a mean followup of 7.1 years 19 patients (86%) had persistent bladder dysfunction and 17 (77%) had persistent bowel dysfunction. Initial evaluation at least 1 month after disease onset revealed detrusor overactivity in 59% of patients, detrusor external sphincter dyssynergia in 41%, low compliance in 47% and detrusor leak point pressure greater than 40 cm water in 12%. Functional motor recovery and absence of lower extremity spasticity did not reflect normal urodynamic findings. Of the 19 patients with imaging available for review 5 (26%) had upper tract changes. One patient had development of chronic renal insufficiency. Low compliance (p = 0.02) and upper tract changes (p = 0.1) were more frequent in patients who started clean intermittent catheterization more than 2 years after disease onset. CONCLUSIONS: Persistent bowel and bladder dysfunction is common in transverse myelitis. Urodynamic abnormalities may be present despite normal neurological examination and absence of urinary symptoms. All pediatric patients with transverse myelitis require baseline renal ultrasound and urodynamic evaluation to guide treatment. Early institution of clean intermittent catheterization appears to preserve bladder compliance and decrease upper tract disease, and should be instituted at disease onset.

Vesicostomy revisited: the best treatment for the hostile bladder in myelodysplastic children?

OBJECTIVE: To evaluate the effects of vesicostomy on the urinary tract of myelodysplastic children in whom conservative bladder management with clean intermittent catheterization (CIC) has failed to preserve upper and lower urinary tract function. PATIENTS AND METHODS: Sixteen children with myelodysplasia underwent vesicostomy. Indications included worsening hydronephrosis, vesico-ureteric reflux (VUR), recurrent urinary tract infections (UTIs), and increasing renal insufficiency despite CIC and/or difficulty with CIC. The mean (range) age at vesicostomy was 36.5 (9-82) months and the follow-up 7.4 (2-16) years. RESULTS: Hydronephrosis resolved or improved in 12 of 14 children, the incidence of UTI decreased to one or fewer per year in 10, VUR resolved or improved in nine, and renal function improved or stabilized in six of seven patients. One patient initially presented with renal insufficiency and subsequently required dialysis despite vesicostomy. Complications occurred in three of 15 children, and included stomal stenosis and bladder calculi. The vesicostomy was closed in six patients after a mean of 4.4 (1.5-9) years. Four of these patients required concomitant bladder augmentation. CONCLUSIONS: Vesicostomy in myelodysplastic children is effective in preventing and/or resolving the deleterious consequences of a 'hostile' bladder. The procedure is uncomplicated, well tolerated, reversible and should be considered in managing children in whom conservative management by CIC has failed.

An assessment of the use of a continent catheterizable stoma in female tetraplegics.

OBJECTIVES: To evaluate the success of a continent catheterizable stoma in females with cervical spinal cord injury which resulted in neurogenic bladder dysfunction, the management of which may require clean intermittent catheterization despite altered hand function. PATIENTS AND METHODS: Six female tetraplegic patients with a lesion at C7 or above (age range 12-22 years) had a continent catheterizable abdominal stoma formed as part of their bladder management. As an objective measure of effectiveness, the time to complete catheterization was assessed before and after surgery. A quality-of-life survey at a mean (range) of 44 (6-90) months was also evaluated. RESULTS: All six patients can catheterize while in their wheelchair. The mean (range) time required for catheterization decreased from 27 (10-40) to 7.8 (1-15) min after surgery. All six reported a significant improvement in continence, body image, independence, convenience, time saving and satisfaction. CONCLUSION: Constructing a continent catheterizable stoma is a valuable option in selected tetraplegic patients.

Spinal cord injury in children: long-term urodynamic and urological outcomes.

PURPOSE: Urological complications in adults with spinal cord injuries (SCIs) are well documented. We sought to determine the effect of SCI on the developing bladder and kidneys in the child. MATERIALS AND METHODS: We retrospectively reviewed cases of SCI with 1-year minimum followup. We identified 42 children with an average age at injury of 5.3 years (range 1 day to 14 years). Mean followup was 5.5 years (range 1 to 15.5). Videourodynamics, sonograms, infection, medications and continence were reviewed. Safe bladder capacity was defined as the pressure specific volume at 40 cm water or less. Patients were divided into 3 groups based on level of injury-cervical (10), thoracic (26) and lumbar (6). RESULTS: Bladder management included clean intermittent catheterization in 40 of 42 patients and antispasmodics in 37. No patient had reflux, hydronephrosis or renal scarring. In the cervical group safe bladder capacity was less than the expected capacity in 80% of patients but all patients undergoing multiple urodynamics had increasing capacity with time. In the thoracic group 58% of patients had a safe bladder capacity less than expected and 76% of those undergoing multiple urodynamics had increasing capacity. In the lumbar group 50% of patients had a safe bladder capacity less than expected and 67% of those undergoing multiple urodynamics had increasing capacity. CONCLUSIONS: To our knowledge this is the largest and longest urological study of young children with SCI. Early clean intermittent catheterization and use of anticholinergics appear to prevent upper tract deterioration, improve continence and decrease infections. Serial urodynamics confirm increasing safe capacity with growth in most children. Close followup is necessary as bladder characteristics may change with time.

Colonic tubes for the antegrade continence enema: comparison of surgical technique.

PURPOSE: The Malone antegrade continence enema has revolutionized the management of intractable fecal incontinence and constipation. When the appendix is absent, surgical options are limited. Small series with short-term followup have demonstrated the feasibility but not the reliability of the continent colonic tube. We present our experience with a lateral based colonic tube. We also compared lateral based colonic tubes to medial based tubes. MATERIALS AND METHODS: The medical records of patients treated with a continent colonic tube for intractable fecal incontinence were reviewed. We identified 8 patients who underwent the procedure between July 2000 and February 2003. The literature was reviewed to compare lateral vs medial based tubes. RESULTS: Average followup was 28 months (range 10 to 41). Stomal stenosis developed in 4 patients (50%) within 3 to 6 months of surgery. Passive dilation at the clinic corrected the problem in 3 patients and 1 required operative stomal revision. All 8 patients reported almost complete relief of rectal incontinence and constipation. A literature review demonstrated a significantly higher rate of stomal stenosis in lateral vs medial based colonic tubes (40% vs 12%). CONCLUSIONS: The continent colonic tube is a safe and effective alternative in patients with refractory fecal incontinence and constipation who do not have an available appendix. These results appear durable during the described period. We believe that this technique is an alternative to the cecostomy button and it should be offered to suitable patients. The lateral based colonic tube appears to have a higher rate of stomal stenosis than medial based colonic tubes, which may be attributed to the local blood supply of the colon.