Endoscopic injection of glutaraldehyde cross-linked collagen for efferent limb incompetence in the Indiana reservoir.

PURPOSE: We determined the clinical applicability, safety and efficacy of endoscopically injected glutaraldehyde cross-linked collagen for the treatment of efferent limb incompetence in the incontinent Indiana urinary reservoir. MATERIALS AND METHODS: Six patients were diagnosed with incompetence of the efferent limb of the Indiana reservoir by video urodynamics. Glutaraldehyde cross-linked collagen was injected through the efferent limb at the level of the ileocecal valve. Outcome was assessed by evaluation of dryness and pouchograms. RESULTS: With a mean followup time of 26 months (range 6 to 36) after the last injection 5 of the 6 patients were cured. The remaining patient, although improved, had a small capacity and subsequently underwent ileal patch augmentation. No patient failed to improve. The mean volume of collagen was 16 ml. (range, 5 to 26). Reservoir volume increased from 150 to 400 ml. CONCLUSIONS: The use of glutaraldehyde cross-linked collagen in the treatment of the incontinent Indiana reservoir is safe and effective.

Augmentation cystoplasty.

The past 15 years have been witness to an explosion in the number of reconstructive procedures using bowel in the urinary tract. As with many concepts in medicine, one must rely on clinical experience while laboratory models and other advancements develop. This article attempts to address bladder reconstruction by enterocystoplasty, as well as the indications for augmentation, types of procedures available, and the early and late complications.

Liposarcoma of the spermatic cord: report of 6 cases and review of the literature.

Liposarcoma of the spermatic cord is rare. We report 6 cases with followup ranging from 3 months to 23 years from presentation. Initially 4 liposarcomas were well differentiated and 2 had poorly differentiated components. All 6 patients underwent radical orchiectomy and 3 required additional surgical procedures. Although most liposarcomas of the spermatic cord are of low grade and stage, the propensity for local recurrence is high. The importance of long-term followup cannot be overemphasized.

The effect of terazosin on bladder function in the spinal cord injured patient.

We prospectively studied the effect of terazosin on bladder compliance in 12 spinal cord injured patients. All study patients had demonstrated previously poor compliance despite clean intermittent catheterization and maximum anticholinergic therapy. Patients were started on 5 mg. terazosin nightly for 4 weeks. They were evaluated with a history, physical examination, symptom score, and synchronous cystoscopy and cystometry before, during and after terazosin therapy. Detrusor compliance improved in all patients during the treatment phase. The change in bladder pressure and the safe bladder volume were statistically and clinically significant. Patients also reported fewer episodes of incontinence and dysreflexia. The improvement in compliance and continence suggests that in the spinal cord injured patient terazosin may have an effect on alpha receptors in the detrusor muscle or central effects and that improved compliance is not due to decreased outlet resistance.

Acquired crossed renal ectopia secondary to a giant renal cyst.

We report a case of contralateral renal displacement due to a giant ipsilateral renal cyst. Drainage and partial excision of the cyst was followed by return of the kidney and liver to their normal positions. Incidentally, a small focus of renal cell carcinoma was found after pathologic examination of the cyst wall. The relevant literature is reviewed.

Periurethral collagen for urinary incontinence after gender reassignment surgery.

We report on 2 patients, one female and one male transsexual; in both, Type III stress urinary incontinence developed after gender reassignment surgery. Both patients were treated by periurethral injection of gluteraldehyde cross-linked collagen resulting in a marked symptomatic improvement in association with a significant rise in abdominal leak point pressures. We believe these are the first reported cases of collagen injection being used for urinary incontinence after gender reassignment surgery.

Synchronous cystoscopy and cystometry in the management of neurogenic bladder dysfunction.

The physical difficulties associated with cystoscopy and cystometry in the spinal cord injury patient led to a clinical trial of synchronous cystoscopy and cystometry in these individuals. Following a disappointing experience with external transducer methodology, a recently available fiberoptic microtransducer system was used and an effective system was developed. A total of 20 individuals with spinal cord injury underwent a standard water cystometrogram on an examination table followed by synchronous flexible cystoscopy and cystometry using a 5F fiberoptic microtransducer while seated in a chair. The results showed both pressure tracings to be clinically identical. Uninhibited contraction spikes, compliance curves and leak point pressures were essentially the same by both methods and artifact was not a problem. Given the speed, ease and reproducibility of this method, the difficulties with patient transfer for these studies have been virtually eliminated. Two urethral instrumentations have been replaced by 1. Examination room time was decreased from 60 to approximately 10 to 15 minutes with half of the required personnel. Perhaps more importantly, these occasionally problematic individuals clearly prefer this streamlined approach and patient compliance with followup has improved.

The management of meatal obstruction due to Kaposi's sarcoma of the glans penis.

Kaposi's sarcoma involving the glans penis was first described in 1902, with a subsequent report of meatal disease in 1943. With the recognition of the acquired immunodeficiency syndrome, genital lesions are becoming more frequently reported, with 51 cases cited in the literature. To date only 4 additional cases of meatal or fossa navicularis involvement have appeared in the literature, 3 of which described difficulty with micturition. We report a case of Kaposi's sarcoma involving the urethral meatus resulting in documented outflow obstruction, relieved with simple urethral serial dilation performed on an outpatient basis followed by intermittent obturation. We believe that this therapy represents a low risk, cost-effective treatment modality aimed at resolution of symptoms and alleviation of a potential source of infection in the patient with the acquired immunodeficiency syndrome.

The management of penile Mondor's phlebitis: superficial dorsal penile vein thrombosis.

Superficial dorsal penile vein thrombosis was diagnosed 8 times in 7 patients between 19 and 40 years old (mean age 27 years). All patients related the onset of the thrombosis to vigorous sexual intercourse. No other etiological medications, drugs or constricting devices were implicated. Three patients were treated acutely with anti-inflammatory medications, while 4 were managed expectantly. The mean interval to resolution of symptoms was 7 weeks. Followup ranged from 3 to 30 months (mean 11) at which time all patients noticed normal erectile function. Only 1 patient had recurrent thrombosis 3 months after the initial episode, again related to intercourse. We conclude that this is a benign self-limited condition. Anti-inflammatory agents are useful for acute discomfort but they do not affect the rate of resolution.

Pubovaginal sling for treatment of female stress urinary incontinence complicated by urethral diverticulum.

To evaluate the practicality of combining urethral diverticulectomy with a procedure for stress urinary incontinence, the records of 14 patients who underwent urethrodiverticulectomy during a 3-year period were reviewed. Noteworthy was that 10 patients (71%) had urinary incontinence as the chief complaint, while 8 (57%) had symptoms of stress urinary incontinence and underwent fluoroscopic urodynamic testing and the others had post-void dribbling. Of the latter 8 patients 7 (50%) demonstrated type II or type III stress urinary incontinence and 1 had a normal study. The 7 women then underwent transvaginal diverticulectomy with a concomitant pubovaginal sling. Of the diverticula 4 (57%) were true diverticula and 3 (43%) appeared to be pseudodiverticula or traction diverticula related to a previous urethral suspension. At 3 to 21 months (mean 17) all patients were cured of stress urinary incontinence. One patient exhibited detrusor instability postoperatively, which was ultimately treated with an Ingelman-Sundberg procedure. Postoperatively, 1 diverticulum recurred, for a recurrence rate of 14%. We conclude that the presence of a urethral diverticulum does not compromise successful repair of associated stress urinary incontinence when the pubovaginal sling procedure is used.

Treatment of renal transplant ureteral complications by percutaneous techniques.

From January 1985 to October 1990, 487 adult renal transplantations were performed at our institution. Of 16 ureteral complications noted 15 were initially managed with percutaneous nephrostomy. Of the 8 complications that occurred during the last 2 years 5 resolved on percutaneous nephrostomy and stenting, or stenting with dilation alone. We conclude that percutaneous nephrostomy is indicated as an initial step in the diagnosis and treatment of urological transplant complications, and that it allows for nonoperative resolution of many of these complications.

Aortic occlusion and lower extremity exercise induced stress urinary incontinence.

An unusual case of intermittent stress urinary incontinence associated with lower extremity exercise in a patient with aortoiliac occlusive disease is reported. Preoperative noninvasive vascular testing revealed severe compromise of lower extremity and pelvic blood flow. Fluoroscopically guided preoperative urodynamic evaluation without exercise revealed a competent urethral sphincter mechanism that became incompetent following exercise sufficient to induce claudication. The claudication and exercise-induced incontinence resolved after aortobifemoral bypass, and postoperative urodynamic studies were normal.

Intermittent self-catheterization of the renal pelvis: report of 2 cases.

We review the long-term outcome of 2 patients in whom cutaneous ureterostomies were performed. Complications included necrosis and distal ureteral stenosis, peristaltic dysfunction, urosepsis, calculus formation and renal impairment. Fluoroscopic ureterometry confirmed high pressure collecting systems in both patients 14 to 17 years postoperatively. Subsequent management during the last 4 to 6 years with clean intermittent self-catheterization has resulted in a significant improvement in the urological status.

Fiberoptic microtransducer pressure technology: urodynamic implications.

The FST 200 is a novel commercially available pressure measurement system that combines microtechnology and fiberoptics and is particularly well suited for invasive urodynamic studies. Pressure recording with this system is highly accurate and reproducible. The pressure curves obtained parallel those from standard water cystometry. Being small and portable, the system lends itself to invasive transurethral monitoring in the privacy of an examination room. Additionally, the 5F catheter size allows the performance of leak point pressures and pressure/flow voiding studies with minimal urethral stenting artifact often seen with larger catheters. The technical aspects of this system are presented.