[Subtotal cystectomy and ileal substitution cystoplasty for complicated vesicovaginal fistula: a case report].

A 68-year old female underwent laparoscopic vaginal hysterectomy for uterine wall perforation, following the removal of an intrauterine contraceptive device (IUD). The patient entered our hospital complaining of persistent genital bleeding, lower abdominal pain and urinary incontinence. She was diagnosed with a vesicovaginal fistula. The diameter of the fistula was over 3 cm and extended from the trigone to the internal urethral orifice, complicating the right distal ureteral obstruction. Therefore, curative surgery required a subtotal cystectomy and substitution cystoplasty due to severe urothelial changes, hydronephrosis and poor bladder compliance. An ileal neobladder (modified Studer's method) was successfully created and the postopertive course was uneventful. Although minor urinary incontinence persists, she can void through the urethra which has improved her quality of life.

[Modifications in the technique for apical dissection of radical retropubic prostatectomy to improve urinary incontinence].

PURPOSE: To evaluate urinary continence after modified radical retropubic prostatectomy. MATERIAL AND METHODS: From March 1999 to May 2004, 110 patients with prostate cancer underwent radical retropubic prostatectomy. In all patients, the fascia of the levator ani was preserved, and the plane between the prostate and rectum was dissected prior to cutting the urethra. A modification to the technique of apical dissection was introduced in May 2002. The modified method included cutting the urethra along a precise line between the prostate and urethra following the shape of the prostatic apex. The grade of early urinary incontinence was analyzed by using the incontinence rate (urinary incontinence volume (ml)/total urinary volume x 100 (%)). The incontinence rate was compared between the conventional and modified surgical techniques. Several other risk factors were also examined in these patients. Continence rates were analyzed among the patients over a one-year postoperative course. RESULTS: The incontinence rate on the day, the next day and 5-7 days after the removal of the urethral catheter were 18.1%, 11.2%, 6.0% in the modified group, and 36.6%, 22.5%, 12.6% in the conventional group, respectively. With the introduction of this modified method, the incontinence rate was significantly decreased (P<0.005). Complete continence rates 3 and 12 months after the operation were 81.3% and 98.3% in the modified and 60.0% and 97.8% in the conventional group. The time to regain complete continence in the modified was earlier than that in the conventional. After one-year, the rate of complete continence was similar and a satisfactory average in each group. Except for surgical techniques, no other factors were associated with a risk of incontinence statistically. CONCLUSIONS: We recommend modified apical dissection to preserve the urethral striated sphincter, which can be useful in improving the early incontinence rate and the recovery of continence.