Update on extracorporeal magnetic innervation (EXMI) therapy for stress urinary incontinence.

Pulsed magnetic technology has been developed for pelvic floor muscle strengthening for the treatment of urinary incontinence. This report includes an update of the prospective multicenter study of extracorporeal magnetic innervation (ExMI) therapy for stress incontinence and a discussion of the possible mechanisms of action. Issues of patient selection for ExMI therapy will also be discussed. One hundred and eleven women with demonstrable stress urinary incontinence were studied. The mean age was 55 +/- 13 years, and the mean duration of symptoms was 11 years. Ninety-seven completed ExMI therapy and analysis. Evaluation before treatment included bladder diaries, dynamic pad weight test, urodynamics, and a quality-of-life survey. For treatment the patients were seated fully clothed in a Neocontrol chair with a magnetic field therapy head in the seat. Treatment sessions were for 20 minutes, twice a week, for 6 weeks. After ExMI therapy, all of the measures were repeated at 8 weeks, including the dynamic pad weight testing and quality-of-life survey. At 6 months, further data were added, including repeat bladder diary, pad use, and quality-of-life survey. Forty-seven women completed 6 months of follow-up; of the 47, 13 patients were completely dry (28%) and 25 used no pad or less than 1 pad per day (53%). Pad use was reduced in 33 patients (70%). The median number of pads was reduced from 2.16 to 1 per day (Wilcoxon signed rank test, P <0.005). The frequency of leak episodes was reduced from 3.0 to 1.7 at 6 months (Wilcoxon signed rank test, P = 0.004). Detrusor instability was demonstrated in 10 before and 6 after ExMI (P <0.05). ExMI offers an alternative approach for the treatment of urinary incontinence. ExMI therapy is effective for both stress and urge incontinence. The best results are achieved in those patients who use no more than 3 pads a day and have had no prior continence surgery.

Use of rectus abdominis muscle flap for the treatment of complex and refractory urethrovaginal fistulas.

PURPOSE: Urethrovaginal fistulas are commonly repaired transvaginally with local tissue flaps, such as the Martius labial fat pad graft. Although this flap is ideal, if it fails and the fistula persists, subsequent treatment options are limited. We describe the use of a pedicled rectus abdominis muscle flap for the repair of complex and refractory urethrovaginal fistulas. MATERIALS AND METHODS: Six women with a mean age of 53 years (range 41 to 62) who had complex and refractory urethrovaginal fistulas were referred to our continence center. Mean number of prior attempted repairs was 1.3 and in all cases at least 1 Martius flap had failed. Transvaginal urethrovaginal fistula closure was performed followed by a pedicled rectus abdominis muscle flap interposed between the fistula closure and vaginal suture line. The muscle flap was based on the inferior epigastric vessels, and provided additional support to the urethra, bladder neck and bladder base. RESULTS: Urethrovaginal fistula repair with the rectus abdominis muscle flap was successful in all cases. No fistula recurred. Of the patients 5 (83%) were continent and able to void to completion at a mean followup of 23 months (range 2 to 66). CONCLUSIONS: The rectus abdominis muscle flap is a useful adjunct in the repair of complex and refractory urethrovaginal fistulas. It can be used with confidence to provide support to the bladder neck and proximal urethra in patients after failed prior repair with the Martius flap procedure. The pelvic surgeon may be able to recognize other applications for the rectus abdominis muscle flap in pelvic floor reconstruction.

Embryology, anatomy, and surgical applications of the kidney and ureter.

This article discusses the embryology and anatomy of the kidney and ureter. Surgical approaches, such as the lumbar and thoracoabdominal, are provided. Operations for kidney (i.e., radical nephrectomy, nephroureterectomy, and partial nephrectomy) and ureteric tumors also are discussed.

Paravaginal defect repair in the treatment of female stress urinary incontinence and cystocele.

OBJECTIVES: To assess the functional and anatomic results of the paravaginal defect repair (PVdR) in women with stress urinary incontinence (SUI) due to bladder neck hypermobility (BNH) and cystocele. METHODS: Fifty-two consecutive patients with a mean age of 61 years underwent PVdR for the treatment of SUI associated with BNH and varying degrees of vaginal prolapse. Twenty-five patients underwent PVdR alone (group 1), and 27 underwent PVdR in association with a rectus muscle sling (group 2) for the treatment of intrinsic sphincter deficiency. All patients had SUI and lateral defect cystocele (paravaginal defect). Associated vaginal and pelvic floor defects included rectocele in 34, vault prolapse in 24, and enterocele in 18; these defects were repaired simultaneously and had an equal distribution among the two groups. RESULTS: At a mean follow-up of 17 months, the cure rate (defined as no pads and no leakage) was 79% (group 1, 72%; group 2, 85%). When expanded to include substantially improved (1 pad/day or less), the success rate was 88% (group 1, 84%; group 2, 93%). Recurrent vaginal prolapse occurred in 8 patients, 6 of whom had PVdR alone. For those patients with failure, time to recurrence of incontinence was 15 and 23 months in groups 1 and 2, respectively. CONCLUSIONS: PVdR restores the normal lateral attachment of the pubocervical fascia to the arcus tendineous fascia pelvis of the pelvic sidewall and provides anatomic repair of lateral defect cystoceles. In women with anatomic SUI, PVdR restores continence by alleviating BNH and should be used in conjunction with a sling procedure in those with intrinsic sphincter deficiency.

Extracorporeal magnetic innervation therapy for stress urinary incontinence.

OBJECTIVES: To report the first data from a prospective clinical study to determine the feasibility of using extracorporeal magnetic innervation (ExMI) for the treatment of stress urinary incontinence. METHODS: We studied 83 women with demonstrable stress urinary incontinence. Treatments were for 20 minutes, twice a week for 6 weeks. For treatment, the patient sits fully clothed on a special chair; within the seat is a magnetic field generator that produces the rapidly changing magnetic field flux. Objective measures included bladder diaries, dynamic pad weight testing, urodynamic studies, and quality of life survey. RESULTS: Fifty patients have been followed up for longer than 3 months (33 patients for less than 3 months); 17 patients (34%) were dry, 16 (32%) were using not more than 1 pad per day, and 17 (34%) were using more than 1 pad per day. Pad use was reduced from 2.5 to 1.3 (P = 0.001) and leak episodes per day were reduced from 3.3 to 1.7 (P = 0.001). The pad weight was reduced from 20 to 15 g. Detrusor instability was found in 5 patients before but was demonstrated in only 1 patient after treatment. CONCLUSIONS: ExMI therapy offers a new effective modality for pelvic floor muscle stimulation. ExMI is painless, there is no need for a probe, and no need to undress for treatments. Longer follow-up is required to determine how long the benefits of treatment last and whether retreatment will be necessary.

Antegrade continence enema for the treatment of fecal incontinence in adults: use of gastric tube for catheterizable access to the descending colon.

PURPOSE: We describe the use of a gastric segment in performing the antegrade continence enema procedure in patients with refractory fecal incontinence. MATERIALS AND METHODS: The antegrade continence enema procedure was performed in 4 women and 3 men with refractory neurogenic fecal incontinence. Preoperative evaluation included defecography and anorectal manometry. Operative technique involves tunneling a 10 cm. segment of tubularized stomach isolated along the greater curve with preservation of the right gastroepiploic vessels through the anterior tenia of the colon just distal to the splenic flexure. After the stoma is mature the patient passes a catheter and runs 1 to 2 l. warm tap water through it while seated on the toilet. Digital stimulation may be required to initiate bowel emptying and irrigation is continued until clear. RESULTS: Creation of a nonrefluxing catheterizable gastric tube to the descending colon was successful in all 7 patients. At a mean postoperative followup of 22.4 months all patients are continent and use antegrade continence enema irrigation every other day on average. One patient required early revision because of stomal stenosis. Special measures include application of a generic antacid tablet to the stoma and use of a skin barrier. CONCLUSIONS: Catheterizable access to the descending colon for the antegrade continence enema procedure more closely approximates normal defecation patterns by emptying ("unloading") the left side of the colon. The stomach is a suitable option in close proximity for this purpose and is especially advantageous when the appendix is not available. The antegrade continence enema procedure using a gastric segment can be safely and effectively performed, and is well suited for use by reconstructive surgeons who are familiar with the Mitrofanoff principle.

Evaluation of staging lymphadenectomy in prostate cancer.

OBJECTIVES: To prospectively evaluate a clinical algorithm that predicts nodal status in patients with prostate cancer and to assess the impact on the outcome. METHODS: Between September 1988 and December 1994, 192 patients with organ-confined prostate cancer and considered surgical candidates for radical perineal prostatectomy (RPP) were stratified using the algorithm: prostate-specific antigen (PSA) 20 ng/mL or less, Gleason score 7 or lower, and clinical Stage T2a or lower. Patients failing any of these criteria were placed in the high-risk group and underwent a pelvic lymphadenectomy. Patients who satisfied all the criteria were placed in the low-risk group and underwent RPP without evaluation of the pelvic lymph nodes. Another contemporaneous cohort of patients (n = 65) underwent pelvic lymphadenectomy and radical retropubic prostatectomy (RRP) without use of the algorithm and were used as a control group. Patients were monitored for at least 24 months. RESULTS: In the RPP group, 177 patients were considered low risk according to the algorithm and were not offered staging lymphadenectomy before surgery, whereas 15 patients were categorized as high risk for metastasis and underwent staging lymphadenectomy. In the RRP and lymphadenectomy group, 41 patients were considered at low risk and 24 at high risk of disease spread according to the algorithm. In the RPP group, low-risk patients (no lymphadenectomy) had a PSA recurrence rate (27%) similar to that of low-risk patients in the RRP group with negative lymph nodes (29%), P = 0.8. Similarly, high-risk patients with negative lymph nodes in both groups had a similar recurrence rate (53% for RPP and 50% for RRP). Univariate logistic regression analysis showed that PSA was the most significant predictor for disease recurrence (P = 0.0004) followed by preoperative Gleason scores (P = 0.02) and clinical stages (P = 0.03). Multivariate stepwise analysis demonstrated that Gleason score and clinical stage did not add to the prediction of recurrence over PSA alone. CONCLUSIONS: Staging lymphadenectomy can be omitted in low-risk patients without deleterious effects on the outcome as measured by PSA recurrence.

Camptothecin analogues/cisplatin: an effective treatment of advanced bladder cancer in a preclinical in vivo model system.

OBJECTIVE: To evaluate the impact of the camptothecin analogs on human TCC xenograft, both as monotherapy and in combination with cisplatin (CDDP). MATERIALS AND METHODS: Human transitional cell carcinoma (TCC) xenograft tumor line (DU4184) tested by subrenal capsule assay in 112 nude mice(NM-SRCA). CDDP and the camptothecin analogs irinotecan (CPT-11) and 9-aminocamptothecin(9-AC) were evaluated. RESULTS: Both of the camptothecin analogs showed significant short term tumor inhibition which translated into enhanced survival. Maximal tumor inhibition (>95%) was achieved when either of the camptothecin analogs was combined with CDDP with minimal host toxicity. This translated into 400% increase in median survival. While all controls were dead 39 days following tumor implantation, none of the combination treated animals had died. CONCLUSION: The combination of CDDP with these camptothecin analogs is an effective therapy against this model of advanced TCC. These observations suggest potential clinical value.

Epidermal growth factor (EGF) and EGF receptor in hypospadias.

OBJECTIVE: To determine whether alterations in epidermal growth factor (EGF), which plays a major role both in the masculinization of the genitourinary tract and in wound healing, or EGF receptor (EGFR) expression are associated with hypospadias. PATIENTS AND METHODS: The prepuces from 22 children undergoing circumcision (median age 27 months, range 5-87) and skin biopsies from 16 children undergoing surgery for hypospadias (median age 12 months, range 3-57) were studied. Fourteen patients had distal, one had mid-shaft and one had penoscrotal hypospadias. Immunoperoxidase staining was carried out for EGF and EGFR and the density of the staining quantified using image cytometry by an operator unaware of the diagnosis. RESULTS: The median EGF density in foreskins obtained by circumcision was 75% (mean 73, SE 2.1) compared with 54% (mean 52, SE 3.9) for tissue samples from patients with hypospadias (P < 0.001); the mean EGFR was similar in both materials. CONCLUSION: The mean EGF value was deficient in skin adjacent to hypospadias defects compared to normal phallic skin, suggesting that the inadequate expression of EGF may be related to the aetiology of hypospadias and to possible wound complications following surgery for hypospadias.

Normal range prostate-specific antigen versus age-specific prostate-specific antigen in screening prostate adenocarcinoma.

OBJECTIVES: Prostate-specific antigen (PSA) has become the most useful serum tumor marker in the diagnosis and screening of prostate adenocarcinoma. The currently cited reference range of normal (0 to 4.0 ng/mL monoclonal) lacks both the sensitivity and specificity to be universally accepted as a screening test, and alternatives to serum PSA have been proposed, such as PSA density, PSA velocity, and age-adjusted PSA. Age-adjusted PSA takes into account the facts that as men grow older the prostate enlarges and that screening should have maximum sensitivity in younger men and maximum specificity in older men. METHODS: A population of 4,710 men with no known history of prostate adenocarcinoma underwent 5,629 examinations by transrectal ultrasound of the prostate (TRUS) from 1987 to 1994. This population consists of Mobile Urology Group, Mobile, Alabama, and Emory University, Atlanta, Georgia, patient databases. We have examined our data to determine the sensitivity, specificity, and positive predictive values for normal range PSA (0 to 4 ng/mL) versus age-specific PSA values. RESULTS: A total of 2040 patients had an abnormal digital rectal examination (DRE) and 3581 procedures were performed for an elevated PSA and a normal DRE. Biopsies were performed in 2,657 patients with 945 (35.6%) positive for cancer. Criteria for biopsy included elevated PSA (more than 4 mg/mL), PSA density more than 0.15 abnormal DRE, or suspicious TRUS. Patients were grouped according to decade: group 1 (ages 40 to 49 years, n = 183), group 2 (ages 50 to 59 years, n = 1018), group 3 (ages 60 to 69 years, n = 2358), and group 4 (ages 70 to 79 years, n = 1687). CONCLUSIONS: Use of the age-specific range for PSA increases the sensitivity in younger men more likely to benefit from treatment, and decreases the biopsy rate in older patients who may not be candidates for aggressive treatment. Age-adjusted PSA is the most valuable for patients over the age of 70 years of whom 22% would be spared TRUS with biopsy.

Radical radiotherapy for localized adenocarcinoma of the prostate. A report of 191 cases.

OBJECTIVE: To assess the results of radiotherapy in the treatment of localized prostate cancer. End points for assessment were survival, local control, development of metastases, and the toxicity of therapy. MATERIALS AND METHODS: The case notes of 191 patients who were treated with radical radiotherapy between 1982 and 1992 were reviewed. The pathology of 130 patients was reviewed by a single pathologist. A multivariate analysis was performed to identify significant prognostic factors with regard to survival and relapse. RESULTS: One-hundred and eighty-two patients were assessable. The minimum length of follow-up was one year (median = 40 months). The actuarial cause-specific 5 and 10 year survival rates were 63% and 35% respectively. Local progression occurred in 41% of patients with 37% developing metastases. Multivariate statistical analysis demonstrated that T stage and Gleason Score were significant predictors for survival. Late complications were usually mild, with only 4% developing serious bladder toxicity. CONCLUSION: Radical radiotherapy has a role in the curative treatment of prostate cancer. Survival is significantly related to T stage at the time of presentation, and to the Gleason Score of the tumour. Survival in this series was not as good as the best surgical series, but it is still not clear which patients should receive radiotherapy and which surgery as their primary management.